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Dual Diagnosis
• In the 1970s it was thought that a minority of
clients suffered from both a mental illness and
an addiction
• Today, we know this is not true....
• Today we acknowledge that a majority of our
clients suffer from both a mental illness and an
Theories of DualDiagnosis
Self-medication theory: Substances are selectively used in
service of alleviating symptoms of mental illness (i.e. stimulant
abuse employed to counter the sedative effects of antipsychotic medications)
Alleviation of dysphoria: mental illness creates dysphoria
(feeling bad) and this dysphoria leads to drug use to mitigate
the experience of these unpleasant feelings
Multiple risk: In addition to the alleviation of bad-feelings, there
are additional risks such as: social isolation, poverty, lack of
daily structure, residing in areas with drug availability, history of
traumatic events
Theories Continued
Supersensitivity: individuals with severe mental illness
have biological/psychological vulnerabilities for substance
abuse caused by genetic and early environmental factors
that interact with life stressors
It is important to note that these theories might all be
present to varying degree’s in looking at the causal links
underlying a dual-diagnosis.
There are no definitive quantitative links correlating
mental illness/substance abuse apart from heavy
adolescent cannabis use and early onset schizophrenia
No Universal Agreed Upon
• Each disorder is intertwined with the other
• Each is able to influence the other (addiction magnifies)
• Chicken and Egg as far etiology
• Difficult to discern symptoms of one from psychiatric disorder
from the addictive disorder
• Many psychiatric symptoms omit once addiction is ceased or
after a period of abstinence
Stigma of the Dually
Likelihood that people with
mental illness will commit
violent acts
No greater than general
Why worry about it?
• Have worse treatment outcomes
• Higher health care outcomes
• Increased risk of violence, trauma,
suicide, child abuse, neglect, involvement
with justice system
• More prone to helplessness, depression,
greater trouble coping
Table 22.1 The Overlap Between Substance Use
and Disorders and Various Psychiatric Disorders
Lifetime psychiatric
Substance use disorder
Bipolar affective disorder
Anxiety disorder
Antisocial personality
Eating disorder
In Canada
(Skinner et al. 2004: Concurrent substances use and mental health disorders, 2009, [CAMH]).
• 30% of people in Canada with a mental
illness will have a substance abuse problem
in their lifetime
• 37% of people who abuse alcohol in their
lifetime will have a mental illness
• Meanwhile, 53% who abuse drugs in their
lifetime will have a mental illness.
Problems in Working with
Dual Diagnosis Clients
• Fractured support systems
• Slow progress
• Off and on meds
• Significant level of denial
• Seeming inability to trust
• Collude and transference / idealization / or devalue
• Feelings on meds
• Field as a whole and turf wars
Dual-Diagnosis “Treatment”
The term “treatment” is a real set up because it points toward
a terminal end-point goal with the dually diagnosed and this, in
my experience, is simply not realistic.
There are some “approaches” and/or philosophies that have
emerged in working with the dual-diagnosed that have varying
degrees of efficacy
These approaches fall under: Serial Treatment, which treats
one condition first followed by the other
“Treatment” Continued
Parallel: These intervention approaches focus on both
substance abuse and mental illness treatment at the same
Integrated: Treatments are delivered at the same time (like the
parallel approach) but are coordinated by the same staff
team members in the same treatment setting
Biological: This is the psychotropic medication arm of treatment
and can be effective toward managing symptoms of mental
illness which in turn can facilitate treatment of substance
“Treatment” Continued
Social and Psychological: This is a broad spectrum term used to
describe therapeutic techniques such as:
Motivational Interviewing: Engaging in supportive and directed
conversation about individuals behaviors and patterns that are
designed to increase intrinsic motivation to change
Cognitive Behavioral: weakening connections between life stressors
and reactive/habitual responses that are negative and destructive.
Self-Help Groups: This includes many 12-step groups that can instill
peer support and self-discipline
Lets get “Meta” Physical
It is interesting to note that the root of “addiction” essentially
means to transcend, to move beyond and to become joined
with something larger than one’s self
To often counselling omits exploring and challenging the
clients basic beliefs about who and what they are as well as
the nature of reality in light of political correctness
Dual Diagnosis presents a classical “double negative” that
wisdom traditions speak of . . . Failure of egoic identity and
failure of strategy to make that false premise work out
Continuum of Being
Self-Inquiry is the oldest practice of “psychology” known and
is designed to uproot the premise of a separate and isolated
From this “non-dual” perspective . . . The sense of self the
dual diagnosis client has is not suffering mental illness and
subsequent substance abuse because of some faulty trait or
characteristic it has . . .
Rather . . . The sense of self the dual diagnosis client has
suffers because of mistaken identity and is trying to
“medicate” this false premise
From “I” to what is aware of “I”
I like to use experiential exercises with the dually
diagnosed as it brings free attention to the narrative
of the drug/etoh abuse as well as the narrative of the
mental illness
You can’t simply “talk” about the suffering and selfmedication but must actively help dually diagnosed
client participate in their identity and experience of
Mental illness contains its own resolution/message
as does addiction.
Share my
experiences /Stories