A Look into the Treatment, 1
Running head: A LOOK INTO THE TREATMENT
Darin LaMar Baskin, M.A.
“A Look into the Treatment of Dual Diagnoses of
Comorbid Substance Use Disorder.”
A Review of the Literature
Capella University
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Since before the early 1900’s when psychology became a study of the mind and
human behavior there was substance abuse. Substance abuse dates back to the Biblical,
Roman and Chinese Dynasty eras. On any given day, at any fancy restaurant you can
order alcohol with your meal. An illegal drug seems to be readily available in our
culture, more so than medication that is prescribed. The treatment of clients with
comorbid diagnosis tends to be a challenge and often a frustrating endeavor. As the
prevalence of substance abuse has grown in the general populace, so has the problem of
treating clients with comorbid psychiatric illnesses and substance abuse. Dual diagnosed
individuals were identified and researcher recognized three issues. The co-occurrence
occurs in more than half of individuals with mental illnesses, having a dual diagnosis
exposes the individual to numerous other negative outcomes and being able to separate
the treatment of the mental illness from the substance abuse. Dually diagnosed clients
are costly and have proven to be among the most difficult to treat, and these clients have
a high rate of relapse.
The abuse of drugs and alcohol is common among individuals who have a
diagnosis of a serious psychological illness. According to the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision (2005) substance abuse is
defined as a disorder that related to the taking of a drug of abuse (including alcohol), to
the side effects of a medication, and to toxin exposure. The term substance can refer to a
drug of abuse, a medication, or a toxin. Substance abuse is said to be influenced by an
individual’s sex, culture, socioeconomic status and age. These factors were determined
as precursors for substance abuse in our society. Individuals use these substances to
mask recurring symptoms of a developing or current mental illness. Mueser, Bellack and
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Blanchard (1992) say “the most prominent hypothesis to account for the high rate of
substance abuse in psychiatric disorders is self-medication. According to this hypothesis
by Mueser, Bellack and Blanchard (1992), patients abuse alcohol and drugs to decrease
distress caused by major symptoms, particularly anxiety and depression” (pg 848).
Under the guise of a substance abuse the individual can have a major psychological
disorder that goes undiagnosed. “Alcohol and drug abuse-dependence have long been
recognized to interfere with the diagnosis and treatment of major psychiatric disorders
(Mueser, Bellack and Blanchard, 1992). Substance abuse hasn’t been linked to the
development of mental illnesses, just the symptom of an existing illness. The presence of
a psychological disorder with the occurrence of the individual having a substance abuse
diagnosis can affect the clients’ treatment. Mueser, Bellack and Blanchard (1992) states
“in the absence of such treatments, these patients are doomed to a poor quality of life,
housing instability, and repeated relapses and rehospitalizations, with society paying the
high economic costs of managing this erratic illness in the community” (pg 845). As
professional we must give special consideration to the psychological side of the
diagnosis.
Having a dual diagnosis creates several outside problems for the individual.
There are issues that may influence comorbid disorders and their treatment. Particular
concern has to be taken into account for the treatment of the dual diagnoses.
Management of dual illnesses can become very costly to the individual and create a
personal hardship. Dickey and Azeni (1996) proclaim that “to summarize our findings
briefly, we found that the costs of psychiatric treatment were substantially higher for
those who had a comorbid substance abuse diagnosis” (pg 976). This will create a new
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quandary for the psychotherapist to treat the mental illness. The cost of treating a
substance abuse disorder is much cheaper than treating a severe mental disorder. Dickey
and Azeni (1996) articulate that in their finding they found that the costs of psychiatric
treatment were substantially higher for those who had a comorbid substance abuse
diagnosis (pg 976). With the cost of psychological treatment clients are reluctant to enter
into therapy for a severe disorder. A second problem that exist for individuals with dual
diagnoses is the readily availability of illegal drugs and the less availability of medical
services. Dickey and Azeni (1996) says “individuals who are substance abusers tend to
congregate in large cities, where drugs are relatively easy to obtain but housing and
mental health services may be relatively less accessible” (pg 977). Most individuals who
are diagnosed with a mental illness rarely seek treatment on their own. If individuals do
seek treatment they are treated with distain and tend to not trust medial professional. A
third dilemma that individuals with dual diagnoses encounter is their quality of life.
