Dual Diagnosis Therapy

A Comprehensive Guide to
Substance Abuse and Mental Illness

What is Dual Diagnosis?

When someone has a dual diagnosis, it means the person has a substance use disorder along with another mental health issue. Examples of dual diagnosis include:

Being dependent on alcohol and also having clinical depression

Abusing meth while also having bipolar disorder

Abusing an anti-anxiety drug (like Xanax) along with an eating disorder

For some, drug or alcohol abuse comes first, and then a mental health disorder develops. For others, mental health issues come first, and the substance abuse follows. In either case, when entering treatment, both disorders must be treated at the same time for a successful recovery. Let’s take a closer look at dual diagnosis.

Substance Use Disorder – Part One of a Dual Diagnosis

A substance use disorder (SUD), also known as an alcohol use disorder (AUD) or drug use disorder (DUD), is when:

There are strong cravings for the substance

Withdrawal occurs when the substance is scarce

A lack of control over using the substance

Experiencing negative consequences, personally or professionally due to substance use

Continued use of drugs or alcohol despite these signs can result in consequences. SUDs range in severity from mild to severe. People with SUDs can have a range of co-occurring mental health issues. This is usually the first part of a dual diagnosis identified in addiction treatment.

Dual Diagnosis by the Numbers

The National Survey on Drug Use and Health reported that, in 2018, more than 9 million Americans struggled with a substance use disorder and mental illness.1

The same study also looked at Americans with AMI (any mental illness), SMI (serious mental illness), and no mental illness and compared each group with any illicit drug use. The dual diagnosis study found that:

37%

Adult Americans with AMI
Used Illicit Drugs in the Past Year

50%

Adult Americans with SMI
Used Illicit Drugs in the Past Year

16%

Adult Americans with No Mental Illness
Used Illicit Drugs in the Past Year

31%

The dual diagnosis study also looked at alcohol use
and mental illness and reported:1

32%

Adult Americans with AMI Were
Binge Alcohol Drinkers in the Past Month

25%

Adult Americans with SMI Were
Binge Alcohol Drinkers in the Past Month

These statistics from the dual diagnosis study bear out that people with AMI or SMI are more likely to abuse drugs or alcohol. Of all people diagnosed as mentally ill, 29% abuse either drugs or alcohol.2 The type of mental health issues in a dual diagnosis can vary from person to person.

Common Dual Diagnosis Mental Health Issues

Anger

Anger is a primal emotion for humans. When someone is offended or experiences injustice or feels a need to protect something, anger can be quite useful. When anger is appropriately expressed, it can help reveal bothersome issues. After the issue is revealed, it opens the door to solutions and anger should fade.

The problem for some, is that anger is not expressed appropriately, or it does not fade. Long after the offense or injustice has occurred, anger lingers. Sometimes the incidents happened months or years ago, but the anger remains fresh. Any new issues can cause a quick, intense and overwhelming response. For some people, the anger never goes away and operates at low-levels, causing bitterness in daily life.

For people with a dual diagnosis involving anger, it can become especially hazardous. Many substances reduce inhibitions. This lack of control, coupled with quick anger, can lead to serious situations and consequences. Rehabilitation programs that have anger management programs can help those with anger problems manage behaviors while undergoing drug or alcohol treatment.

Anxiety in a Dual Diagnosis

Anxiety is a reaction that comes along with feeling nervous, tense, apprehensive, and fearful. The reaction is caused by a threat or danger that can be coming from the outside or within. It’s natural to experience anxiety at times. But for some people, an anxiety disorder develops. Anxiety disorders are terms used to describe different groups of symptoms of anxiety and panic attacks.

A commonly seen anxiety disorder is called Generalized Anxiety Disorder (GAD). People with GAD have high levels of anxiety, fear, or worry and might try to self-medicate. The worry or feeling anxious must occur most days of the week for a minimum of 6 months to be diagnosed with GAD. The focus of the worries may involve:

Physical health

Work

Social Interaction

Everyday common life situations

Fearfulness and anxiousness can lead to major problems socially at work and in school.

