Dual Diagnosis:

The relationship between mental illness and substance abuse

Which develops first, the emotional issues or the substance abuse problem?

Often the psychiatric problem occurs first. In an attempt to feel better the individual self-medicates with alcohol or drugs which can lead to chemical dependency. In other cases, the alcohol or drug dependency is the primary condition which over time can lead to depression, anxiety and more severe emotional and mental problems. Regardless of the cause, the first step to living a more healthy life is to cleanse your system of the substances. Ideally, detoxification should take place under medical supervision and the process can last from a few days to more than a week, depending on what substances the person abused and for how long.

The difficulty in identifying dual diagnosis

Dual diagnosis can be difficult to identify because the symptoms of one disorder often mimic the symptoms of the other disorder. Many of the symptoms of drug abuse, such as extreme anxiety, depression, paranoia, delusions and hallucinations are similar to symptoms of mental illness. The impact that the symptoms have on a person’s life causing severe decline in self-care and functioning can also be a symptom of a psychiatric problem.

The families of people afflicted with a mental illness and the professionals who treat these cases can easily underestimate the severity of the person’s problem with drugs or alcohol for several reasons:

• Drug abusers can covertly use substances without their families knowing
• The behavioral signs of drug use look like the signs of a mental illness and it may be difficult to separate the two
• It takes time to unravel the interacting effects of substance abuse and mental illness

Treatment for dual diagnosis

People struggling with mental illness and chemical dependency have unique problems that need to be addressed simultaneously. Mental health services on the whole are not well prepared to deal with people who have both afflictions. Often only one of the two problems is identified. If both are recognized, the individual may bounce back and forth between services for mental illness and those for substance abuse, or one or both treatment facilities may refuse treatment, putting the person and their family between a rock and a hard place. Furthermore, fragmented and uncoordinated services create a service gap for persons with co-occurring disorders. Today more programs are being developed to treat both disorders together which is the optimal way to treat dual diagnosis. When a multiple team approach is used, chances for recovery improve instilling more hope and optimism for the families and those suffering from concurrent disorders.  

TYPES OF TREATMENT PROGRAMS FOR DUAL DIAGNOSIS
Inpatient treatment
Admission to this level of treatment for dual diagnosis requires an assessment. Usually an appointment is necessary and there are many centers available 24 hours a day. If you have a serious problem you can also go directly to an emergency room
Medical detoxification (detox)	Usually involves a 3-5 day stay for alcohol detox in a medically supervised treatment center. The program includes counseling, medications, and group sessions
Long-term residential programs	Usually involves a stay for a few months but it can last 12 months. These therapeutic communities are geared toward addicts and those with mental illnesses who have more severe problems and more than one relapse. There is an emphasis on group affiliation and counseling to prevent relapse
Dual diagnosis treatment centers	To be effective, dual diagnosis services are tailored to the individual and include different types of assistance that go beyond standard therapy or medication: assertive outreach, job and housing assistance, family counseling, even money and relationship management. A comprehensive program takes into account a number of life’s aspects including stress management and social networks. These programs view substance abuse as intertwined with mental illness, and therefore provide solutions to both illnesses at the same time
Outpatient programs
Partial hospitalization	This relapse prevention treatment program usually meets 3-5 days a week, 4-6 hours/day and is for people who require medical monitoring on an outpatient basis
Intensive Outpatient Program (IOP)	Usually meets 3 days a week, 2-4 hours/day. Insurance companies encourage attendance at IOPs. These relapse prevention treatment programs are scheduled around your work or school schedule
Intensive case management	A case manager is assigned to the individual to provide frequent weekly contact and phone calls to follow-up regarding their compliance with attending doctor’s appointments, medication management, and aftercare
Counseling (Individual, Group, Couple or Family Therapy)	Talk therapy offers an opportunity for emotional healing through exploration and education. Looking at your issues from a different perspective can help to identify the root causes of your drinking, and can be beneficial in helping you learn how to make more constructive choices in your life. Treatment is most effective when it occurs once a week. Sessions usually last 50 minutes. There are many types of therapy and each therapist is different. The therapeutic relationship is important. If you don’t feel comfortable with one therapist, try another until you find the right connection

Attention should be given to finding support groups for people with co-occuring disorders that can serve to reinforce important issues such as opportunities to socialize, having access to recreational activities, and developing peer relationships. Attendance in groups that deal with education and awareness of dual diagnosis issues, medication management, life skills, and improvement in activities of daily living is also helpful.

