Addiction Treatment Vs. Residential Dual Diagnosis Treatment

What is a dual diagnosis treatment program?

A dual diagnosis treatment program helps people who have a substance use disorder and one or more co-occurring psychiatric diagnoses, including a mood disorder like major depression or bipolar disorder, an anxiety disorder, schizophrenia or another thought disorder, or a personality disorder. Therapies and programs are structured to help patients address both issues simultaneously instead of sequentially. Research indicates that evidence-based dual diagnosis treatment programs help people with co-occurring disorders reach better long-term outcomes for both their substance use and psychiatric disorders.

What is the difference between an addiction treatment program and a dual diagnosis program?

Significant variety exists among addiction programs and dual diagnosis programs, and it can therefore be difficult to describe each category universally. Some dual diagnosis programs and addiction treatment programs are very similar. Generally, addiction treatment programs are focused on helping patients stop drinking or using substances by enforcing rules and expectations and by providing counseling and therapeutic activities to help people start adopting skills to resist urges and maintain sobriety. They often are focused on the 12-step approach.  Some addiction programs also provide medical supervision for patients who need to detox from substances like alcohol, heroin, opioids, or benzodiazepines.

Dual diagnosis programs have some of the same elements as addiction programs in terms of programming, and also offer evidence-based treatment and therapies for mood, thought and anxiety disorders. The treatment team has expertise in helping patients explore the connection between their psychiatric illness and their alcohol or substance use. Patients learn about 12-step programs as a way to maintain sobriety and also learn skills from cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and other evidence-based therapeutic approaches depending on their psychiatric diagnosis. Substance use is viewed as part of a larger pattern of pathology, thoughts, emotions, and behaviors.

Addiction treatment programs are usually more appropriate for individuals with a primary substance use disorder. They may have symptoms of depression or anxiety, but those symptoms may result more from substance use than from an underlying clinical mood or anxiety disorder. For these patients, their psychiatric symptoms may begin to improve once they establish sobriety and begin working a recovery program. After beginning to address the substance use disorder, many experience a decrease in psychiatric symptoms – at least to the extent that those symptoms cause disability or meet the criteria for a clinical diagnosis of major depression or an anxiety disorder.

Patients who require a dual diagnosis program have a different experience. If they focus singularly on addressing their substance use disorder without also treating their psychiatric symptoms, they often have poor outcomes for both issues. Psychiatric symptoms like depression and anxiety often get worse when a patient stops drinking or using drugs. Many patients may have initially started using substances in an attempt to manage psychiatric symptoms. When faced with sobriety, without psychiatric treatment to support the use of effective and healthy coping mechanisms, those symptoms are exacerbated. This feeling of powerlessness can lead to relapse and continued substance use.

How do I know if I need an addiction program or a dual diagnosis program?

It can be difficult to determine which program would be the best fit for you, and a psychiatric assessment often is required to determine the relationship between your substance use and psychiatric symptoms.

As part of an assessment, a mental health professional will consider your history and explore which developed first – symptoms of depression, anxiety or psychosis – or experimentation with alcohol, marijuana, or other drugs. They will also ask about any periods of sobriety you’ve had in the past and how that affected, or did not affect, your psychiatric symptoms. When you stopped drinking for six months, did you feel less depressed or more depressed? When you stopped smoking marijuana, did you still hear voices that no one else could hear?

Other aspects of an assessment will evaluate the severity of both the substance use and the psychiatric symptoms. Some addiction treatment programs may offer programming that would be sufficient for someone with less severe psychiatric symptoms. Likewise, some dual diagnosis treatment programs may not be able to support a patient who needs to detox from severe or prolonged substance use. Some substances – like opioids, alcohol, heroin, or benzodiazepines – require specific medical treatment for detoxification that may not be available in a dual diagnosis program.

The most important first step if you need treatment is to get treatment. If, after beginning treatment, you and your treatment team determine that a different type of program would be better for you, you can make adjustments. Taking the first step is critical. If a person is willing to enter a treatment program, family and friends should help connect them with services as soon as possible.

Many patients complete a short-term addiction treatment program and then enroll in a dual diagnosis program to sustain and continue their recovery. Sometimes addiction treatment is required prior to entering a dual diagnosis program if detox is needed or if the patient is not able to establish a period of abstinence from substances.

Do I need dual diagnosis treatment if I recreationally use alcohol or marijuana?

A psychiatric assessment from a mental health professional is the best way to determine an answer. An assessment can help determine the extent to which substance use impacts your mood, cognitive skills, relationships, energy levels, etc. Even if you do not enter a formal dual diagnosis program, understanding the relationship between your substance use and your mental health can be important.

Many psychiatric treatment programs offer education and therapy groups to help patients better understand that relationship and incorporate goals related to substance use or sobriety in their wellness plans to help them stay healthy long-term. You may determine after examining your history that drinking with certain people or in specific situations is not healthy for you. Or you may decide that ending use of a substance, at least for a period of time, is the best way for you to feel good or make progress toward your goals.