A panic attack is when a high level of discomfort or fear causes a sudden, serious physical reaction. Heart palpitations, trembling, sweating, hyperventilating, and tingling or numbness all can happen during a panic attack. Mental reactions can also occur, such as fear or fainting, feeling out of the body, fear of or feeling nauseous. Some people feel like fainting, dying, or losing control.

Obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are two more examples of anxiety disorders.

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is an anxiety disorder. There is a feeling of being plagued by repetitive unwanted and disturbing thoughts or images. These thoughts and images provoke anxious feelings. Some thoughts and images may involve thoughts of causing harm or being overcome by germs. It’s OCD if there is excessively worrying, along with performing repeated rituals and acts (compulsions) to relieve distress or stress. These compulsive acts happen so frequently; they are inconvenient and often harmful.

Repetitive hand washing, as well as checking and rechecking things are physical signs of OCD. Mental signs include silent counting and word repetition. Taken together, these OCD signs take up a lot of time and impair day-to-day functioning. The possibility of developing an addiction to drugs or alcohol to self-medicate in an attempt to control symptoms also increases the risk of a dual diagnosis

Trauma and Post-Traumatic Stress Disorder (PTSD)

People with SUD were found to be 1.6 times more likely to have PTSD.3 Post-traumatic stress disorder (PTSD) is a disorder that develops out of experiencing psychological trauma. Some examples of a trauma event can be the threat of death or injury or sexual assault. The person experiences helplessness, extreme fear, or deep shock when the event happens.

Afterward, if PTSD develops, the experience of living the trauma event happens again and again. Thoughts and images related to the event pop up frequently. Nightmares, reliving the event in dreams, and sometimes hallucinations occur.

People living with PTSD often deal with irritability, insomnia, a high level of vigilance, and an overdeveloped response when startled. People with PTSD will always try to avoid anything related to the event such as feelings, thoughts or acts associated with the trauma event. The possibility of developing a dual diagnosis with addiction to drugs or alcohol is increased by attempts to “medicate away” the thoughts or feelings.

Bipolar Disorder (BPD) in a Dual Diagnosis

People with SUD were found to be 1.8 times more likely to have a borderline personality disorder.3 A borderline personality disorder is a mental illness characterized by a repeated pattern of shifting moods, behaviors, and self-image. These patterns result in impulsive actions and relationship problems and increase the risk of a dual diagnosis. Borderline personality disorder signs include:

Intense episodes of anger

Depression

Anxiety

People with borderline personality disorder can also experience the following:

Initiating intimate relationships quickly to avoid abandonment

Dissolving a relationship in anticipation of being abandoned

Many unstable and intense relationships with family, friends, and loved ones

Relationships switch back and forth from loving to hateful

Unstable and distorted self-image

Impulsive and often dangerous behaviors, such as unsafe sex, reckless activities, overeating, and substance abuse

Impulse Control Disorder in a Dual Diagnosis

People with impulse control disorder have a hard time controlling their impulses. It’s difficult to overcome urges to harm themselves or others. Lacking impulse control often leads to drug use and a dual diagnosis. Examples of impulse control disorders include:

Eating disorders

Compulsive gambling

Stealing

Arson

Rage

Codependency

People dealing with codependency suffer from feelings of emptiness. They may also experience isolation, self-alienation, and shame. For many who suffer from a dual diagnosis with codependency and addiction, these issues can come from growing up in a dysfunctional family. Some then turn to drugs or alcohol and develop an addiction that provides temporary relief from feelings, but this only serves to distance long-term solutions further.

Depression in a Dual Diagnosis

People with SUD were found to be 1.3 times more likely to suffer a dual diagnosis with clinical depression.3 A CDC (Centers for Disease Control) survey that looked at the years 2009 to 2012 reported:

7.6% People in the US Aged 12 and Older Had Clinical Depression

The age group 40 to 59, as well as women, saw the highest rates of depression

Clinical depression is having moderate or severe depressive symptoms that last two weeks or more. Depression can trigger drug or alcohol use.

