Co-occurring Disorders Can Pose a Double Threat In Treatment

By Ben Brafman

Co-occurring Disorders

Dually diagnosed individuals suffer from coexisting independent disorders that require simultaneous integrated intervention to achieve the best outcomes. The general strategy is to blend recovery model notions with mental health ones. The term dual diagnosis is a general designation used to describe those individuals who suffer from co-occurring substance abuse/dependence as well as a psychotic, affective, behavioral, or severe personality disorder. People with these disorders often pose a “double” treatment challenge.

Common examples of dual disorders include the combinations of major depression with cocaine addiction, alcohol addiction with anxiety disorder, polydrug addiction with schizophrenia, and borderline personality disorder with episodic polydrug abuse. Dual disorder implies two things are wrong with someone but it is well researched that a dual diagnosed individual may have more than two disorders or multiple disorders.

The combination of alcohol or drug problems and psychiatric disorders vary along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild or one may be more severe than the other. Indeed, the severity of both disorders may change over time. Levels of disability and impairment in functioning may also vary. There is no single combination of dual disorders; in fact, there is great variability among them. However, individuals with similar combinations of dual disorder are often encountered in certain treatment settings. For instance, some drug treatment programs treat a high percentage of opiate-addicted individuals with personality disorders. Individuals with schizophrenia and alcohol addiction are frequently encountered in psychiatric hospitals, mental health centers, and programs that provide treatment to homeless individuals. Individuals with mental disorders have an increased risk for alcohol and drug disorder, and individuals with alcohol and drug disorders have an increased risk for mental disorders. In my experience, it seems that individuals with a primary alcohol and drug diagnosis have about a 90% chance of also having a co-occurring mental health disorder. In addition, those individuals with a primary mental health disorder have about a 60%-70% chance of a co-occurring alcohol or drug disorder.
Whatever percent¬age/category a dual-diagnosed individual falls into, they often experience more severe and chronic medical, social, and emotional problems because of the difficulty with having at least two disorders. Further, addiction relapse often leads to further psychiatric illness, and worsening of psychiatric problems often leads to addiction relapse. Therefore, relapse preven-tion must be specially designed for individuals with dual disorders. Compared with individuals who have a single disorder, individuals with dual disorder often need longer treatment, have more crises, and progress more slowly in treatment.

Recovery model notions are blended with mental health ones to achieve the best outcome.

Individuals with dual disorders often need longer treatment, have more crises, and progress more slowly in treatment.

According to studies funded by the National Institute on Mental Health, 10 million individuals are affected by dual disorder, 3 million individuals are affected by three disorders, and at least 1 million individuals are affected by four disorders each year. Associated with these statistics and the millions of people affected by dual disorder, the chronic relapser seems to be a population that needs more attention and care. A chronic relapser could be someone who has tried and failed many different types of substance abuse/mental health settings with varying degree of success. I have found that these types of dual diagnosed individuals utilize a high level of defense mechanisms to protect themselves from the pain of re-experiencing shame/guilt, abandonment, and loss/grief issues. The challenge is to help the individual shed their false self and allow their true selves to emerge. Keeping this in mind, professional treatment for the dual-diagnosed, chronic relapser especially in residential treatment goes beyond symptom reduction. True recovery looks at making changes for the person’s life. This may include personality traits that are a roadblock to a patient being successful, trauma-related issues, and family conflict. Because dual diagnosis individuals, especially chronic relapsers, show worse treatment adherence rates compared to those with one disorder, this issue needs to be considered and addressed early during the treatment plan phase. These individuals need to be pulled into treatment in a positive manner. Motivational enhancement and outreach efforts often help improve patients’ adherence and impact the outcome of treatment.

The treatment goal is always abstinence from drugs and alcohol. In many cases, however, related to outpatient environments the mentally ill patient is not “ready” or willing to commit to total abstinence when first admitted to treatment. In these cases empirical evidence indicates that these patients respond positively when early treatment goals are harm reduction while using motivational interviewing to increase the possibility of accepting abstinence as the preferred goal. It is also essential, especially early in treatment, to identify relapse behaviors leading up to using to change the negative outcome. Along with motivational enhancement, educational and persuasion groups appear effective with this difficult population.

In summary, the patient with co-occurring disorders presents a clinical challenge. They challenge treatment centers’ clinical skills, tolerance, and ability to truly individualize treatment to meet patients’ needs. However, when the clinical team is up to the task and provides good individualized therapy, explores and helps develop insight, and is motivated to action and commitment the difficult patient often commits to abstinence and successfully completes treatment.

Ben Brafman is Owner-President-Leader of Destination Hope Addiction Treatment, Sylvia Brafman Mental Health Center, The Academy for Addiction Professionals and Guardian Behavioral Health Foundation. Ben is a published author, motivational speaker and highly successful Entrepreneur in the Behavioral Health Industry. Ben can be reached at 954- 771 2091 or