Does entering a dual diagnosis program mean I’m an addict?

Entering a dual diagnosis treatment program means that you need evidence-based treatment for a substance use disorder and a psychiatric illness like depression, bipolar disorder, anxiety, or schizophrenia. It means that, right now, you need treatment. Treatment can help you understand your current relationship with substances and then determine how that relationship may need to change for you to experience a healthy future you define for yourself.

Should everyone with a mental illness abstain from using alcohol or marijuana?

Using alcohol or marijuana has potential risks for everyone – whether you have a mental illness or not. The decision to abstain from all alcohol and marijuana or to regulate use in some way depends on:

• your clinical diagnoses based on assessments from mental health professionals
• the medications you are taking for your psychiatric or medical diagnoses
• your family history of addiction and/or psychosis
• what happens to you physically, emotionally, and cognitively when you drink or smoke based on your history

Some patients with schizophrenia who do not meet the clinical criteria for addiction become psychotic when they smoke pot. They do not have a substance use disorder, but they should not smoke marijuana because of the way it affects their brain and thinking. Marijuana presents more risks for individuals with schizophrenia and other thought disorders than for the general population.

According to the National Institute on Drug Abuse, “Recent research suggests that smoking high-potency marijuana every day could increase the chances of developing psychosis by nearly five times compared to people who have never used marijuana. The amount of drug used, the age at first use, and genetic vulnerability have all been shown to influence this relationship. The strongest evidence to date concerns links between marijuana use and psychiatric disorders in those with a preexisting genetic or other vulnerability.”

Similarly, a patient with a history of suicide attempts when they are intoxicated from alcohol may not meet the clinical criteria for alcohol addiction, but, based on their history, likely will be safer and healthier if they abstain from using alcohol.

As another example, a patient with bipolar disorder has made substantial progress in stabilizing their mood through taking prescribed medications and adopting therapeutic skills. The result of drinking alcohol or smoking marijuana for anyone is mood destabilization; we often drink or smoke to feel different – to get a “buzz” or a “high” or to relax or take the edge off. Someone with bipolar disorder who starts drinking or smoking pot and experiences these substance-induced changes in mood may risk regressing in their work toward mood stabilization.

In addition, many psychiatric medications have potential interactions with alcohol ranging in severity from mild to life-threatening. Patients should talk to their physicians about any potential interactions.

What are the goals of a dual diagnosis treatment program?

The goals of the dual diagnosis treatment program at Skyland Trail are helping patients build insight into their substance use disorder; see and acknowledge consequences of their substance use on their health, relationships, school, or work; talk more honestly about their substance use; adopt new healthy behaviors to handle discomfort, stress, pain, or conflict; and establish a foundation for sobriety and a more healthy future.

What does a dual diagnosis program look like?

The Skyland Trail residential dual diagnosis program combines evidence-based treatment for mood, anxiety, and thought disorders with an abstinence-based 12-step approach to recovery. Patients must be willing to maintain sobriety while in treatment and be open to the 12-step approach as one strategy for managing their symptoms and staying healthy.

Adult patients at Skyland Trail are assigned to two recovery communities: one focused on their psychiatric diagnosis – like CBT, DBT, or cognition and first episode-  and one focused on substance use. They are assigned to a primary counselor, psychiatrist, and treatment team with expertise in dual diagnosis who collaborate to adjust a comprehensive treatment plan as needed. Dual diagnosis patients meet with a psychiatric core group like CBT every day and with a dual diagnosis daily core group. Additional groups throughout the day focus on specific skill sets or challenges as well as expressive therapies like art, music, or horticultural therapy. Nutrition and fitness groups are also part of a structured weekly schedule.

Group and individual therapeutic sessions help patients combine ideas and skills from cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) with the 12-step model and other relapse prevention strategies. Patients have the opportunity to build a whole “tool kit” that they can take with them to stay healthy. Because 12-step programs are so effective for so many people, 12-step programs are easy to find in many communities and are always free. Embracing the 12-step approach as a tool for recovery can help patients maintain their sobriety over time, which supports long-term recovery from psychiatric illness.  

How are DBT and dual diagnosis related?

At Skyland Trail, some clients are assigned to both the dialectical behavior therapy (DBT) core group and the dual diagnosis core group. The DBT core group often is appropriate for clients who struggle with emotion regulation and impulsive behaviors or who have a co-occurring diagnosis of borderline personality disorder.

The dual diagnosis program intersects with the residential DBT curriculum at Skyland Trail in several ways. For many patients, using alcohol or drugs is an impulsive behavior or a behavior that leads to other impulsive actions. Strategies learned in DBT can be applied to maintaining sobriety, and the 12-approach reinforces many of the same concepts.  Skills such as wise mind, opposite action, urge surfing, radical acceptance, turning the mind, and TIPP are just a few examples of DBT strategies that a patient can use alongside a 12 step program to support their sobriety.

