What does it mean to have a co-occurring disorder (a dual diagnosis)? What constitutes effective dual diagnosis treatment? What does effective dual diagnosis treatment have to do with preventing addiction relapse?

In simple terms, a dual diagnosis means to be diagnosed as having two brain diseases (aka disorders): an addiction and a mental illness. This is also referred to as having co-occurring disorders. You will also hear this referenced as having co-occurring mental health and substance use disorders. But, this is not as scary as it sounds because BOTH are treatable and recovery from both – living a satisfying, enjoyable life – is entirely possible and here’s why.

“Disease” by its simplest definition is something that changes cells in a negative way. Addiction and mental illness change cells in the brain, which is what makes them brain diseases and why both change the way a person thinks, feels and behaves. [Please note: in terms of this post, I am referring to drug and alcohol addictions and mental illnesses, such as depression, anxiety, PTSD, bipolar, schizophrenia, as examples.]

Effective dual diagnosis treatment treats both the mental illness and the addiction as primary illnesses at the same time in the same setting. This is commonly referred to as “Integrated Treatment.”

Co-occurring brain disorders weren’t as understood as they are, today, until relatively recently (the past decade or so) and by no means are they fully understood – much research continues and new findings are ongoing. These new understandings are due in large part to the Decade of the Brain (1990s) and the Decade of Discovery (2000s) – two decades in which advances in imaging technologies (PET, fMRI, SPECT) have allowed neuroscientists and medical professionals to study the live human brain in action, over time, under the influence, with mental illness, with addiction, with addiction or mental illness medications, after treatment, influenced by trauma…. In other words, the findings have been explosive and are still coming!

What This Means in Terms of Understanding Dual Diagnosis | Co-Occurring Disorders Treatment

It’s now understand that addiction is a chronic, often relapsing – but treatable – brain disease and that mental illness is a  treatable medical condition that changes a person’s thinking, feelings, and/or behavior [functions controlled by the brain] causing distress and difficulty in functioning. With these relatively new understandings, it’s now also understood that BOTH must be treated as primary diseases. Meaning – they both count equally and both must be treated concurrently in order to effectively treat the individual. In other words, in order to effectively treat and heal their brain.

It helps to think of this in terms of having breast cancer and diabetes. Medical professionals do not stop treating a person’s diabetes while they treat their breast cancer. Both diseases (cell changers) are viewed as primary diseases requiring concurrent treatment in order to return the individual to health.

THIS IS A BIG, BIG CHANGE and one not fully understood nor embraced in the addiction treatment community. Traditionally, co-occurring disorders were treated separately. It was believed you had to treat the addiction and then you could treat the mental illness. It was not understood how intertwined the two could be, nor how risk factors for one (childhood trauma, for example) often overlapped as risk factors for the other. According to NIH: National Institute on Drug Abuse, “Sometimes the mental problem occurs first. This can lead people to use alcohol or drugs that make them feel better temporarily. Sometimes the substance abuse occurs first. Over time, that can lead to emotional and mental problems.”  The National Alliance on Mental Illness (NAMI) explains the relationships between substance use and mental illness as follows:

• 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 “feel 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 illnesses. This can happen both during acute intoxication (e.g., a person with depression becomes suicidal in the context of drinking alcohol) and during withdrawal from a substance (e.g., a person with panic attacks experiences worsening symptoms during heroin withdrawal).

• 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 of his head and becomes paranoid that his chemistry professor is poisoning his food after smoking marijuana could represent a reaction to the drug (potentially called a “substance-induced psychosis”) or the first episode of psychosis for this individual.

Given these new understandings about the relationships between substance use and mental illness, it is now understood that effective dual diagnosis treatment requires BOTH be treated at the same time in the same setting. In other words, treated with an integrated approach by a treatment team that involves professionals (addiction specialists, mental health specialists, therapists, nutritionists, life skills professionals…) working together in the same setting with one medical chart recording all treatment protocols used. And why is this so important? Because without treating the mental illness, the individual will likely relapse in their addiction.

Dual Diagnosis | Co-Occurring Disorders – How Widespread Is It?

NIDA (the National Institute on Drug Abuse) For Teens shares these facts:

• As many as 6 in 10 people with a substance use disorder also suffer from a mental health condition such as depression, post-traumatic stress disorder, or bipolar disorder, to name a few.
• Fewer than 10% of adults with co-occurring disorders receive treatment for both conditions—and more than half of them receive no treatment at all.
• Teens also can suffer from co-occurring disorders.

