A person struggling with a dual diagnosis, or co-occurring disorder will typically suffer from both a psychological condition such as depression, anxiety or schizophrenia alongside a substance misuse issue like alcoholism or drug addiction. A combination of any mental health condition and substance misuse qualifies as a dual-diagnosis.

Often it can be difficult to identify the relationship between the two disorders, as each one typically exacerbates the other, despite the usual intention of alleviating the symptoms of the psychological condition with the substance misuse.[1]  It can also be difficult to judge which condition predates the other; as each disorder will be extremely complex in isolation. An example of this could be a person smoking cannabis to alleviate symptoms of anxiety; initially the cannabis may help ease symptoms but after a dependency is formed, the impact on the central nervous system can cause a severe disintegrative effect, such as increased heart rate, paranoia and isolation.

It is common for people to attempt to self-medicate their condition, and others may be unaware that the symptoms they experience are a psychological disorder such as Post Traumatic Stress Disorder (PTSD). It is important that practitioners understand that this is an attempt to be self-sufficient and resourceful, rather than respond with exasperation or judgement. Furthermore, as extremely high numbers of people will experience a trauma of some sort in their lifetime, the prevalence of co-occurring disorders is high; and often people who seek help are unable to get appropriate treatment due to eligibility criteria some professionals work by. It is common for mental health professionals to reject clients with active addictions, as well as addiction centers refusing treatment for those who require psychotropic medication for their conditions, such as Bipolar Disorder or Schizophrenia.

The Epidemiologic Catchment Area Study by Regier et al found that co-occurring substance abuse in people who suffer from serious psychological conditions is between 30% and 60%. Furthermore, victims of violent or sexual abuse seeking help for alcohol or drug addiction is around 50%.[2] A Study by Pirad et al found that up to 75% of women in addiction treatment centers suffered from PTSD as a result of childhood sexual abuse.[3]

These research findings are strong indications that therapists must be aware of the complexity between dual diagnoses and feel equipped to treat such disorders; rather than the client being rejected or signposted from provider to provider. This risks the person feeling that they are stuck in their conditions, losing confidence in professionals and continuing their harmful self-medication.

It is vital that providers of care can coordinate and share information and best practice between them. This has historically proven to be difficult, and with limited resources and divisions in methods and philosophies of “what works”. However, if practitioners and providers are able to work in a client-centered format, it enables the client to engage positively with treatment, rather than it being a forceful or re-traumatizing experience.[4]

In this article, we will outline and discuss five important strategies practitioners should work with, in order to effectively and confidently treat clients with co-occurring disorders.

1. Create and deliver a positive therapeutic alliance to engage a client in treatment

People who suffer from co-occurring disorders are likely to feel misunderstood, dejected and hopeless due to the difficulty of navigating their situation and often not achieving the treatment objectives they desire, or have been advised are necessary to stabilize or treat their condition.

Therefore, it is vital, and necessary, to facilitate a safe, welcoming and positive space for the client. By doing this it will create a constructive, trusting relationship whereby real progress can be made. Petry and Bickel found in from their research on people with dual diagnoses that only 25% of those with severe psychiatric disorders achieved treatment goals when there was a poor ‘therapeutic alliance’, or therapist/client relationship, in comparison to 75% that had positive, strong therapeutic alliances. The research also found that often those that do not feel they have a good working relationship with their therapist do not finish treatment.

It is well known that people who suffer from substance misuse and a psychological condition can display some difficult behavioral traits that can make it particularly challenging to work with. However, without establishing trust, respect and positivity, these behavioral traits will likely be exacerbated as a means of protecting themselves from what they perceive to be an attack on their personality.

It benefits both the client and practitioner to make the therapeutic alliance a key part of the treatment; as Ziedonis and D’Avanzo state, ‘working with the dually diagnosed requires a primary focus on the therapeutic alliance.[5]’

2. Ensure a continued focus on recovery

There are two important parts which constitute maintaining a recovery perspective. The first, is to create a treatment plan that enables care to be continuous. The second is to formulate treatment plans specifically to the client’s needs, that focus on potential challenges at each stage of the recovery process.

Recovery looks different to different clients and care providers. This is poignant, as when dealing with a dual diagnosis, there may be conflicting perceptions of what recovery involves. For example, alcohol and drug treatment facilities tend to focus on the cessation of using drugs and alcohol; but what if the person is still suffering with a poor quality of life, unhealthy thought processes and behaviors? It is likely that abstinence will not last, and the client will not feel that they have achieved recovery.

In order to achieve recovery, a person suffering with dual diagnoses should work towards better health, a greater capacity for independent living, to take care of themselves (cooking, cleaning, personal hygiene, sleep patterns), improved confidence and self-esteem. To work by these indicators should, as a by-product, help reduce or cease substance misuse.

Furthermore, it is essential that practitioners have a comprehensive understanding of the stages of change, most popularly stated in Miller & Rollnick’s literature, such as ‘Motivational Interviewing’[6]. If a practitioner is able to accurately gauge what stage the client is in the primary stages of treatment, they can tailor their approach without risk of appearing confrontational or enabling. For example, if a client is not ready to fully address the extent of their issues, it would be far more beneficial to understand what is necessary to help guide them into the stage of acceptance, rather than begin creating goals that they might not feel they need.