Why dual diagnosis is inherently resistant to treatment

Effective treatment depends on an integrated treatment approach

DRUG USE AND CHALLENGES TO TREATING DUAL DIAGNOSIS
Difficulty Developing Social Relationships	Environmental Factors	Relapse
Some people find themselves more easily accepted by groups whose social activity is based on drug use	As a consequence of their mental illness they may find themselves living in marginal neighborhoods where drugs are easily accessible	Drug use can increase relapse risk
An identity based on drug addiction/alcoholism is sometimes more acceptable than one based on mental illness	Drug use can interfere with the efficacy of prescribed medication and increase symptoms of a mental condition	Relapse then triggers feelings of failure and alienation
Peer pressure and a lack of healthy coping mechanisms  contributes to drug use	Drug use leads to housing difficulties as there is non-tolerance of drug use in the rehabilitation facilities	Drug use can lead to a loss of support systems, resulting in frequent relapses and hospital stays

Group support programs for alcohol and drug abuse

Alcoholics Anonymous

AA estimates that it serves more than 2,000,000 people worldwide in more than 114,000 groups. AA meetings are always free and are facilitated by fellow addicts, not health professionals or social workers. These participants have walked in your shoes and provide empathy and support to one another by sharing their stories and knowledge in applying the program principles. The only requirement for membership is a desire to stop drinking.

A list of the 12-steps is provided by 12-step.org. This approach helps you examine what effect your behavior has had on your life. Skipping ahead to Step 9, you’re asked to be willing to make amends to all persons you have harmed by your words or actions. When you get to this place in the process, remember to think about forgiving yourself which is an important part of your healing as well. 

The 12-step approach has a strong spiritual component in that the treatment recovery steps include admitting powerlessness over the addiction and surrendering to a “higher power,” which you can interpret according to your own beliefs. It’s a program that promotes total abstinence which is achieved one day at a time.

Other group support programs for dual diagnosis

Group support programs call upon the alcoholic to take responsibility for their own life, while fostering self-acceptance and self-esteem. Each type of program encourages the individual to understand the dangers involved in prolonged drinking and provides the support needed during the recovery process to maintain sobriety and prevent relapse. There are many different types of alcohol support groups available. Check the internet for groups in your area. Here are examples of what you will find:

SMART Recovery®

Self-Management and Recovery Training (SMART), a cognitive-behavioral intervention based on Rational Emotive Behavioral Therapy offers free online 90 minute meetings. Based on a four-point method that teaches self-empowering skills designed to help you become and stay motivated; cope with cravings; problem solve; and prevent relapse by achieving a balanced lifestyle

Secular Organizations for Sobriety/Save Our Selves (SOS)

SOS provides an alternative path for those who are uncomfortable with the spirituality of the 12-step programs. Check out their sobriety toolkit which includes: self-empowerment; achieving and maintaining sobriety through abstinence; avoiding people, places or things that are a danger to your sobriety; interrupting negative thoughts; taking action no matter how small it seems; and real time online chat meetings

Providing appropriate, integrated services for people with dual diagnosis can improve recovery and overall health, and restructure the effects their disorders have on their family, friends and society at large. By helping these people stay in treatment, finding housing and jobs, and developing better social skills, insight and judgment, there is the potential to reduce the prevalence of HIV/AIDS, domestic violence and violent crimes.

Related links for dual diagnosis and treatment

General resources

Dual Diagnosis and Integrated Treatment of Mental Illness and Substance Abuse Disorder - Fact sheet on dual diagnosis and treatment options. [National Alliance for the Mentally Ill (NAMI)] Dual Diagnosis in Adolescence – Fact sheet on dual diagnosis in adolescence (NAMI)

Dual Diagnosis – Offers information about treatment of dual diagnosis, and a searchable database of treatment services. [Mental Illness, Drug Addiction, and Alcoholism (MIDAA)]   

Treatment Information

Substance Abuse Treatment Facility Locator – Provides a searchable database of private and public facilities that are licensed, certified, or otherwise approved for inclusion by their state substance abuse agency. Listings provide specific information, including specialized programs such as dual diagnosis. SAMSHA also has referral helplines: 1-800-662-HELP, 1-800-662-9832 (Español), 1-800-228-0427 (TDD). [Substance Abuse and Mental Health Services Administration (SAMSHA)]

Dual Diagnosis Resource Center – Contains several articles of interest on dual-diagnosis including personal stories, crisis information, treatment, and gender-specific issues. (Dual Diagnosis Recovery Network)

Dual Recovery Anonymous – Independent, twelve-step, self-help organization for people that are chemically dependent and also affected by an emotional or psychiatric illness. Includes an outline of the twelve steps, personal stories and a discussion forum. [Dual Recovery Anonymous (DRA)] 

Helpguide thanks Steve Elam of Step Up on Second for his major contributions to this article. Step Up on Second helps individuals, housed or homeless, with severe and persistent mental illness including schizophrenia, bipolar disorder, and severe depression to develop opportunities to reintegrate into the community.

Deborah Cutter, Psy.D., Steve Elam, Jaelline Jaffe, Ph.D., and Jeanne Segal, Ph.D., contributed to this article. Last modified in March 08