Dual Diagnoses
Principles of the Minkoff model
for treating co-occurring mental
health & substance use disorders
1
1. “Dual diagnoses are an expectation,
not an exception”

According to epidemiological
studies, approximately 50%
of people with a diagnosis of
severe mental illness also
meet lifetime criteria for a
diagnosis of substance use
disorder. (Drake, 1995)
2
Prevalence of substance use
disorders with mental illness
60
50
40
% of
respondents
30
with substance
use disorder 20
10
0
Gen pop
Schiz
Bipolar Maj dep
Regier et al, JAMA 1990
OCD
Panic
“Dual diagnoses are an expectation,
not an exception”

According to the National
Comorbidity Study,
people with mania are
9.7 times as likely as the
general population to
meet the lifetime criteria
for alcohol dependence.
(Kessler et al, 1996)
4
% of respondents
Prevalence of Co-Occurring Substance
Use Disorders with Schizophrenia (ECA Study)
100
90
80
70
60
50
40
30
20
10
0
Schizophrenia
General Population
Alcohol Use
Disorder
Regier et al., JAMA, 1990
Drug Use
Disorder
Alcohol or
Drug Use
Disorder
5
“Dual diagnoses are an expectation,
not an exception”

In community studies evaluated for the
Epidemiologic Catchment Area (ECA)
study, 33.7% of people diagnosed with
schizophrenia or schizophreniform
disorder and 42.6% of people with bipolar
disorder also met the lifetime criteria for
an alcohol use disorder (AUD) diagnosis,
compared with 16.7% of people in the
general population. (Regier et al, 1990)
6
2. “Use the Four-Quadrant model to
understand & inform effective
treatment”
HIGH PSYCHIATRIC
LOW PSYCHIATRIC
(SPMI)
(psychiatrically complicated)
HIGH SUBSTANCE
HIGH SUBSTANCE
(Dependence)
IV III
(Dependence)
HIGH PSYCHIATRIC
LOW PSYCHIATRIC
(SPMI)
(mild psychopathology)
LOW SUBSTANCE
LOW SUBSTANCE
(Abuse)
II
I
(Abuse)
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3. “Emphasize the empathic, hopeful,
integrated aspects of the treatment
relationship”


The most significant predictor of treatment
success is an: (1) empathic, (2) hopeful,
(3) continuous treatment relationship in
which (4) integrated treatment and (5)
coordination of care can take place
through multiple treatment episodes.
Within this context, (6) case management
/ care and (7) empathic detachment /
confrontation are appropriately balanced
at each point in time.
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4. “Consider both disorders primary and
integrated, and treat accordingly”

Both treatment
systems (Mental
Health & Substance
Abuse) have myths
that clinicians can’t
treat one illness while
also treating the
other.
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4. “Consider both disorders primary and
integrated, and treat accordingly”

In fact, treatments for each
condition work well together,
and staff can learn to
integrate both.

Both substance disorders
and mental illness fit into the
disease-management /
recovery model.
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5. “Apply the Disease / Recovery model
with diagnosis-specific and stage-ofchange-specific interventions”
(r/d-1)














