Dual Diagnosis Demystified

By Andy Kang LICSW, JD

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Some History

In the last 20 years, we have learned a lot about the mechanisms of addiction. New technologies, like MRIs and other forms of brain scanning, have shed light on the processes within the brain when addictive substances are introduced. We have finally begun to understand the functions of different parts of the brain, that they are interconnected and how they function together. But as far as we have come, we still do not know exactly how many brain functions work. As we get into more complex operational concepts like mood, consciousness, and mental illness, our basic understanding breaks down and remains inadequate to describe what’s actually happening up there.

What Is Dual Diagnosis?

And that leads us to today’s topic: Dual Diagnosis. What is it? What does it mean? How is it relevant to treatment for addictions? Dual diagnosis is generally defined as describing the condition of having a mental health diagnosis and a concurrent substance use diagnosis (thus, the “dual”). This can be virtually any combination of diagnoses, such as say, depression combined with an alcohol abuse disorder. In that case, the person is dually diagnosed with depression, a mood disorder, and alcohol abuse, a substance disorder. These diagnoses exist independently, but are inextricably intertwined. While it is possible that such a person could get sober and quit drinking, their depression would likely remain if unaddressed. Moreover, not dealing with the depression greatly increases the likelihood of relapse.

This of course begs the question, how does one deal with multiple conditions at the same time? Is that even possible? Can you deal with them together or must it be one at a time? Many people think that addiction is a symptom of deeper issues troubling a person, which causes them to seek escape from reality. If that were strictly the case, then solving the underlying issue would lead to remission of the addictive symptoms. Unfortunately, things are rarely that simple. And here is where we return to what we know and don’t know about the brain. Because we are dealing with mechanisms that are so complicated, we still don’t completely understand how they interact.

How Is Dual Diagnosis Treated?

What we do know for sure is that treating a dually diagnosed person is more complicated and challenging than a person with a strict substance abuse issue. Many will debate whether the latter is even possible given what we are learning. This represents an evolution of thought in the substance abuse/addiction field: that most substance abuse disorders do not exist in isolation. Thus, treatment of substance abuse issues must take into account both pre-existing and concurrent mental health issues in order to be successful.

Most treatment facilities claim to treat dually diagnosed patients. Indeed, it has become commonplace for treatment to include specialized dual diagnosis programs. Such programs vary in quality and rigorousness. All too frequently, a dual diagnosis program consists of 12-step based work, plus the addition of weekly counseling. This has allowed many programs to claim to treat dual diagnosis without a great deal of change in their programs. And while the 12-steps are a solid and proven treatment for addiction issues, the mental health issues need additional and coordinated efforts so that both treatments can work in tandem.

Conventional wisdom has been that the underlying mental health issues cannot be worked through until a certain amount of sobriety and stability have been established. And while it is certainly the case that a person cannot hope to do real mental health work while using or drinking, it is not necessarily true that mental health issues have to wait for a certain amount or even full sobriety to happen first. More programs are being created that integrate treatments relating to mental health while in early sobriety. For instance, it is possible to work through changing emotional distress-related behaviors even with very little sober time. In fact, doing so helps the chances of maintain sobriety going forward.

What To Ask Of A Dual Diagnosis Program?

It can be a daunting task to navigate the sea of treatment programs for dual diagnosis. As noted, most facilities and programs claim to treat mental health and substance use issues together. However, some programs specialize in this area more than others. As a general matter, the more complex the mental health issue, the more important this becomes. For instance, if a person has a history of schizophrenia, bipolar disorder or a personality disorder, a rigorous dual diagnosis program will be absolutely essential.

So, what do you need to know from a program before going there or sending a loved one? Here are a few important questions to get you started:

1. What does your dual diagnosis program entail and how is it different from your standard substance abuse program?

2. How has your staff been specifically trained in dual diagnosis treatment?

3. What is the composition of the mental health specific staff, including psychiatrists, psychologists, and counselors? How are they utilized?

4. Does your program have a particular philosophy about treating mental health and addiction issues together?

5. Has your program ever treated someone with the combination of issues that I am presenting? If so, how many, and what was the approach?

There are many other questions to ask, and you should ask them. You have a right to know what course the treatment is going to take before you commit to it. And if you still aren’t sure about a program, you can keep asking questions until you are satisfied. You can also reach out to others with particularized expertise, like OPG, for assistance.

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