The term dual diagnosis is used when a person suffers from both a drug or alcohol problem and co-occurring (aka “co-morbid”) emotional or psychiatric disorder. Mental illnesses that commonly co-occur with substance abuse include depression, anxiety and personality disorders. Dual diagnoses often present a chicken and egg question—were drugs and alcohol abused in order to medicate a pre-existing mental health issue, or did the drug or alcohol abuse lead to mental illness? While the answer to this question may inform the treatment plan, effective therapies address both issues simultaneously and as equally important.
In addition, a good treatment strategy addresses the fact that the co-occurring substance abuse and mental health issue(s) interact in a way that can create a compounded effect. This means that new issues are generated not as the direct outgrowth of either substance abuse or mental illness, but of their interaction with each other. This fact adds a high level of complexity to the treatment process for those serving patients with a dual diagnosis.
Many professionals believe that patients with a dual diagnosis require an integrated approach to treatment. This means that treatment is delivered by a single team of caregivers whose approach to treatment is philosophically congruent, intensely collaborative and well coordinated. As much as possible, substance abuse treatment and mental health treatment should be delivered seamlessly by a single team. This interdisciplinary team should include professionals with medical, psychiatric, substance-abuse, and mental-health expertise. Generally speaking, this level of treatment coordination is best delivered in a residential setting so that the entire milieu supports an integrated approach. Since denial and manipulation can operate powerfully in patients with dual diagnoses, an integrated approach is important for preventing counterproductive splitting and triangulation.
It is not uncommon for those with a dual diagnosis to be treated only for either substance abuse or for the co-occurring mental illness. When only the substance abuse is treated, the patient may be prone to relapse because of unresolved mental health issues which may have led to substance abuse in the first place. In the case of patients who are treated only for mental illness, undetected drug and alcohol issues may persist and progress after treatment, leading to a reemergence of mental illness symptoms. When withdrawing from substance use, some patients with dual diagnoses exhibit apparently psychotic behaviors normally associated with other mental illnesses, leading to misdiagnosis. These patients may be given treatments that are not appropriate or even harmful, and their underlying addiction may go untreated.
Since residential treatment is not sustainable for the long term, it represents only the first of a multi-stage process. Following an intensive, integrated program of intervention and treatment, patients with dual diagnoses need a program of aftercare that includes assistance building a self-managed program of community support. A multi-stage approach to treatment that includes aftercare and community-based resources is critical for preventing relapse and maintaining gains made in residential treatment. In addition, optimal care for patients with dual diagnoses includes family work at every stage of treatment. Since the family operates as a powerful system, it is typically either a vehicle for or obstacle to long-term recovery. For this reason, as much of the family system as possible should be involved in every stage of treatment in order to achieve and sustain success.