DUAL RECOVERY ADDICTION AND RELATED PERSONALITY/MENTAL HEALTH PROBLEMS

Terence T. Gorski

Many chemically dependent people are also suffering from coexisting personality and mental health disorders. These coexisting disorders are serious because if they are not properly treated they can lead to a relapse back into active addiction. The active addiction can then make the coexisting personality and mental health problems more severe. This makes it more difficlt for the person to get back into recovery.

People sufferring from addiction and coexisting disorders often have more serious problems that in an ideal world should require a longer period of treatment. Unfortunately, limitations in health care financing are forcing counselors and therapists to provide treatment to these complex patients in a shorter period of time at a lower level of care. As a result, most therapists have adopted brief, targeted, and strategic interventions for helping patients suffering from coexisting disorders.

• Brief means that a treatment episode must be completed in between twelve and twenty sessions.
• Targeted means that clinicians need to quickly identify both target disorders and the target treatment problem, that if resolved, will stabilize the target disorder.
• Strategic means that clinicians must develop concrete and specific interventions based upon cognitive and behavioral therapy principles for rapidly resolving the target problems and bringing the target disorder into stable remission.

To provide brief and strategic interventions, clinicians needs to quickly get their clients focused upon recovery. To do this, it is helpful to use the term dual recovery instead of dual disorders. The term dual disorders focuses clients upon what is wrong and invites them to identify themselves by a particular diagnostic classification. The term dual recovery focuses clients upon what they can do proactively to recover from both addiction and related personality and mental health disorders.

How Addiction Is Related To Coexisting Mental Health Problems

The first step in treating dual recovery clients is to determine how the addiction and mental health problems are related and what special needs the client will have during the recovery process related to each disorder.The addiction may be primary, secondary, or coexisting.

Primary addiction is a cluster of problems related to the use and abuse of alcohol and other drugs that are not directly caused by or related to personality or mental disorders. Primary substance use disorders may cause or complicate other mental disorders, but the coexisting mental disorder will spontaneously remit when the chemical dependency is treated. An example of this would be a client who develops a serious depression as a consequence of the physiological changes in the brain caused by chronic alcohol abuse coupled with the serious losses suffered as their alcoholism progressed. As the person gets sober and rebuilds his life, the depression will often spontaneously remit without being directly treated.

Secondary Addiction is a cluster of problems related to the use and abuse of alcohol and other drugs that are directly caused
by personality or mental disorders. The mental and personality disorders create pain and dysfunction. The person turns to alcohol or other drugs in an effort to medicate the pain and cope with
the dysfunction. This usually doesn’t work and the person begins abusing alcohol and other drugs but does not always become addicted to them. They are dependent upon the mood altering drugs to cope with the symptoms of their mental or personality disorder. As a result, the chemical dependency will spontaneously remit with the treatment of the mental disorder.

An example of this would be a schizophrenic who uses alcohol and drugs to try to manage his/her hallucinations. When he/she begins on antipsychotic medication, the hallucinations stop and the urge to use alcohol and drugs disappears. Another example would be a person with an antisocial personality disorder who uses alcohol and drugs to overcome internal deterrents and act out in destructive antisocial ways. As the personality disorder is treated and the person stops using antisocial behaviors, the need for alcohol and drugs to overcome internal deterrents diminishes and the alcohol abuse stops.

Even though the alcohol and drug abuse is secondary to the mental or personality disorder, most clinicians agree that all alcohol and drug use must be stopped in order for treatment to be effective. The person will be incapable of responding to treatment interventions as long as they are abusing alcohol or other drugs. They will be unable to maintain abstinence unless the primary mental and personality disorders are treated.

Coexisting Disorders are the most common in dual recovery clients. The term “coexisting disorder” means that both the addiction and the mental/personality disorders are independent and inter-related disorders. Both disorders require concurrent treatment because they are independent disorders. This means that treating one disorder will not cause spontaneous remission of the other disorder. An example of this would be the person who has sufferred from depression most of their lives and then began drinking and developed alcoholism. When they attempt to get sober without treating the depression, they become so impaired that they become suicidal and often start using addictively to manage the depression. When they attempt to treat the depression with medication and cognitive therapy while still drinking, the out-of-control symptoms of alcoholic drinking prevents them from feeling or functioning better.

Dual disorders are best conceptualized as coexisting disorders that are interrelated and require simultaneous treatment. It is generally not helpful in early treatment to try to determine which disorder is primary and which is secondary. It is better to recognize the substance abuse and work directly to get the patient abstinent. Once abstinent, the patient’s physical, psychological and social symptoms can be profiled, an accurate diagnosis of the type of chemical use disorder and related personality and mental disorders can be established, and a treatment plan to stabilize the symptoms of both disorders simultaneously can be developed.

As a general rule, clients must stop using alcohol and other drugs of abuse before any form of treatment can be effective. Chemical dependence is present in between 40% and 60% of all mental health clients. It is therefore recommended that all mental health clients be screened for substance abuse and dependence. Once diagnosed, the first goal is to get the patient abstinent from the use of alcohol and other drugs.

Clients with severe mental and personality disorders cannot recover from chemical dependency until they achieve a stable mental status. If someone is suicidal, depressed, psychotic, or experiencing such severe mood swings that they cannot function, treatment interventions for chemical dependency are condemned to fail. The severe debilitating symptoms are interfering with rational thought, emotional management, and behavioral self-control. In some cases, the stabilization of the mental and personality disorders may require the use of appropriately prescribed psychoactive medication. In chemically dependent clients however, the use of such medication should be done cautiously to avoid creating an unnecessary dependency or setting the stage for prescription drug abuse addiction.

As can be seen, the dual disorder client suffering from both chemical dependency and related mental and personality disorders will need to be simultaneously detoxified and psychiatrically stabilized.

Effective clinical systems integrate a biopsychosocial model
for diagnosis, a developmental model of recovery for treatment planning, and a relapse prevention therapy for identifying and managing the problems that lead to relapse.

Terence T. Gorski is the Founder and President of The CENAPS Corporation. He is an internationally recognized expert on substance abuse, mental health, violence, and crime. He is best known for his contributions to relapse prevention, managing chemically dependent offenders and developing community-based teams for managing the problems of alcohol, drugs, violence, and crime. He is a prolific author and has published numerous books and articles. www.terrygorski.com, www.relapse.org