Effective Dual Diagnosis | Co-Occurring Disorders Treatment

This is where it can be difficult. Many treatment centers state they treat co-occurring disorders, but the bigger question is, “How?” And the even bigger question is, “What is effective dual diagnosis treatment?” Please know this will likely feel way too complicated and overwhelming, so take your time. You don’t have to read nor fully understand this all at once. But if you or your loved one has been through several treatment efforts and still struggling with relapse, ruling a dual diagnosis out (or in) and then effectively treating both, if both exist, may just be what you or your loved one has needed all along.

Here are four next steps suggestions:

1.  Use a treatment facility locator, such as Chooper’s Guide, whose “Find Treatment Co-Occurring Disorders Treatment Program,” whose module only includes programs requesting inclusion on their site that have demonstrated compliance with either the DDCAT or DDMHT assessment protocols. SAMHSA’s (Substance Abuse and Mental Health Services Administration) also provides a Treatment Facility Locator, in which you will be able to include a selection criteria to search providers offering a mix of mental health and substance abuse treatment services.

2.  With your short list of providers as identified in step 1, you’ll next want to determine a treatment provider’s dual diagnosis treatment capabilities. To do this, you will want to ask, “Have you had a DDCAT [DDMHT] assessment and what were the results?” I know what you’re saying, now – “A WHAT?!?”

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 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.

3.  You will also want to be sure their treatment planning assessment tools identify the presence/ possible presence of co-occurring disorders and provide an effective treatment plan for the individual – not a one-size-fits-all plan they try to push all individuals through. To help you identify the additional elements of effective dual diagnosis treatment, I quote from the list of things to look for or ask that Anne M. Fletcher shares on pages 325-26 of her book, Inside Rehab (Viking 2013):

• Treatment that routinely addresses both disorders equivalently – in addition to recognized addiction treatment approaches and medications when appropriate, clients should receive specialized mental health interventions such as symptom management groups, individual therapies focused on specific mental disorders, and education about mental health disorders and how they interact with substance use disorders.

•  Multidisciplinary team involvement with professionals working in one setting who regularly discuss client progress and coordinate all aspects of treatment.

•  Treatments (in addition to medication) that focus directly on mental health problems such as depression, anxiety, and PTSD. Ask about qualifications of those delivering these treatments.

•  Collaboration of clinicians with the client (and often the family) to develop a treatment plan for both problems that’s tailored to the individual.

•  “Stagewise” treatment, recognizing that clients are at different points in their readiness to deal with their problems and that focusing on one problem over another is helpful at different stages of recovery.

•  An approach in which clients are not discharged if they stop taking their medications or continue to use substances.

• Comprehensive approach, taking into account social networks, employment, housing, and recreational activities.

•  Family education and support groups specifically for co-occurring disorders.

•  Continuity of care after treatment, recognizing both problems as primary, with plans for on-site or off-site follow-up and formal plans for indefinite management of mental health needs (ideally in the same facility).

Please recall, this is a list prepared by Anne M. Fletcher and shared in her new book, Inside Rehab. It is not her complete list – the rest can be found on pages 325-26 of her book.

Bottom Line

Yes, this is complicated, but remember – we’re healing a brain of two brain diseases (disorders) – two diseases / disorders that often influence one another and/or share common risk factors. Thus treating one as secondary to the other is a big mistake, a mistake that can confound addiction recovery and lead to relapse. So take your time reading through this.

And know – there are four key brain healers you can employ immediately, if you can, which will enhance effective dual diagnosis treatment because they are good for optimum brain health. They are: nutrition, aerobic exercise, sleep and mindfulness practices.

Lastly, though I’m not a doctor nor clinician, I’m always happy to answer questions or suggest further resources, so feel free to call 650-362-3026 or email at lisaf@BreakingTheCycles.com.

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Lisa Frederiksen

Author | Speaker | Consultant | Founder at BreakingTheCycles.com

Lisa Frederiksen is the author of hundreds of articles and 12 books, including her latest, "10th Anniversary Edition If You Loved Me, You'd Stop! What you really need to know when your loved one drinks too much,” and "Loved One In Treatment? Now What!” She is a national keynote speaker with over 30 years speaking experience, consultant and founder of BreakingTheCycles.com. Lisa has spent the last 19+ years studying and simplifying breakthrough research on the brain, substance use and other mental health disorders, secondhand drinking, toxic stress, trauma/ACEs and related topics.

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