Treating All of You: Hybrid Psychotherapy When You Have a Dual Diagnosis

After being hospitalized, Michael*, 45, had successfully detoxed in five days, from his destructive drinking habit of three-plus bottles of wine a night. Feeling strong, he refused inpatient rehabilitation for addiction and returned home to his wife and three boys, ages 12, 10 and 9.

“I was in denial and found a psychotherapist who allowed me to stay in denial,” he said. “She was well-meaning but totally fed in to the fact that drinking was a symptom of my burned-out marriage and depression. She ignored the fact that addiction had its hold on my brain, body and soul.

I was self-medicating my shame about leading a double life. I felt helpless, hopeless, out of control again with alcohol…-Michael

“Within a month (after detox) I was back to moderating with two glasses of wine at night,” he said. “But within weeks, I had rekindled my affair with my lover…and wine. I was self-medicating my shame about leading a double life. I felt helpless, hopeless, out of control again with alcohol – and suicidal.”

Now, looking back after almost one year of sobriety combined with successful treatment of his depression, it’s hard to tell what came first with Michael. Was he self-medicating depression with lots of alcohol? Or had large daily doses of wine – a potent depressant – left him depressed and suicidal?

Michael needed treatment for all of his coexisting problems, his dual diagnosis. The National Institute of Mental Illness describes “dual diagnosis” as a “term used to describe people with mental illness who have coexisting problems with drugs and/or alcohol.”

“The first treatment with detox and the nice therapist was just not enough,” he said. “I now know that I should have listened to the professionals in the first (treatment center). I should have stayed and gotten treatment for both my mental illness and addiction.”

The circumstances leading up to a dual diagnosis are all too common. Many people with mental illness have ongoing substance abuse problems. And many who abuse substances experience mental illness.

The relationship between mental illness and addiction is complex so let’s break it down.

• Drugs and alcohol are used as forms of self-medication, especially in conditions of anxiety and depression. When anxiety or depression become unbearable, it’s considered socially acceptable to reach for a legal drug. Alcohol is an old faithful, but now marijuana is being sold as medicinal in many states, and is legal in Colorado and Washington. But these substances don’t treat the underlying illness. And without exception, if these substances are abused, they make the mood disorder worse.
• The chances of over self-medicating to the point of acute intoxication greatly increase the chance of suicidal thoughts and chance of an attempt. But also, during withdrawal from a toxic substance, depression can deepen and anxiety can escalate to panic attacks, exacerbating mood swings and desperation.
• Then there is psychosis. Drugs and alcohol, used for the first time, can cause a person even without a known mental health illness to suddenly become psychotic due to a drug reaction. Substance-induced psychosis is more common than we like to admit.

The good news is that, in the last 15 years, treatment professionals have come to realize that many people struggle with both conditions in tandem.

The National Survey on Drug Use and Health (2010) states that 45 percent of people with addiction have a co-occurring disorder such as mental health issues and medical complication. The bad news is that, of those, only 7.4 percent receive appropriate treatment.

Psychiatric health and treating addictions are all a part of a continuum.-Dr. Donna Brehm

Donna Brehm, M.D., has been practicing psychiatry in Wisconsin for more than 25 years. She remembers that, until 15 years ago, psychiatrists wouldn’t treat a mental illness until the patient had been sober for at least 30 days. She also remembers when recovery programs would shun a person who was taking medication to treat a mental illness.

“But segregating treatment is not very realistic, is it?” Brehm said knowingly. “Psychiatric health and treating addictions are all a part of a continuum.”

“Many people have no idea that, when they overuse substances, they are self-medicating a depression, anxiety disorder, bipolar disorder or some other mental illness,” she said. “But in most cases the alcohol, pot or whatever they can get their hands on, is fueling their mental illness.”

The terms “dual diagnosis” or “co-occurring disorder” are used when an addiction presents itself with a mental illness. The relationship between the two is complex. Recent scientific studies have suggested that nearly one-third of people with all mental illnesses and approximately one-half of people with severe mental illnesses (including bi-polar and schizophrenia) also are abusing substances. Conversely, more than one-third of all alcohol abusers, and more than one-half of all drug abusers are also battling mental illness.

To increase your chances of achieving a full recovery with dual diagnosis, your care should include:

• An all-encompassing treatment of your mental health diagnosis and substance use disorders by members of a highly trained team that are sensitive to the complexities of dual diagnosis treatment.
• A treatment team comprised of a medical doctor, preferably a board certified psychiatrist, who is experienced and has working knowledge of psychotherapeutic medications with the presence of addiction. Psychotherapists who are trained in addiction with specialties in systemic family therapy and cognitive behavioral therapy will treat your entire family.
• A supportive approach to treatment that reinforces self-esteem and builds self-confidence through psychotherapy, group treatment, psycho-educational training and healthy living. There is also new research that suggests that gender-specific treatment leads to more success, with retention.
• An inclusive systemic family treatment program that brings partners, spouses, children and other members into therapy for individual counseling, group meetings or education.

If all of this seems like a lot, you deserve the best possible treatment. After practicing psychotherapy for 25 years, I can tell you that the most valuable person on the treatment team is YOU. I firmly believe that bringing my patient smack dab into the team brings the best results.

After all, you are fighting for your life. You, and you alone, decide how compliant you will be with the various inpatient and outpatient treatments. Once you’ve admitted powerlessness and demand the best treatment, you are in the perfect position to save your own life.

*Name has been changed for patient confidentiality.