Co-occurring Disorders Require Co-Occurring Disorders Treatment
What happens when co-occurring disorders treatment doesn’t happen?
Consider the following exchange I had with one of my clients, a 45-year old male who had been ticketed for a DUI. His wife was threatening legal separation. He was worried about losing his license, which would cost him his job. The DUI had prompted him to complete a 28-day rehab program for alcoholism to show the judge he was intent on changing, but he wanted to know what else he could do – mostly to prevent losing his license and preserve his marriage.
I asked him a few questions, which his how I start these exchanges. My work with clients is not as a therapist or counselor, rather I listen to their story and then provide educational services and resources that can help them and/or their families take next steps.
Do you think you’re an alcoholic?
Yes.
Have you been through rehab before?
Yes – about 10 years ago but that was for drugs.
Have you ever been diagnosed with a mental illness?
Yes. Bipolar, OCD and PTSD.
Have you sought treatment for your mental illnesses or did your most recent rehab treatment team address them?
No and no.
Did you tell them about your diagnoses?
Yes and they encouraged me to see a therapist when I got out.
Have you?
No.
What are you doing for your recovery?
Going to a lot of AA meetings. I got a Vivitrol injection for the cravings – I’ll do another one in a month.
Unfortunately, this is not an unusual scenario for the person with addiction or their family member who calls me at their wits end over the vicious cycle: rehab – relapse, rehab – relapse. Time and again, what is missing is the complete lack of understanding of co-occurring disorders and the need to treat them simultaneously and for a long time.
What are Co-occurring Disorders?
Co-occurring disorders (aka dual diagnosis) is the term to describe a person with both a mental and substance use disorder. Approximately 23 million Americans struggle with the brain disease of addiction (one of the substance use disorders). Approximately 40% of individuals with substance use disorders have a co-occurring mental disorder (aka mental illness). Yet less than 10 percent receive treatment for both conditions and more than 55 percent receive no treatment at all. (SAMHSA)
Co-Occurring Disorders required Co-Occurring Treatments
Some of the common mental (psychiatric) disorders co-occurring in individuals receiving treatment for addiction are:
• anxiety and mood disorders
• post traumatic stress disorder
• pathological gambling
• sexual and eating disorders in adults and adolescents
• conduct disorders and attention deficit disorders in adolescents.
(ASAM Public Policy Statement on Co-occurring Addictive and Psychiatric Disorders)
Some of the common addictive disorders co-occurring in individuals receiving treatment for mental (psychiatric) disorders are:
• alcohol
• nicotine
• opiates
• sedatives
• stimulants
• marijuana
• hallucinogens
• prescription drugs.
(ASAM Public Policy Statement on Co-occurring Addictive and Psychiatric Disorders)
Sadly, both mental illness and addiction are so thoroughly misunderstood by the general public, let alone by the people who have one or the other or both or their loved ones, that secrecy and shame keep people stuck. We routinely hear statements like the following:
No way addiction is a disease. Cancer is a disease. All he has to do is put down the bottle.
We all have rough patches. I mean, really – my mom died, but I didn’t fall apart. All she has to do is get out of bed and do something – anything – and she’d be right back to her old self in no time.
He’s been in rehab so many times – I’m done. Done!
Societally we still believe a person can simply “choose” not to drink or “choose” to stop being depressed, and by not choosing either, a person is weak-willed or does not care enough about those they love the most. But I ask you, what could possibly have made Philip Seymour Hoffman “choose” to die by a lethal injection of heroin, in his underwear, alone, on a bathroom floor in his apartment, leaving his girlfriend and three children, whom by all accounts he loved very much, to cope with the tragedy?
The answer lies in understanding addiction for what it is: a chronic, often relapsing, developmental brain disease and understanding what constitutes effective addiction treatment. But that is just the addiction disorder. What happens to the person who has both a mental illness and an addiction, in other words – co-occurring disorders?
Co-occurring Mental Illness and Addiction – A Complex Dynamic
Thanks to advancements in imaging technologies (fMRI, SPECT, as examples), research funding opportunities and the collaborative efforts of brilliant minds – especially in the recent 10-15 years – the way co-occurring disorders are identified and treated is finally, ever-so-slowly starting to change.