Signs of depression include:

Overwhelming sadness

Hopelessness

Numbness

Isolation

Sleeping problems

Digestive issues

Eating disorders

When people experience these depression symptoms, they may self-medicate for relief. Seeking relief from depression for extended periods can lead to addiction and a dual diagnosis.

On the other hand, when people take certain drugs or drink alcohol for long periods, the changes made in the brain and body from these substances can lead to the development of depression.

Grief

People experiencing grief can also develop an addiction and dual diagnosis. Different types of grief that can put a person at risk for drug or alcohol misuse include:

Frozen grief (grief on hold)

Partial grief (parts of grief are expressed, but the deeper parts are held back)

Survivor guilt (feeling bad about surviving an event where some else died)

Unfinished business (feeling bad about an issue that was not dealt with before someone died)

People who do not deal with grief in healthy ways can get “stuck.” This can play a big part in how these individuals behave. Behavioral addictions are common, include process addictions to food, drugs, alcohol and other addictive behaviors. To heal, treatment is needed to properly mourn sorrows and work through grief while treating substance use disorder.

Narcissistic Personality Disorder (NPD) in a Dual Diagnosis

It is estimated that 50% of people with narcissistic personality disorder(NPD) have a dual diagnosis with some type of addiction.5 Symptoms of NPD include:

An overinflated sense of self-importance

A preoccupation with boundless success

A belief that one is special and unique

The exploitation of other people

A lack of empathy

An arrogant attitude

Jealousy of others

These symptoms cause extreme distress in a person’s life, within their families, in their jobs, and in other areas of life. To relieve the uncomfortable distress that causes problems, people with NPD may drink or take drugs which can lead to addiction.

Dual Diagnosis Treatment Programs

Dual diagnosis treatment programs can either be outpatient or inpatient.

Outpatient Treatment for Dual Diagnosis

Outpatient treatment is any program where counseling sessions occur a few times (or more) a week while living at home. Sessions include:

Individual counseling

Group therapy meetings

Family therapy sessions

Outpatient treatment suits people who have a mild to low-moderate dual diagnosis. It’s a good choice for anyone who has less severe symptoms and needs time for work, school, or to meet family obligations.

Inpatient Treatment for Dual Diagnosis

Inpatient treatment is a program where there is an extended stay living in a rehab facility. Residential treatment can last from several weeks, a month, several months, or longer. Treatment involves one-on-one therapy sessions and group meetings.

Inpatient rehab is best suited to people with mild-moderate to severe symptoms of a dual diagnosis or anyone with a high risk of relapse. Inpatient rehab is a highly engaging, rigidly structured, and constantly monitored setting. Triggers and stressors are removed to help support healing, growth and recovery in a protected atmosphere.

Dual Diagnosis Therapies

There are different types of therapies that can help individuals with dual diagnosis recover. Since mental health disorders can both contribute to and result from drug or alcohol addiction, treatment plans typically use a variety of therapy approaches. The following are some of the most common and effective therapies.

CBT (Cognitive Behavioral Therapy)

CBT is one of the most commonly found therapies in dual diagnosis rehab programs. CBT focuses on helping individuals learn how their thoughts can affect feelings and behaviors. There is usually a limit to the number of CBT sessions needed. Goals are agreed upon between the therapist and client early on.

CBT uses a hands-on, practical approach to problem-solving. CBT works by changing people’s attitudes and behaviors by focusing on thoughts, images, beliefs, and attitudes (cognitive processes). The focus is on looking at how these processes relate to how a person behaves as a way of dealing with emotional issues.

DBT (Dialectical Behavioral Therapy) in Dual Diagnosis Treatment

DBT is a specialized form of CBT. DBT builds upon the foundation of CBT to help make CBT more effective. DBT focuses on how people interact with others in different settings and relationships. Some people tend to react more intensely and inappropriately in certain emotional situations. Mostly these out-of-the-ordinary reactions happen within family, friend, or romantic partner relationships. DBT works to bring down the intensity of the person’s reactions.

