Kevin Stevenson, LMHC, MCAP

Dual Diagnosis

Dual diagnosis is a term used to describe a person who has both a mental illness and and alcohol or drug problem.  The relationship between the two is complex, and the treatment of people with co-occurring substance abuse and mental illness is more complicated than the treatment of either condition alone.  The term dual diagnosis is often used interchangeably with the terms co-morbidity, co-occurring illness, concurrent disorders, co-morbid disorders, co-occurring disorder, dual disorder, and, double trouble.

In a dual diagnosis, both the mental health issue and the drug or alcohol addiction have their own unique symptoms that may get in the way of your ability to function, handle life’s difficulties, and relate to others.  To make the situation more complicated, the co-occurring disorders also affect each other and interact.  When a mental health problem goes untreated, the substance abuse problem usually gets worse as well.  And when alcohol or drug abuse increases, mental health problems usually increase too.

According to reports published in the Journal of the American Medical Association :

  • Roughly 50 percent of individuals with severe mental disorders are affected by substance abuse.
  • 37 percent of alcohol abusers and 53 percent of drug abusers also have at least one serious mental illness.
  • Of all people diagnosed with a mental illness, 29 percent abuse either alcohol or drugs.
The relationship between mental illness and substance abuse or dependency is complex.  These relationships are often considered in the following ways:
  • Drugs and alcohol can be a form of self-medication.  In such cases, people with mental illness may have untreated – or incompletely treated – conditions (such as anxiety or depression) that may “fee; less painful” when the person is high on drugs or alcohol.  Unfortunately, while drugs and alcohol may feel good in the moment, abuse of these substances doesn’t treat the underlying condition and – almost without exception – makes it worse.
  • Drugs and alcohol can worsen underlying mental illness.  This can happen both during acute intoxication and during withdrawal from a substance.
  • Drugs and alcohol can cause a person without mental illness to experience the onset of symptoms for the first time.  For example, a twenty-year old college student who begins to hear threatening voices inside his head and becomes paranoid that his chemistry professor is poisoning his food after smoking marijuana could represent a reaction to the drug or the first episode of psychosis for this individual.
Abuse of drugs and alcohol always results in a worse prognosis for a person with mental illness.  People who are actively using are less likely to follow through with the treatment plans they created with their counselors, are less likely to adhere to their medication regimens and more likely to miss appointments which leads to more psychiatric hospitalizations and other adverse outcomes.  Active users are also less likely to receive adequate medical care for similar reasons and are more likely to experience severe medical complications and early death.  People with mental illness who abuse substances are also at increased risk of impulsive and potentially violent acts.  Perhaps most concerning is that people who abuse drugs and alcohol are more likely to both attempt suicide and to die from their suicide attempts.

Individuals with mental illness and active substance or alcohol abuse are less likely to achieve lasting sobriety.  They may be more likely to experience severe complications of their substance abuse, to end up in legal trouble from their substance use and to become physically dependent on their substance of choice.

Treatment for co-occurring disorders or dual diagnosis

The best treatment for co-occurring disorders is an integrated approach, where both the substance abuse problem and the mental disorder are treated simultaneously.