It Comes Down to Neural Networks
It is now understood the brain controls everything we think, feel, say and do through neural networks. Neural networks are the way brain cells (neurons) “talk” to one another. They, in turn, exchange information with other neurons (cells) throughout the body via the nervous system. This “talking” is done through an electro-chemical signaling process, which is easier to understand if you think of neural networks as strands of holiday lights. Anything that happens along a strand of holiday lights – a loose bulb, frayed wire, power surge – changes how that strand works. This in turn changes how all other strands connected to it work.
Changes or Differences in Neural Networks Can Cause a Person to Think, Feel and Behave Differently
Thus if any of the “things” that make this electro-chemical signaling process possible are changed or “different” (inherited), it changes the way neural networks perform. These “things” include cues, neurons, axons, dendrites, neurotransmitters, receptors and synapses, as examples. Both mental illness and addiction change several of these “things,” which is why both disorders must be treated individually and simultaneously.
Causes of Co-occurring Disorders (aka Causes of Neural Network Changes or Differences)
Not surprisingly, addiction and mental illnesses can have similar contributing causes. These include:
• genetics
• brain chemistry imbalances
• brain injury
• childhood trauma
• environmental stressors
• presence of the other
• stage of brain development at onset – especially ages 12-25.
Having similar contributing causes, however, does not mean you fix one and the other is automatically fixed. This is because of the complex dynamic that exists with co-occurring disorders.
The Complex Dynamic
The National Alliance on Mental Illness (NAMI) explains the co-occurring disorders’ dynamic this way:
• Drugs and alcohol can be a form of self-medication [for the mental illness]– the drug or alcohol chemicals work on the brain’s pleasure-reward pathways, the ones that make a person feel good.
• Drugs and alcohol can worsen underlying mental illnesses – alcohol is a depressant, for example, which can worsen the depression mental illness symptoms.
• Drugs and alcohol can cause a person without mental illness to experience the onset of symptoms for the first time.
Because of this complex dynamic, it is imperative both disorders be treated simultaneously or else one can be the trigger for the other and/or the person still won’t feel “normal,” even though one of this disorders has been treated.
Co-occurring Treatments – The Right Kind of Help
Both mental illness and addiction are highly treatable, with tremendous opportunities for success, but only when their complex dynamic is understood and both are treated simultaneously. Effective co-occurring disorders treatment is extremely difficult to find, however. Many treatment providers try and some do it very successfully, but as we saw in the case of the 45-year old male ticketed for a DUI, many do not. This is primarily because the mental illness, addiction, brain and co-occurring disorders treatment research is relatively recent and not mainstream, yet.
To help you in your search of effective co-occurring disorders treatment, please find the following suggestions:
Understand the Brain Disease of Addiction and Principles of Effective Addiction Treatment
Check out the National Institute on Drug Abuse (NIDA) Drugs, Brains and Behavior: The Science of Addiction and NIDA’s Principles of Effective Treatment.
Understand Mental Illness
Check out the National Alliance on Mental Illness (NAMI) Mental Illness.
Understand Co-Occurring Disorders
Check out the Substance Abuse and Mental Health Services Administration (SAMHSA) – About Co-Occurring Disorders and the National Institute on Drug Abuse (NIDA)’s – Comorbidity: Addiction and Other Mental Illnesses.
Understand and Only Settle for Integrated Co-occurring Disorders Treatment
In January 2010, SAMHSA released the Integrated Treatment for Co-Occurring Disorders KIT. While this is designed for the treatment provider, it will give you the information you need to assess a provider’s program. In a nutshell, evidence-based Integrated Treatment programs means the consumer receives treatment for both the mental illnesses and the substance use disorders from the same practitioner or treatment team. Key elements of Integrated Treatment include:
• integrated services
• cross-trained practitioners
• stage-wise treatment
• motivational interventions
• cognitive-behavioral approach
• multiple formats
• integrated medication services.
You will also want to be sure a provider’s treatment planning assessment tools identify the presence or possible presence of co-occurring disorders and deliver an effective treatment plan for the individual – not a one-size-fits-all plan they try to push all individuals through. For this I suggest you consult Anne M. Fletcher’s list of things to look for or ask, shared on pages 325-26 of her book, Inside Rehab (Viking 2013).