MAT (Medication Assisted Treatment)

Medication-assisted treatment is an evidence-based method that’s a combination of traditional therapies and the use of medication. Medication helps individuals manage cravings and relieves detoxification symptoms. MAT is especially useful for those with opioid or alcohol use disorders as part of their dual diagnosis program.

REBT (Rational Emotive Behavioral Therapy) in Dual Diagnosis Treatment

REBT takes a close look at beliefs and if those beliefs are logical or actual. Beliefs can be either positive or negative. A negative belief may be useful, but if it is false, it’s called an irrational belief.

Irrational beliefs can make the person unhappy and malcontent. Irrational beliefs can block love, approval, comfort, and success. During dual diagnosis treatment, REBT works to question irrational beliefs and uses a process to develop rational ones as replacements.

MI (Motivational Interviewing)

Motivational interviewing is a team effort between a therapist and client to bring about change and strengthen motivation. The therapist guides conversations with the client to help the person realize his or her own personal and genuine motivation for changing problem behaviors caused by their dual diagnosis. Motivational interviewing focuses on inspiring the client to create a plan for moving forward to reach his or her goals.

MI is not a standalone therapy but is one way of inspiring change for people who have a hard time changing. MI is a 4-step process that works to:

Define unique and personalized goals

Form a plan on how to move towards those goals

Support regular motivation for change

Give guidance on how to move forward to make those changes

MET (Motivational Enhancement Therapy) in Dual Diagnosis Treatment

Motivational Enhancement Therapy (MET) is meant to produce quick, internally motivated changes. MET is based on principles of Motivational Interviewing (MI).

The motivation for how the client is currently living is examined. Then, problem-solving and interpersonal skills are worked on. The therapist guides the person to see that there is a problem based on discovering the motivations behind how that person is currently living and the reasons behind the dual diagnosis.

Meditation & Yoga

An integrated rehab program will treat the whole person (holistic). That involves a physical, mental, emotional, and spiritual approach to recovery. A “whole person” program will have a blend of traditional therapies as well as alternative ones. Meditation and yoga are two popular and effective forms of alternative therapies.

Taking good care of one’s self means taking time to heal and grow. Meditation, or quiet time alone, is healthy and healing self-care. Just 10 minutes of meditation each day can help create positive changes.

Meditation is also a good tool for fighting relapse. It’s estimated that about 60% of people with SUDs relapse.6 Meditation can help a person form mindful responses to stresses and triggers to help avoid relapse. Yoga is a great way to incorporate mindfulness while improving physical health when recovering from a dual diagnosis.

Finding the Right Dual Diagnosis Treatment

Is an inpatient program right for you or a loved one? First, do some researches as you make a list of your unique requirements. Important factors you should consider are:

Program length (check the minimum stay requirements as well)

Ensure it is a dual diagnosis program

Location (away from home may be the better choice if somebody wants more isolation from familiar people and places while one recovers)

Costs and a budget that lays out what your insurance will cover and what your out-of-pocket might be

Gender segregated vs. coed setting

Any special needs such as pregnancy, ex-military veteran, serious trauma, sexual assault, or homelessness

Take the first step toward sobriety by reaching out. Talk with your doctor, mental health professional, or treatment center to see what options are best for you or someone you love. Getting sober is the first step towards gaining the healthy and renewed life you deserve.

Resources

  1. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf
  2. https://jamanetwork.com/journals/jama/article-abstract/383975
  3. https://www.ajmc.com/focus-of-the-week/nih-study-most-drug-disorders-among-single-poor-white-men
  4. https://www.ajmc.com/journals/supplement/2005/2005-06-vol11-n3suppl/jun05-2075ps80-s84?p=2
  5. https://pro.psychcentral.com/exhausted-woman/2015/06/the-addicted-narcissist/
  6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800788/

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