Saatcioglu, Yapici and Cakmak (2008) say that “quality of life is recognized increasingly
as an important component in the evaluation of disease processes” (pg 83). With
substance abuse being classified as a psychological disorder it should be treated as a
quality of life issue. Saatcioglu, Yapici and Cakmak (2008) states that “comorbid
psychiatric diagnoses accompanying alcohol addiction, especially severe cases of anxiety
or depression, may have a negative impact on quality of life” (pg 83). It can be
hypothesized that quality of life issues are successful predictors or an individual’s
dependence on non-prescribed substances. Quality of life issues aren’t just the problem
of the diagnosed individual but also a problem developing for our society. Mueser,
Bellack and Blanchard (1992) states that they “would be remiss if we did not emphasize
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that substance abuse by schizophrenia patients is a societal problem, not simply a
problem for the mental health establishment” (pg 852). Individuals with comorbid issues
are likely to be homeless, jobless and socially isolated.
Once the individual’s cost constraints have been considered, the next step in
treatment should be to determine which of the dual disorders presents the most severe.
The psychotherapist has to distinguish between the primary and secondary disorders.
Which disorder do they treat first? According to Mulsow (2007) a disorder can be
“chronologically secondary, regardless of the nature of the relationships between the
primary and secondary disorders” (pg 128). A psychotherapist has to make a
determination which mental illness is the original disorder, which typically creates the
secondary disorder. According to McKay (2005) “the other point worth stressing here is
that effective, coordinated management of co-occurring disorders may not, in many
cases, require extended intensive treatment for both disorders” (pg 1,756). If the dual
disorders are ignored the individual may be placed in long term ancillary care for
substance abuse when they may have a primary mental illness that caused the self
medication, which requires the long term care. Mulsow (2007) believes that a primary
disorder must be ruled out before a substance-induced disorder can be diagnosed.
It is this writer belief that a successful treatment should include the participation
of the individual immediate family members or a supportive team. Having a strong
supportive team has proven to be a victorious tool in dealing with dual diagnoses.
Mulsow (2007) states that “the family needs to know that social support, which they may
be in the best position to provide to the person in treatment, is the most important
predictor of recovery from both alcohol and comorbid disorders (pg 127)”. A strong
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social support acts as a protective barrier around the individual. Active family member
may be able to assist the psychotherapist in determining whether the symptoms of the
comorbid disorder were causes by the substance abuse disorder. Family members should
also be aware of the fact that they also need support and adequate training to help deal
with the diagnoses of the individual. Mulsow (2007) discussed that “when the family is
engaged in the treatment process for comorbid alcohol and other disorders, one of the
greatest needs that most families have is for information about both the alcohol disorder
and the comorbid disorder as well as coping skills for dealing with these issues” (pg 127).
Familiar support can also assist in the individual following through with the treatment
that is set in place by the psychotherapist. Families should be involved with the treatment
plan when at all possible.
It can be hypothesized that a successful treatment plan for comorbid dual
diagnoses should include a medication regime, cognitive behavior therapy and treatment
for the substance abuse such as a group based program like Alcoholic Anonymous.
Hilarski and Wodarski (2001) states that “a review of the literature regarding the
treatment of comorbid substance abuse and psychiatric disorders reveals a mental health
model, an addiction recovery model, and an integrated model” (pg. 112). A
psychotherapist has to decide which model or treatment plan will work best for the
individual. No one plan works the same for any individual. Conrad and Steward (2005)
says “treatment usually involves medication management for the psychiatric disorder,
group-based programming for the SUD, psycho education and support, and routine drug
screening” (pg 263). One dilemma with having a mental illness is the need for
psychotropic medications which could affect the substance abuse disorder.
