The words “dual diagnosis” have been jostled around the treatment/recovery field since the 1980s. It is a concept that has steadily ballooned in popularity, but I am unsure how many people in the community really understand what it means and the clinical implications it may have on treatment.
My exposure to patients struggling with substance abuse began in my early graduate school years. I myself didn’t truly understand what dual diagnosis was all about other than they were catchy buzz words families liked to hear when searching for help for their loved ones. Over the years and working with countless clients with addiction, it became apparent that working with dual diagnosis could be a daunting endeavor but at the same time a rewarding experience.
Define Dual Diagnosis
But before moving any further, let us first define what is meant by dual diagnosis. According to the National Alliance on Mental Illness (NAMI), “dual diagnosis is a term for when someone experiences a mental illness and a substance abuse problem simultaneously.” NAMI also states that one third of people struggling with mental illness and half of people challenged with severe mental illness also experience some type of substance abuse problem.
Kindly note, the following discussion will specifically encompass my personal take on the dysfunctional relationship between substance abuse and mental health. With regard to mental health, I will predominantly speak to how unresolved traumas either bring about the onset of a mental illness (e.g., depression, anxiety, PTSD) or exacerbate an already existing psychiatric condition and how substances are maladaptively used to cope with these traumas.
Initial Research
My first encounter with the term dual diagnosis came about after thumbing through a Biopsychosocial book while waiting for the next class to start, because that is what green, first year graduate students do—inhale every ounce of information they can get their antsy hands on, for the fear they might not know “everything” they need to for the exam. I was so captured about the new concept while voraciously flipping through the pages that even Liberace would have been impressed by my fluid finger speed. It was an intriguing concept that stirred my thinking. From that moment on, the question that constantly plagued me in clinical supervision was, “what came first?” Does a person have a substance abuse problem because of his/her mental illness, or is the person’s mental illness a byproduct of his/her substance abuse? After numerous headaches trying to solve what to me seemed like an unsolvable question, I soon realized that it was not worth the effort trying to figure out what came knocking first but rather it was more important to figure out a way to treat both. A light bulb soon went off and I surmised that my endeavors were better suited to understand the working mechanics between the two. In other words, how does mental illness and substance abuse fuel one another in their symbiotic yet dysfunctional marriage?
If I may, for a second, stand on my soapbox, I would like to discuss a misconception about dual diagnosis treatment. From a clinician’s standpoint, the implication is that if a patient is rendered a dual diagnosis, it means that he/she meets the diagnostic criteria for two separate diagnoses. That then begs the question: If a person does not meet all of the necessary criteria for two diagnoses, does that negate a dual diagnosis treatment approach? To illustrate one aspect of my concern, a statement that has never made sense to me is when a patient is referred to as solely chemical dependent (“CD”). A therapist may then conclude that his/her approach will need to strictly focus on the CD, since the patient is not officially diagnosed with a mental illness. That assumption baffles me because I believe that a person who has reached a point of chronic or uncontrollable substance abuse most likely struggles with some aspect of mental health like excessive worry, low self-esteem, fearfulness, etc. though on paper he/she is not assigned a dual diagnosis. Hopefully, my treatment recommendations below will justify the need for a dual diagnosis approach whenever someone presents with substance dependence and whether or not they concurrently meet the diagnostic criteria for a mental illness. I’m getting back off my soapbox and onto the article.
Real Life Story
My unrelenting search for an answer crystallized when working with a particular patient during my training, who I will refer to as Tammy to protect confidentiality. She was in her late teens and dabbled in marijuana and alcohol and was previously diagnosed with depression and generalized anxiety disorder. Tammy was attending a university in which a large segment of the student population helped foster a social, “party hard” culture. On the outside, Tammy presented as your above average college student with lots of friends and an active social life. She smoked and drank at parties. But as the semester went on, her partying transitioned to a weekday norm. She would drink the majority of the week and would black out when her partying reached an excess on the weekends. An even more constant was her marijuana use, which occurred daily and in increasing amounts. Tammy would attend class high, go to work high, go to family functions high. Heck, she may have even come to my sessions high, and I would not have known it given the novice radar I was relying on in my early graduate training. Alcohol and marijuana became a new normal way of life for Tammy.