By allowing the client to come to their own realizations and move through the stages of change at their pace, it is likely they will become more committed to the treatment plan, and feel more empowered and gain a higher self-esteem; an essential part of recovery. This theory is supported by the American Association of Community Psychiatrists (AACP). They state that ‘pessimistic attitudes about people with co-occurring disorders present major barriers to successful system change and to effective treatment interventions.[7]’

3. Deliver empathetic and supportive treatment

Similar to creating a therapeutic alliance; it is important to deliver treatment in an empathetic and understanding way. An empathetic style is defined by Ormont as the capacity to “experience another person’s feeling or attitude while still holding on to our own attitude and outlook”[8].

It is crucial for a practitioner to understand their own feelings in order to help another process theirs. It is very likely that subject matters discussed with those suffering from dual-diagnoses could evoke strong feelings in the therapist and client; so it is necessary for the practitioner to manage theirs appropriately, allowing the client to mirror this positive behavior so they can recognize, manage and process their own feelings. The result should be that the client learns to demonstrate empathy for others. As Miller and Rollnick succinctly states, empathy “requires sharp attention to each new client statement, and a continual generation of hypotheses as to the underlying meaning”.

Furthermore, Miller and Rollnick maintain the following key points that outline what is necessary to achieve empathy in oneself, and help develop in others[9]: 

• Communicate respect for and accept the feelings of clients
• Encourages a non-judgmental, collaborative relationship
• Allow yourself to be a supportive and knowledgeable practitioner
• Compliment and reinforces the client whenever possible
• Prioritize listening, over telling
• Gently persuade, and understand the decision to change lies solely with the client
• Provide support throughout the recovery process

It is understood that when treating substance abuse, there can be a conflict between empathy and enabling a person to continue in their denial, evasion, minimization and deceitfulness. However, it is possible to understand why behavior is taking place, while guiding the client to a more positive place by outlining and highlighting the positives of change; working with positive reinforcement rather than naked confrontation or agreement in behaviors that are detrimental to the client and to the recovery process.

4. Tailor treatment according to cultural differences

It is important that support and treatment for co-occurring disorders are accessible to all. The diversification of the United States requires care providers to ensure there are not further barriers than already exist for those suffering with dual-diagnoses.

Practitioners must ensure that they familiarize themselves with the cultural practices of their clients to prevent the possibility of letting stereotypical culture biases negatively impact on treatment plans. For example; asking too many questions, making assumptions of family dynamics, cultural practices or expectations around their role in the family can drive clients away, exacerbate feelings of isolation and misunderstanding and ultimately act as a hinderance to recovery[10].

5. Increase Structure and Support

It is understood that structure and routine are essential to those suffering with co-occurring disorders. Therefore, a practitioner should develop strategies with their clients as to how they will spend their free time. Too much time without an activity, hobby or responsibility increases the risk of boredom, loneliness and isolation; which are commonly cited triggers for substance misuse, self-harm and negative outlook on themselves and surroundings. Incorporating hobbies, especially exercise, can help elicit a ‘high’ without the use of illegal or harmful substances. Furthermore, it can be useful for the client to use spare time constructively, reflecting on their professional or intimate relationships, with the goal of improvement and development.

Practitioners can help a client manage their time effectively, creating a healthy balance of activities that help strengthen bonds between family, friends, colleagues and the possibility of moving away from negative people in their life that have contributed to their condition into new, positive relationships.

By incorporating these five elements into therapeutic practices with people who suffer from co-occurring disorders, it can be possible to help rid the practice of negativity, trepidation and judgement that can often be the cause of a lack of training and understanding.

Sources: 

1. https://americanaddictioncenters.org/co-occurring-disorders – accessed 26/12/2019

2. Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B.Z. Keith, S.J., Judd, L.L., & Goodwin, F.K. (1990). Co–morbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiological Catchment Area (ECA) study. JAMA, 264, 2511–2518

3. Pirard, S., Sharon, E., Kang, S.K., Angarita, G.A., Gastfriend, D.R. (2005). Prevalence of physical and sexual abuse among substance abuse patients and impact on treatment outcomes. Drug and Alcohol Depen, 4;78(1),57-64.

4. https://www.socialworktoday.com/archive/mayjune2007p18.shtml – accessed 26/12/2019

5. Ziedonis, D.M., and D’Avanzo, K. Schizophrenia and substance abuse. In: Kranzler, H.R., and Rounsaville, B.J., eds. Dual Diagnosis and Treatment: Substance Abuse and Comorbid Medical and Psychiatric Disorders. New York: Marcel Dekker, Inc., 1998

6. Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press, 1991

7. www​.comm.psych.pitt.edu/finds/dualdx​.html – accessed 26/12/2019

8. Ormont LR. Establishing transient identification in the group setting. Modern Psychoanalysis. 1999;24(2):143–156

9. Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press, 1991

10. https://www.ncbi.nlm.nih.gov/books/NBK64179/ – accessed 26/12/2019