From this box, you can narrow your search.
To begin your search for treatment facilities that report treating co-occurring disorders, you might want to start with SAMHSA’s Facility Locator. If you’re not sure where to start, one place is to search the United States by typing that into the search bar at this link SAMHSA’s Facility Locator. The page that appears will have a box in the top right corner of the page that looks like the image to the right. You will see I have checked the box for SA & MH (Substance Abuse and Mental Health). You will see the word, “options,” and other boxes you can check to start narrowing your search.
Lastly, please know that treating the adolescent brain is not the same as treating the adult brain. This is the result of brain developmental processes occurring ages 12-25. Effective co-occurring disorders treatment for teens requires the same approaches described above, but targeted specifically to the adolescent brain.
Bottom Line
Thankfully, it is a whole new world when it comes to diagnosing and treating co-occurring disorders. Unfortunately protocols for effective treatment of co-occurring disorders are not, as yet, mainstream.
© 2014 Lisa Frederiksen
Lisa Frederiksen
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I tend to think it is higher than 40% of addicts having co-occurring disorders. I think many people have mental health issues that do not present at a level for them to go to a doctor for.
So they are mildly depressed and use alcohol as a crutch. They think the problem is drinking until they get sober and realize there is more wrong.
AA has done so much to help people but their approach to helping people is very limited, however, their ability to get out their message is very effective.
There is a really good video interview of Carl Hart on this exact subject. I think you’ll be surprised. I think we look at this wrong, we say the addiction is followed by the disorder. I think addiction can enflame disorders or aggravate them, however I think the disorder is more the reason for the addiction.
Anyways it’s a good video if you want to check it out on msnbc’s website.
http://www.msnbc.com/all-in/watch/challenge-everything-you-know-about-drugs-183730755827
Hi Charles – Thank you for sharing the link to Carl Hart’s video. I look forward to watching it. And I agree – it works both ways.
Hey Lisa,
This is a very informative post. “The answer lies in understanding addiction for what it is: a chronic, often relapsing, developmental brain disease and understanding what constitutes effective addiction treatment.” says it all. It is that understand piece that is essential for thorough and appropriate treatment. Thank you for being a voice that continues to inform and educate.
You’re welcome, Cathy! I so agree that education / understanding is what is changing how we talk about and treat both disorders. I appreciate you adding your voice to this conversation!
What A Great Article. I had to re-post on Twitter, as well as my Facebook page,Pinterest Board, and Google page. Awareness and Education are Paramount. Keep up the fine work you do.
Best Regards
Why thank you, Dr. Houston!! And thank you so much for sharing it so widely – very much appreciated!
This is excellent information, Lisa – and vitally important. Leave it to you to be so thorough – that’s what you do.
I don’t know why in the world the notion of co-occurring disorders flies under the radar, as though it’s some sort of revolutionary concept. Hello! Folks who endure emotional/mental woes may seek comfort. And folks who over-indulge may become depressed and/or anxious. It’s a real and living – reciprocating – relationship. I inquire about all personal goings-on in my intake process, just as you shared at the beginning of the piece. And all areas of concern are addressed. Actually, I don’t consider emotional/mental and, say, compulsive behavior issues separate entities. It’s just all part of what’s occurring in the client’s mind. Certainly, treatment strategies and techniques may differ; however, one mind – no separate entities. You know me, always bucking tradition and the manual-based approaches rigidly adhered to by most recovery centers – because the insurance know-it-all’s mandate them. Just makes me silly-goofy! Like Dr. Herby Bell says, “…how ’bout we just save some lives?!”
Great, as always, Lisa. Thank You…
Bill
And boy does it fly under the radar! And, “Why?” for as you say, “It’s a real and living – reciprocating – relationship.” I recall when my loved one entered treatment in 2003 – the prevailing protocol for co-occurring disorders was to stop the substance use and then (with little understanding or discussion about when “then” was) treat the mental illness, which typically did not occur during rehab as that was typically 28 days. And based on the calls I receive regularly, even now, from persons with co-occurring disorders or their family members, not much has changed. You sum it up beautifully, “Certainly, treatment strategies and techniques may differ; however, one mind – no separate entities.” Thank you, Bill!