An Exploration of the
Dual-Diagnosis Client
Shifting from “Treatment” to the Art of Self-Inquiry
An Historical Overview
What is Dual-Diagnosis and how common is it?
Definition
Prevalence
Theories of dual diagnosis
Factors associated with dual diagnosis
A Definition
Dr Burns: “I will tell you what dual diagnosis means . .
. It is a freaking nightmare to deal with, that’s what it
is!”
The term ‘dual-diagnosis’ and ‘co-morbidity’ are used
interchangeably to define an individual with a
combination psychiatric disorder and substance misuse
(e.g. depression and cannabis abuse)
There are sub-sets with in this definition that place
various points of emphasis on the mental disorder
causing the substance abuse and vise-versa.
Theories of Dual-Diagnosis
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
anti-psychotic 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, which seems to
have a strong evidence based link.
Some Key Factors
Studies in the UK and United States have indicated
that individuals with dual-diagnosis have a number of
difficulties and poorer outcomes including:
Increased severity of symptoms and relapse
More frequent inpatient hospital admissions
Higher treatment costs
Increased hostility and involvement with the legal
system
Key Factors Continued
Increase likelihood of suicide
Increased rate of homelessness and insecure housing
Increased risk of HIV infection
Family problems or intimate relationships
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 time
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
Specific approaches with in these 3 philosophies include:
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
misuse
“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 ego/”I”
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
being
Mental illness contains its own resolution/message as
does addiction.