The 12-step focus on repairing relationships also complements skills learned in DBT to improve relationships through validation, radical acceptance, and interpersonal skills.

Dual diagnosis treatment may be especially important for DBT clients. Impulsive behaviors like self-harm or parasuicidal behaviors that are intended to express pain or seek help can become fatal when combined with alcohol or drugs.

Dual diagnosis combined with DBT helps Skyland Trail clients learn to ask for help in healthy ways and end patterns of impulsive behaviors involving self-harm or substance use.

How are CBT and dual diagnosis related?

Some Skyland Trail clients are assigned to both the cognitive behavioral therapy (CBT) core group and the dual diagnosis core group. The CBT core group often is appropriate for clients who struggle with negative core beliefs or who have diagnoses of major depression, anxiety, or bipolar disorder.

CBT and dual diagnosis share many of the same principles. For example, a skill in CBT is examining cognitive distortions – looking closely at an idea we have about ourselves or the world and questioning whether that thought is a) a fact with evidence to support it, or whether it is b) an opinion that is not actually supported by the facts. Similarly, in the 12-step approach this skill is called “stinking thinking” and provides a framework to help patients examine their thoughts about alcohol and substance use.

Dual diagnosis treatment may be especially important for CBT clients because of the high incidence of co-occurring substance use among people with major depression, anxiety, and bipolar disorder. Studies consistently show that the lifetime prevalence of substance use disorders among patients with bipolar I disorder is at least 40 percent.

In addition, symptoms of anxiety and depression include withdrawing from or avoiding the people and activities that previously made you feel content or happy. Alcohol and substances can exacerbate this process of withdrawal and avoidance and make it even harder to connect with the people and activities that can help you make positive steps toward recovery. Combined with sobriety, behavioral activation, a CBT skill, can help patients counteract a pattern of isolation and take actions that will help improve their mood.

How is psychiatric treatment for schizophrenia and dual diagnosis related?

Skyland Trail clients with schizophrenia and other thought disorders are assigned to the cognition and first episode (CAFÉ) core group. CAFÉ clients with a co-occurring substance use disorder also are assigned to the dual diagnosis core group.

Many of the perspectives taught in the CAFÉ curriculum – building community, having accountability, finding meaning, being of service, connecting to other people, not isolating – are all supported by being a part of a community 12-step program like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). Being part of the CAFÉ core group and dual diagnosis core group can help these individuals begin to build a stronger support system in the community and reinforce skills they can use to stay healthy or ask for help when they experience relapse or a return of psychotic symptoms.

Dual diagnosis can be especially important for CAFÉ clients because some symptoms of thought disorders, including command auditory hallucinations, are a serious risk factor for suicide. Combining symptoms of psychosis with intoxication from alcohol or drugs can compound the risk for death from suicide.

How do dual diagnosis programs help patients feel better?

Being able to generalize coping skills across a range of challenges is important for patients with complex diagnoses and histories. You can sometimes think about dealing with intertwined mental health diagnoses as a game of whack-a-mole. When one issue – like substance use – recedes, another issue – like disordered eating, sex addiction, gaming addiction, or urges to self-harm – often pops up. Being able to apply skills to any type of maladaptive behavior gives patients a better chance at long-term recovery.

By treating co-occurring diagnoses simultaneously, dual diagnosis treatment helps patients generalize skills and sustain recovery through a range of strategies in addition to sobriety.

Dual diagnosis programs not only help patients get sober, they help patients feel whole. They help patients address the often longstanding psychiatric conditions that can contribute to relapse and fuel substance use. And they help patients explore new connections to their communities and positive sources of strength and support.

What if my loved one with a substance use disorder does not want treatment?

Helping a loved one enter treatment can be difficult if your loved one is not yet ready or able to acknowledge that they have a problem and need help.

People tend to recognize they have a problem with substances when they start to experience consequences. One thing family members can do is consider whether they are, with the best of intentions, shielding their loved one from the negative consequences of their drinking or using. Often family members will step in to make sure their daughter doesn’t fail a test at school or to help their husband avoid trouble at work. One step for family members might be to stop trying to protect their loved one from those consequences. This can be painful, but could be necessary to help your loved one get treatment to address a serious illness.

Setting boundaries and sticking to them can also be important. Set expectations for your loved one about their behavior in your home or at school and outline the consequences for not meeting those expectations.

Make treatment available. Continue to offer treatment as an option and offer to help them apply to a treatment program. The admissions process might feel overwhelming to someone struggling with substance use. Offer to tour the campus with them, participate in an inquiry call, or help them develop a list of questions to ask the admissions representative.

Joining a group like Families Anonymous, Al-Anon, Alateen, or Nar-Anon, can be a good place for families to start their own recovery process even if their loved one is not open to entering treatment yet. Families may also want to consider talking to a therapist individually to help support their mental health.