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Psychotherapist may be reluctant to use a psychotropic treatment for the risk of
individual misuse. Kendall (2004) states that “research indicates that psychotropic
medications are effective in the treatment of clients with dual disorders” (pg 184). A vast
preponderance of studies has shown that pharmacotherapy is presenting promise with the
management of dual diagnoses. San, Arranz and Raga (2007) research concluded that the
use of conventional antipsychotics has remained limited; the majority of studies suggest
the effectiveness of second-generation antipsychotics, particularly clozapine, for patients
with schizophrenia and a comorbid substance use disorder. Many individuals lack the
motivation or the will to maintain a constant medication regiment. Mueser, Bellack and
Blanchard (1992) believe that “an adequate medication regime must be determined, and
the patient must be taught the value of compliance” (pg 852). After clients are motivated,
they seem to acquire the necessary skills and become effective in their treatment.
Cognitive behavior therapy is a successful therapy technique used for
psychological disorders. CBT hasn’t shown much effectiveness in treating SUD.
Researchers believe that CBT doesn’t focus on the SUD treatment but solely on the
mental disorder. Conrad and Steward (2005) believes that the “CBT approaches have not
been shown to be any more effective than traditional 12-Step approaches in helping
dually diagnosed clients achieve abstinence, maintain abstinence, or reduce their
psychiatric and psychosocial disturbance” (pg 264). CBT has been proven to being
helpful with the individual understanding that they have a problem and on becoming
motivated with finding an intervention program. According to Kendall (2004)
“cognitive-behavioral therapy (CBT), supportive therapy, and counseling provide the
client with hope and assist the client to gain insight into the illnesses, substances of
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abuse, needed medications, treatment, and goals” (pg 184). CBT gives special
consideration to the psychiatric aspect of the diagnosis. Group based programs have had
proven success in treating SUD but not CBT. Substance abuse programs work from the
premise that the individual has a problem and they can admit their problem which will
allow the individual to overcome the abuse. According to Mueser, Bellack and
Blanchard (1992) who believes that Alcoholic Anonymous groups “use confrontation as
a therapeutic tool (i.e., to get the patient to realize the consequences of abuse and accept
himself or herself as an addict), and they emphasize the need for self-control and personal
responsibility” (pg 851). This type of program also requires its participants to practice
abstinence as a precondition to joining the program and this includes prescribed
medications. Current research is focused on the 12-step program which is used by
Alcoholics Anonymous groups. Mueser, Bellack and Blanchard (1992) say “the majority
of addictions programs are based on the 12-step approach characteristics of Alcoholics
Anonymous: (pg 851). This may be a successful approach to clients who have just a
SUD but not for dual diagnosed individuals.
Treatment of comorbid diagnoses will also differ as it relates to the psychological
disorder for which it is associated with. Certain disorders are more associated with SUD
than others. Conrad and Steward (2005) says that “while SUDs are often comorbid with
various anxiety disorders, including social phobia (SP), posttraumatic stress disorder
(PTSD), panic disorder, and generalized anxiety disorder, to our knowledge, only SP and
PTSD have been investigated for efficacy of dual-focused treatments” (pg 264). The
treatment plan for the combination of dual disorders changes as it relates to a specific
disorder. Conrad and Steward (2005) states that “there was also some indication that
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CBT treatments for personality disorders may also provide an alternative to behavior
therapies, which appear limited in their ability to target multiple symptoms and
behaviors” (pg 279). Of the disorders that are covered in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision (2005), schizophrenia is the
disorder that is prevalent in its association with SUD. Research conducted by San,
Arranz and Raga (2007) says “this high prevalence of substance abuse in patients with
schizophrenia has sometimes been explained as a form of ‘self-medication’, with patients
using substances to alleviate negative symptoms” (pg 231). Given the common cooccurrence between schizophrenia and SUD, clinicians must be accurate in their ability to
diagnosis the dual illnesses and be proficient in identifying a treatment plan.
In conclusion, this writer hypotheses that having a strong social support with an
integrated therapy program, which includes CBT and psychotropic medication has a
lasting impact on dually diagnosed individuals. There must be a careful assessment done
on the individual before a diagnosis can be given. For comorbid disorders, concurrent
treatment plans have proven to be the most successful treatment. Dually diagnosed
individuals don’t move towards treatment in a linear motion. This issue is beginning to
become an urgent challenge and more should be done to solve this social issue.
Diagnosing an individual with dual illnesses is essential to help the individual to achieve
a healthy mental outcome. The mental health community is quiet capable of developing
an effectual treatment program for the dually diagnosed individuals.
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Reference
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