What is Dual Diagnosis in Substance Abuse?
Although the word dual means two, patients can have more than two conditions.
Substance abuse can change the brain and cause emotional or psychiatric disorders. And independent mental health issues can cause a person to drink or take drugs in the first place.
Substances are seen as a way to escape problems. But they complicate the situation because individuals end up with side effects and co-occurring disorders (COD). COD are also known as co-morbid disorders. This is because the effects of one disorder can contribute to or worsen the effects of the other.
Alcohol and illegal drugs also make medications like antidepressants less effective. In addition, mixing substances and prescription drugs can be life-threatening.
Dual Diagnosis: A Common Condition
COD has only been studied for about four decades. A 2004 study found that about 50% of patients in three different substance abuse outpatient clinics had co-occurring mental health conditions.
There are similarly high numbers of substance abuse disorders in mental health admissions. This means that it is important for mental health clinics and substance abuse clinics to accommodate patients that have both issues.
Mental health issues can range from depression and obsessive compulsive disorder to borderline personality disorder and schizophrenia. And indeed, substance abuse can differ in severity. The blanket term, COD, thus describes combined conditions that vary from one patient to the next.
In the past, the health system has not been sure how to treat patients with a dual diagnosis. Consequently, about 72% of relevant respondents in a national household survey reported not receiving any treatment in the previous year. In 2004, only 35% of substance abuse treatment facilities catered to COD and provided joint services.
Single disorder treatment for a dual diagnosis is not suitable. Although they have been on the rise, dual diagnosis programs offering appropriate services tend to be in the minority. Patients in this group have historically been under-served.
Co-occurring disorder treatment is important because dual diagnosis is linked to major problems. These include homelessness, unemployment, violence, unlawful behavior and infectious diseases like HIV. Clients with COD also have high risk factors for suicide.
Effective Dual Diagnosis Treatment Plan
Negative emotions create cravings and a high risk for relapse. Treatment for substance abuse includes private counseling which can bring about positive changes in behavior.
Cognitive behavioral therapy (CBT) in substance abuse programs has worked for some patients suffering with post-traumatic stress disorder (PTSD). It also improves symptoms of anxiety and depression and lowers the risk of future criminal activity.
CBT changes negative attitudes and beliefs and sets out new ways of thinking and acting. Grounding techniques are taught to patients so that they can handle triggers linked to past trauma.
These strategies help with self-soothing when patients feel a panic attack coming on. CBT can use videos, role-play, visual or other tools to help patients remember these concepts in tough moments.
Social Support and Expert Monitoring
Recovery involves dealing with two or more serious illnesses. It’s an uphill battle but not a hopeless one, and it can mean the difference between life and death. Social support, including friends and family members, is necessary. Treatment programs offer family education. Families are given information about potential obstacles and resources.
Dual diagnosis treatment facilities can also find sponsors for patients. This paves the way for participation in COD-friendly 12-step programs. Programs like Alcoholics Anonymous encourage self-help within a community space. When addicts with shared experiences outline why they quit and how they are recovering, it can be a positive reinforcement.
Formal check-ups are necessary post-treatment to help patients stay on track. This is linked to ‘assertive outreach’. Here, individuals gain access to treatment, form relationships with staff, and staff become a part of their lives. Respectful meetings to monitor progress take place at patients’ homes or other places where they feel comfortable.
Research evidence suggests that CBT is more effective than the 12-step approach. However, combining the two offers even better results.
CBT and support groups alone cannot meet the needs of people with serious mental health problems. Support in the form of medication and special therapy is necessary. These are provided in what are called ‘dual diagnosis enhanced programs’.
Stages of Treatment
Treatment plans differ depending on the patient. Generally, the first step would be to analyze patients after about a month of sobriety. This way, the immediate effects of drug use and withdrawal symptoms won’t interfere with assessing any mental health disorders. Multiple assessments should be done over time so that the diagnosis is as clear as possible.
Post Detox Treatment
- Trust between the patient and treatment team. Connection is key to recovery.
- Motivational interventions to educate the patient and convince them to pursue recovery.
- Active treatment involving counseling, medicine and illness management, and life skills training.
- Post-rehabilitation support for self-management, control of symptoms, stable remission and relapse prevention.
Patients may be in different stages for each of their co-occurring mental health and substance use issues. They might not move through the stages in order. But the stages do correspond with specific actions from the medical team.
Motivational interventions can take a while to produce results. Patients can be in denial or have a lack of impulse control. They might be young enough to still see substance use as a way to have a good time. For treatment to continue, patients have to recognize that they have a problem and they must want to change.