I knew that her use went far beyond social partying, as she began drinking and smoking alone in the privacy of her own room. My Sherlock Holmes “wannabe” skills then throttled into hyper drive and I began my investigation. I decided to delve more into her history and find out what was behind the driving force that was “numbing” her on a daily basis. As my persistent inquisition revealed, Tammy had been repeatedly molested by a family member growing up and sexually assaulted as a teenager by a friend of the family. Having never told anyone and suppressing her dark secrets, she engaged in numerous sexual relationships with males to evade her shame and guilt. Romantic relationships were more for mere companionship, validation, and safety rather than a meaningful union. This merry-go-round pattern had been her Modus Operandi for the past 5 years. When she was introduced to alcohol and marijuana in her senior year of high school, it was like a shot of relief from her disturbing memories. It was as if these elements served as a sound dial to quiet all the chaotic noise in her head. Marijuana and alcohol were the easier means to compartmentalize her traumas when nothing else seemed to work.
It all began to make sense to me. After working with Tammy and subsequent patients challenged with dual diagnosis, my perspective to this day still holds that chronic and/or uncontrolled substance use is more often than not a coping skill masking deeper core underlying issues. It’s as if taking a mind altering substance can “turn down the volume” on the tragic experiences one has endured.
The Clinical Approach for Dual Diagnosis
That is where dual diagnosis treatment seems to fit in with my clinical approach. I definitely support the use of treatment interventions that focus on the substance dependence side of dual diagnosis such as understanding the disease of addiction, dealing with substance cravings, strengthening relapse prevention, etc. But there is another side to the fight—the mental illness side vis-`a-vis traumas. Patients can overconfidently feel in the clear once they believe they have acquired all of the tools necessary to not pick up a drink, take a pill, or light up a joint. However, if a person is unable to accept that his/her traumatic experiences are a part of who they are (but not a definition of who they are) and not some separate entity that they can cut out of his/her life, he/she will eventually run out of alternative coping skills and resort back to the default substances that have historically been able to hush the memories.
Furthermore, relentless pushing of a patient to veer far away from his/her drug of choice is not my major goal in dual diagnosis treatment. Rather I am more focused on the factors that will eventually get him/her back to that bad place such as low self-worth, chronic isolation, or unrelenting resentment as a result of trauma. Once that person enters that vulnerable place, the sand timer will commence and he/she will most inevitably be greeted by their drug of choice in a finite matter of time. For instance, a female patient can leave treatment with all the coping skills essential to not relapsing on heroin, but if she has not begun to work through the acceptance of her mother’s suicide when she was a child (the impetus of her major depression and fear of abandonment), she will sooner or later find her way back to that lonely abyss filled with drug use and will most likely be reunited with heroin again.
Time and time again, I have worked with countless patients who have resorted to substance use as a way to calm their internal storm. As clinicians, it is sometimes easier to identify the more obvious traumas such as sexual abuse, sudden death of a loved one, tragic accident, near death experience, etc. However, these more intensive experiences can overshadow less obvious ones such as a divorce years past, loss of a job, and an estranged relationship with a son/daughter which all can wreak emotional havoc for a person leading to substance abuse as a way to cope. Therefore, attending closely to one’s story is essential in identifying his/her’s significant traumas.
I am not saying that these past traumas can or should be resolved in intensive dual diagnosis treatment, for these issues may necessitate a longer timeframe to process through. What I am saying is that beginning to address these issues in treatment can give a patient permission to talk about these experiences in a safe and validating environment, lay the groundwork for facing these issues head-on without turning to numbing substances, and begin the process of acceptance.
What I’ve Learned
Through my work with Tammy and many others who presented with dual diagnosis, I have learned that an important aspect of my treatment is to take a two-prong approach. It is essential to address the addiction side of one’s disease, but it is equally important to help them work towards integration and acceptance of the traumatic issues that perpetuate their cycle of abuse. One can never forget their experiences, nor should they ever have to. That is an unhealthy and impossible undertaking. But what they can do is begin talking about it. My belief is the more we engage in dialogue about one’s traumas in therapy, the emotional intensity attached to those traumas will gradually wane.
I never did hear again from Tammy after completing my training. But I sure hope I helped lay the foundation for her to start working through her issues. I also wonder if she realizes the profound impact that her willingness to share her narrative had on the insight I still draw upon today when helping others struggling with dual diagnosis.
Brian F. Licuanan, PhD, MS