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The Evolution of Dual Diagnosis Treatment (And How it Affects Your Recovery)

This is a guest post from Joe Koelzer, co-founder, and CEO of The Clearing, a 12 Step Alternative residential addiction treatment program especially for individuals with dual diagnoses. He has years of counseling experience and a master’s degree in Spiritual Psychology from the University of Santa Monica. In co-founding The Clearing, Joe realizes his dream of creating and sharing the innovative Spiritual Psychology approach with others in a structured clinical setting.

“Dual diagnosis treatment” is a new catchphrase in the recovery industry; if you’ve been doing your research, you’ll see it everywhere from academic studies to rehab websites. But why is dual diagnosis treatment important for you and your recovery journey?

Dual Diagnosis

Simply put, dual diagnosis is the term for a substance addiction coupled with a mental health concern. For example, if you are addicted to prescription painkillers and you’re also dealing with depression and anxiety, then you have a dual diagnosis.

This post will provide an overview of the history of dual diagnosis treatment in the United States, and a discussion of how the evolution of dual diagnosis treatment impacts your recovery today.

As you learn more about what works, what doesn’t and why, you’ll be empowered to make well-informed decisions about your own treatment plan.

The Prevalence of Dual Diagnosis

Until recently, many people believed that there was little overlap between addiction and mental health conditions. Dual diagnosis was seen as fairly unusual. However, statistics show that dual diagnosis is actually the norm for people dealing with addiction. Today, we know that most people who abuse substances have a concurrent mental health condition.

Though some people do have purely physical addictions, most are coping with physical addictions that came into being as a result of mental and emotional drivers.

According to the National Alliance on Mental Illness (NAMI) website’s Mental Health by the Numbers page:

“Among the 20.2 million adults in the U.S. who experienced a substance use disorder, 50.5%—10.2 million adults—had a co-occurring mental illness.”

Many in the recovery industry believe that those numbers are much higher, but even so, this is an astonishing statistic. Likewise, the 2011 National Survey on Drug Use and Health found that:

“Among the 18.9 million adults with a past year substance use disorder, 42.3 percent (8.0 million adults) had a co-occurring mental illness in 2011.”

Clearly, there is a strong connection between substance abuse and mental health. Yet if mental health concerns impact at least half of individuals with addictions, then why isn’t dual diagnosis treatment standard in the recovery industry? In order to answer that question, we need to look at past approaches to addiction treatment and see how these traditions persist in present-day rehabs.

One Past Approach: Sequential Treatment

Integrated dual diagnosis treatment is very much a modern development. In times past, the preferred approach to addiction treatment was called “sequential treatment”.

The theory behind sequential treatment was that addiction treatment and mental health treatment should be separate. Recovery professionals thought that individuals needed to stabilize one aspect of their lives before addressing another. In many cases, individuals were required to undergo treatment for their substance abuse issues before they’d be eligible to receive mental health treatments. The results of sequential treatment proved poor over time. As the article Dual Diagnosis Treatment states:

“‘Sequential treatment’ was the norm before the 1990s … Clients with a Dual Diagnosis were excluded from one area of treatment until they were considered stable in the other … [Yet] research showed that [sequential treatment] led to a higher rate of relapse.”

Another Past Approach: Parallel Treatment

When a growing body of evidence suggested a correlation between mental health issues and addiction, a protocol known as “parallel treatment” came into being.

In parallel treatment, an individual receives professional services for both addiction issues and mental health concerns concurrently. Nevertheless, the division between addiction and mental health treatment persists in that the support teams operate independently. The individual’s doctors and therapists rarely communicate with one another.

As such, there’s a lack of continuity and cohesiveness to the treatment approach. It can even be counterproductive. For example, if a psychiatrist prescribes a medication and doesn’t consult with the individual’s therapist, the individual may experience side effects that affect their ability to progress in therapy.

The Results of Sequential and Parallel Treatment

Research shows that both sequential and parallel treatment yield sub-par results. Unfortunately, they’re also prevalent in modern rehabs.

True, many people with dual diagnosis do receive some mental health treatment from psychiatrists and therapists. However, often their concurrent “addiction treatment” approach simply involves attending Alcoholics Anonymous (AA) or a similar 12 Step meeting.

Though 12 Step groups have helped millions to recover, their overall success rates are not strong. In fact, in a 2014 Radio Boston interview Harvard researcher Dr. Lance Dodes cited the AA success rate as 5-10%. Furthermore, AA and similar groups were not designed to provide dual diagnosis treatment; rather, they are nonprofessional groups that offer mutual aid and fellowship to people dealing with addiction.

As’s article Mental Health and Addiction Treatment Systems notes:

“While self-help programs [such as AA] are not considered treatment … they are integral adjuncts to professional treatment services.”

In other words, while you can find support and camaraderie at an AA meeting, you won’t find professional addiction treatment.

A Modern Approach: Integrative Treatment

Sequential and parallel treatment approaches have left millions of people frustrated and discouraged. Increasingly, individuals with dual diagnosis – that is, most people dealing with addiction! – are seeking out more integrative approaches.

What does integrated treatment look like? The Centre for Addiction and Mental Health’s What Should Happen: Integrated Treatment page describes it this way:

“Integrated treatment means that treatment for substance use and mental health problems are combined and ideally provided in the same treatment setting by the same clinicians and support workers, or same team of clinicians and support workers. This ensures that a client receives a consistent explanation of substance use and mental health problems and a coherent treatment plan.”

In other words, an individual needs to receive addiction and mental health services concurrently, from the same support team if possible. This kind of holistic treatment offers the best opportunity for healing on all levels.

Integrative Dual Diagnosis Treatment

Many recovery programs are focused on helping participants to avoid drugs and alcohol. They emphasize coping skills and teach people how to not drink or use substances through behavior modification approaches.

Behavior modification certainly has its place, but effective addiction treatment goes beyond that. Ideally, it zeroes in on underlying core mental health issues. In truly integrative treatment, individuals process their buried anger, grief, and traumatic experiences.

Why? Because those core issues are the very things that are creating the intense negative emotions that lead people to reach for addictive substances in the first place! If a person doesn’t have those intense negative emotions arising from within, then they will not need to reach out for those substances to mitigate their feelings.

As I noted in a recent interview on Healing Underlying Core Issues:

“We unravel [the addiction] by working with the mental health issue. Let’s work with the depression, the anxiety, the self-loathing and hopelessness … [Let’s teach] the counseling skills and strategies and the concepts that each person needs so that they can … hold that stuff differently in their consciousness and not have the negativity anymore.”

Looking back over the history of dual diagnosis treatment, it becomes clear: It’s time to stop doing what doesn’t work. It’s time to take an integrative approach to healing.

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