If there’s a slip or lapse, the stage of treatment changes but it’s not considered a failure. Rather, it’s a chance to use taught strategies to prevent a full-blown relapse and downward spiral.
In COD patients, a lapse also refers to when patients stop taking prescribed drugs. This can be as a result of unclear ideas about what the medication does. It can also be because of external pressure from people who hold these incorrect beliefs. Patients need to be educated about the differences between illegal drugs and medication aimed at creating stability in their lives.
Therapy for Dual Diagnosis
A good quality of life requires addicts to make lifestyle changes. Patients need to change habits and find better ways of handling stress. They have to remove bad influences and social contact with drug users as far as possible.
Residential treatment is an intensive way to begin the process in a safe environment with improved nutrition and 24-hour support.
Therapy can take place one-on-one and it can involve family. Group therapy takes place with other patients at least once a week. Group therapy is important to dual diagnosis treatment. It includes peer support staff members who are farther along on their recovery journeys.
Counseling guides patients towards coping mechanisms. Attention is paid to patient strengths. Patients think about and set goals. They develop skills for employment, and learn how to look after money. This reduces feelings of hopelessness in some individuals. Patients also identify disconnects between their goals and current or previous behaviors.
Counseling for those struggling with COD usually goes a little slower than in regular addiction treatment. Cognitive problems can lead to patients being, for example, less equipped to deal with confrontation. Therapists communicate with, rather than confront, patients.
The pace reflects the need for repetition and more time to work through various concepts. Before exploring new material, concepts from previous sessions need to be reviewed.
Therapists have to avoid using abstract ideas with COD patients who might not understand them. Coping methods should be practiced so that they are more easily remembered. Even small improvements should be acknowledged and praised.
Therapists should also prepare COD patients for their first support group sessions. This starts with detailed instructions for how to find the group and ends with working through problems after sessions take place.
Patients are more open to treatment if therapists are knowledgeable about and sensitive to their cultural or other backgrounds. This awareness can help therapists ask the right questions to make progress. Therapists also have to be careful not to show negative feelings based on previous encounters with other patients.
Counselors are humans. For example, if a client expresses an intention to seriously harm someone, it’s hard to remain calm. There are strategies for managing negative feelings, including occasional supervision from other members of the team.
Counseling within the context of addiction is difficult. But if a patient is bipolar or antisocial, attempts at developing a connection with them can be truly challenging. It requires time and patience.
One way to gain trust is to listen without judgment. Good therapists strike a balance between care and criticism for dishonest or irresponsible behavior.
In addition, the therapist can help the patient with some of their immediate external concerns and physical symptoms. By assisting in this way, therapists confirm that they have the patient’s best interests at heart.
Contingency Management (CM)
Empowerment takes place when crises are prevented. CM is based on this. Prizes and the expected loss of them are used to prevent setbacks.
CM is centered on:
- Regular drug testing
- Rewards for staying sober
- Healthy alternative habits
Best Dual Diagnosis Treatment Models
Integrated Dual Disorder Treatment (IDDT) Model
When it comes to treatment for dual diagnosis, an integrated approach is preferred. The IDDT model was created by the New Hampshire–Dartmouth Psychiatric Research Center and is considered to be best practice.
The research in this area supports the effectiveness of this model, especially when it comes to long-term treatment over many years. If patients don’t respond to initial treatment, further actions are taken.
Sticking to this model often means a higher success rate. When patients and family members start to see positive results, there is renewed commitment to treatment.
What is IDDT?
- In IDDT, substance abuse and mental health issues are treated at the same facility by specialists who are cross-trained. The patient comes into contact with only one team of doctors, medical professionals and social workers.
- IDDT reduces the duplication of services and costs and increases the chances for a patient to live independently. In addition to the treatment mentioned in previous sections, wellness services are offered. They cover books, meditation, excursions, physical health, mental fitness, and finding jobs and housing.
- IDDT is time-unlimited. This provides for continuity of care. Plans are made for patients to have constant access to outpatient services and support in other forms. This includes times when patients are doing well and symptoms don’t occur frequently.
Parallel Treatment Model
In this model, treatment for co-occurring disorders takes place at the same time via different healthcare providers. There is separate but coordinated treatment between facilities. If integrated treatment is not possible, the U.S. Department of Health and Human Services recommends the parallel approach.
Getting Help from a Dual Diagnosis Treatment Facility
It is not uncommon for people to suffer with substance abuse and mental health issues, both of which are treatable. If you or someone you know might be experiencing co-occurring disorders, get in touch with healthcare professionals.
At Bedrock Recovery Center, we have long-term, two to three month, residential programs to turn to. Treatment helps patients manage illnesses and lead lives that are more stable and fulfilling. A sense of self-worth and dignity are within reach.