Leads to lack of control of behavior &/or emotion
Symptoms can be controlled with treatment
Physical, mental and spiritual disease
Progressive illness w/o treatment
Disease miscast as a moral issue
Affects the entire family
Depression & despair
Shame and stigma
Hereditary factors
Biological Illness
Guilt and failure
Denial factor
Incurable
Chronic
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“Apply the Disease/Recovery model with
diagnosis-specific & stage-of-changespecific interventions”
(d/r-1)
1.
Initial phase is stabilization, which
may require hospitalization, &/or
medication (detox), &/or psychotropic
medication
2.
Following stabilization, the next
phase is rehabilitation
3.
Rehabilitation involves maintaining stability by
following a long-term program (don’t use, attend
meetings, work the 12 Steps, etc / take meds, use
therapy or other helpful supports / services, etc.)
4.
Denial needs to be overcome
12
“Apply the Disease/Recovery model with
diagnosis-specific & stage-of-changespecific interventions”
(d/r-1)
5.
Powerlessness over the disease needs
to be acknowledged
6.
Help must be asked for, from a power
greater than the self, in order to control
symptoms (higher power, AA, NA,
sponsor, meds, therapist, doctor, case
manager, etc)
7.
Recovery proceeds ‘One Day At A Time’
8.
Recovery is never done, but gradual
progress can be made
13
“Apply the Disease / Recovery model with
diagnosis-specific &
stage-of-change-specific interventions”
(d/r-2)
9.
Relapse is always a risk
10. Families / friends benefit from involvement
in a program to get help for themselves in
dealing with the disease
11. Education about the disease is an
important piece
12. Treatment must include focus on feelings
about the disease, and feeling good
about oneself
13. Recovery is a physical, mental, emotional
and spiritual process
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6. “Apply the disease / recovery model with
diagnosis-specific and stage-of-changespecific interventions” (Prochaska, Norcross, & DiClemente)
Precontemplation
Relapse / Recycle
Contemplation
Maintenance
Preparation
Action
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Evaluating Stages of Change


Precontemplation (Denial)
•
Contemplation
(Ambivalence)
•

“What problem? I’m not thinking
about it.”
“I wonder if I might have a problem?
I’m thinking about it but not ready to
decide anything yet.”
Preparation /
Determination (Admission)
•
“I have a problem.”
16
17
Evaluating Stages of Change

Action (Taking steps /
Making changes)
•

Maintenance (Continuing
what works)
•

“I have a problem and I’m ready to
do something about it.”
“I’m stabilized and doing well. How
can I support my ongoing recovery?”
Relapse / Recycle (Trying
again)
•
“I’m stabilized but have relapsed.
How can I get back into active
recovery?”
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7. “There is no single correct intervention!”
Individualize treatment per . . .

. . . Quadrant designation (see)

. . . Diagnoses (DSM-IV)

. . . Level of functioning (evaluate –
GAF, other tools)

. . . External constraints (Assessment, Tx plan)

. . . External supports (Assessment, Tx plan)

. . . Phase of Recovery / Stage of Change
(see)

. . . Multidimensional assessment of level-ofcare requirements (ASAM PPC-2R)
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8. “There is no single correct destination!”
Individualize outcome expectations per . . .

. . . Quadrant designation (see)

. . . Diagnoses (DSM-IV)

. . . Level of functioning (evaluate –
GAF, other tools)

. . . External constraints (Assessment, Tx plan)

. . . External supports (Assessment, Tx plan)

. . . Phase of Recovery / Stage of Change
(see)

. . . Multidimensional assessment of level-ofcare requirements (ASAM PPC-2R)
21
NH Dual Diagnosis Study (1989-1994)
(Drake et al, 1998)
Proportion of Days in Stable Community Housing
1.0
0.9
0.8
0.7
Beginning
6 months
12 months
All DD Patients (N = 203)
18 months
24 months
30 months
36 months
Patients in Recovery (N = 54)
22
NH Dual Diagnosis Study (1989-1994)
(Drake et al, 1998)
Percentage of Persons Hospitalized
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
Beginning
6 months
12 months
All DD Patients (N = 203)
18 months
24 months
30 months
36 months
Patients in Recovery (N = 54)
23
NH Dual Diagnosis Study (1989-1994)
(Drake et al, 1998)
Number of Arrests and Incarcerations (N=203)
60
50
40
30
20
10
0
Beginning
6 months
Arrests
12 months
18 months
24 months
30 months
36 months
Incarcerations in Jails or Prisons
24
NH Dual Diagnosis Study (1989-1994)
(Drake et al, 1998)
Median Treatment Costs: Patients in Recovery (N=54)
$ 14,000
$ 12,000
$ 10,000
$ 8,000
$ 6,000
$ 4,000
$ 2,000
$0
Begi nni ng
6 months
12 months
Inpatient
18 months
24 months
30 months
36 months
Outpatient
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