  • There is hope: Recovering from co-occurring disorders takes time, commitment, and courage.  It may take months or even years but people with substance abuse and mental health problems can and do get better.
  • Combined and comprehensive treatment is best: Your best chance at recovery is through integrated treatment for both the substance abuse problem and the mental health problem.  This means getting combined mental mental health and addiction treatment from the same treatment provider or team along with coping skills/stress management, education, and social skills.
  • Motivational interventions: Through education, support, and counseling, helps empower deeply demoralized clients to recognize the importance of their goals and illness self-management.
  • Counseling: Helps develop positive coping patterns, as well as promotes cognitive and behavioral skills.  Counseling can be in the form of individual, group, or family therapy or a combination of these.
  • Treatment includes education: Basic education about the mental illness problem along with the alcohol or drug problem.
  • Establish Trust: Establishing trust between the consumer and caregiver helps to motivate the consumer to learn the skills for actively controlling their illnesses and focus on goals.  This helps keep the consumer on track, preventing relapse.
  • Teaching healthy coping skills: Healthy coping skills and strategies are taught to hep minimize substance abuse, cope with negative feelings, and to help strengthen relationships.
  • Participate in decision making process: The person is actively involved in setting goals and in developing strategies for change.
  • Relapses are part of the recovery process: Don’t get too discouraged if you relapse.  Slips and setbacks happen, but, with hard work, most people can recover from their relapses and move in with recovery. Developing a relapse prevention plan is an essential component of treatment.
  • Peer and family/social support: You may benefit from joining a self-help support group like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA).  They give you a chance to lean on others who know what you’re going through and learn from their experiences. Family and friends are involved in treatment and offer ongoing support.
Ideally, both the alcohol or drug problem along with the mental health issue should be treated simultaneously.  Drug and alcohol withdrawal can lead to medical emergencies requiring immediate treatment.  For any substance abuser, however, the first step in treatment must be detoxification – a period of time during which the body is allowed to cleanse itself of alcohol or drugs.  In certain situations detoxification should take place under medical supervision.  It can take a few days to a week or more, depending on what substances the person abused and for how long.
Once detoxification is completed, it’s time for dual treatment; rehabilitation for the alcohol or drug problem and treatment for the mental health problem.  Rehabilitation for a substance abuse problem usually involves individual and group psychotherapy, education about alcohol and drugs, exercise, proper nutrition, and participation in a 12-step recovery program such as Alcoholics Anonymous.  The idea is not just to stay off the alcohol and drugs, but to learn to enjoy life without these “crutches.”
Treatment for a mental health problem depends upon the diagnosis.  For most disorders, individual and group therapy as well as medications are recommended.  Expressive therapies and education about the particular mental health condition are often useful adjuncts.  A support group f other people who are recovering for the same condition may also prove highly beneficial.  Adjunct treatment, such as occupational or expressive therapy, can help individuals better understand and communicate their feelings or develop better problem – solving or decision – making skills.
With both rehabilitation for substance abuse and treatment for a mental health problem, education, counseling sessions, and support groups for the patient’s family are important aspects of overall care.  The greater the family’s understanding of the problems, the higher the chances the patient will have a lasting recovery.
When family and friends participate in the recovery program, they learn how to stop enabling.  Enabling is acting in ways that essentially help or encourage the person to maintain their habit of drinking or getting high.  For instance, a woman whose husband routinely drinks too much, might call in sick for him when he is too drunk to go to work.  That’s enabling.  Likewise, family members or friends might give an addict money which is used to buy drugs, because they’re either sorry for him or afraid of him.  That’s enabling also.  If family members and friends act on what they’ve learned, the recovering substance abuser is much less likely to relapse into drinking or taking drugs.
Basics of dual diagnosis recovery
Recognize and manage overwhelming stress and emotions:
  • Learn how to manage stress.  Stress is inevitable, so it’s important to have healthy coping skills so you can deal with stress without turning to alcohol or drugs.  Stress management skills go a long way towards preventing relapse and keeping your symptoms at bay.
  • Know your triggers and have an action plan.  If you’re coping with a mental disorder as well, it’s especially important to know signs that your illness is flaring up.  Common causes include stressful events, big life changes, or unhealthy sleeping or eating.  At these times, having a plan in place is essential to preventing drug relapse.  Who will you talk to?  What do you need to do?
Stay connected:
  • Get therapy and stay involved in a support group.  Your chances of staying sober greatly improve if you are participating in a social support group like Alcoholics Anonymous or Narcotics Anonymous and if you are getting therapy.
  • Be compliant with treatment providers.  Once you are sober and you feel better, you might think you no longer need medication or treatment.  But arbitrarily stopping medication or treatment is a common reason for relapse in people with dual disorders.  Always talk with your doctor before making any changes to your medication or treatment routine.
Make healthy lifestyle changes:
  • Practice relaxation techniques.  When practiced regularly, relaxation techniques such as mindfulness meditation, progressive muscle relaxation, deep breathing and visualization can reduce symptoms of stress, anxiety, and depression, and increase feelings of relaxation and emotional well-being.
  • Adopt healthy eating habits.  Start the day right with breakfast, and continue with frequent small meals throughout the day.  Going too long without eating leads to low blood sugar, which can make you feel more stressed or anxious.
  • Exercise regularly.  Exercise is a natural way to bust stress, relieve anxiety, and improve your mood and outlook.  To achieve the maximum benefit, aim for at least 30 minutes of aerobic exercise on most days.
  • Get enough sleep.  A lack of sleep can exacerbate stress, anxiety, and depression, so try to get 7 to 9 hours of quality sleep a night.
Helping a loved one with a dual diagnosis
Helping a loved one with both a substance abuse and a mental health problem can be a roller coaster.  Resistance to treatment is common and the road to recovery can be long.
The best way to help someone is to accept what you can and cannot do.  You cannot force someone to remain sober, nor can you make someone take their medication or keep appointments.  What you can do is make positive choices for yourself, encourage your loved one to get help, and offer your support while making sure you don’t lose yourself in the process.
  • Seek support.  Dealing with a loved one’s dual diagnosis or mental illness and substance abuse can be painful and isolating.  Make sure you’re getting the emotional support you need to cope.  Talk to someone you trust about what you’re going through.  It can also help to get your own therapy or join a support group.
  • Set boundaries.  Be realistic about the amount of care you’re able to provide without feeling overwhelmed and resentful.  Set limits on disruptive behaviors, and stick to them.  Letting the dual diagnosis disorder take over your life isn’t healthy for you or your loved one.
  • Educate Yourself.  Learn all you can about your loved one’s mental health problem, as well as substance abuse treatment and recovery.  The more you understand what your loved one is going through, the better able you’ll be to support recovery.
  • Be patient.  Recovering from a dual diagnosis doesn’t happen overnight.  Recovery is an ongoing process that can take months or years, and relapse is common.  Ongoing support for both you and your loved one is crucial as you work toward recovery.
As with any illness, a person with a dual diagnosis can improve once proper care is given.  As a family member or friend, you can play an important role in encouraging a person to seek professional help.  By seeking out information, you can learn to recognize the signs and symptoms of dual diagnosis – and help someone live a healthier or more fulfilling life.

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                    Kevin Stevenson, LMHC,CAP