In order to accurately discuss a dual diagnosis, it is necessary to refer to the Diagnostic and Statistical Manual of Mental Disorders (known at present as DSM-5). A publication of the American Psychiatric Association, DSM-5 is considered the go-to resource for clinicians, researchers, and other professionals in the field of mental health. The manual lists all of the officially recognized mental health disorders and provides clinicians with a list of symptoms for each disorder for diagnostic purposes. Even beyond this utility, DSM-5 is the final authority on whether a mental health disorder is officially recognized. For instance, insurance companies most often will only cover claims for mental health conditions recognized in DSM-5.
As the National Institute of Mental Health (NIMH) makes available, the following is a list of the broad categories of mental health disorders in DSM-5:
NIMH also provides the public with extensive data on the prevalence of mental health disorders in America. According to a survey for 2012, the following are highlights regarding the occurrence rates of mental illness in the nation:
The National Center for Children in Poverty (NCCP) provides statistical data that focuses on adolescents. According to NCCP, the following are some important facts about teenagers and mental health disorders:
It is important to again note that in DSM-5, substance use disorder is classified as a mental health disorder. Discussions of dual diagnosis, however, often separate substance abuse from mental health disorders for purposes of discussing the possible relationship between the two disorders. This happens mainly because there are different approaches to substance abuse treatment and mental health treatment, but one is no less a clinical condition than the other.
The classification of substance use disorder as a mental health disorder stems from the now general consensus in the medical community that substance abuse and addiction is an illness akin to other chronic conditions, such as diabetes. In turn, there is increasingly less stigma around substance abuse because it is far less a matter of personal choice than it was thought to be earlier in American history. However, the fact remains that the initial decision to use a drug is voluntarily.
A dual diagnosis may be made in a host of different contexts. In some cases, one diagnosis will precede the other; in other cases, both conditions (and possibly more) may be diagnosed at the same time. However or whenever a dual diagnosis is made, the general consensus in both the addiction treatment field and the medical community is that effective treatment for each condition means treating both conditions at the same time.
There are numerous reasons for this advisement. For example, as the National Alliance on Mental Illness (NAMI) explains, illicit drug use can exacerbate and escalate the symptoms of mental illness and vice versa (such as an increase in suicidal tendencies among individuals with depressive disorder who also abuse alcohol). In light of the recommendation for treatment, a concerned person may ask: What are the prevailing treatment approaches when a teenager simultaneously has a substance use disorder and another mental health disorder?
According to author and neuroscience journalist Maia Szalavitz writing for TIME, many parents who have sent their teenage children to rehab were in the dark about the quality of the services. As Szalavitz points out, parents will want to learn if rehab centers of interest provide research-based approaches to treatment of their clients. Many rehab programs will begin with a one-on-one assessment (approximately one hour) between a qualified addiction counselor and the teen.
At the conclusion of the assessment session, the addiction counselor will advise parents as to whether the rehab center can offer the needed treatment and make advisements about the type of programming on offer, such as inpatient or outpatient care. If the teenager is admitted, a team of addiction treatment professionals will typically work together to create a tailored plan. In the case of a dual diagnosis, the addiction treatment team will include a psychiatrist and provisions for the treatment of the other mental health disorder.
Rehab programming that accommodates a dual diagnosis typically offers the traditional methods for treatment of each disorder, alongside one another. For example, a teenager who abuses heroin and has a diagnosis of bipolar disorder will typically be tracked to receive the medications and therapy associated with treatment for each disorder. Primary benefits of a rehab program that accommodates a dual diagnosis are that the treatment is centralized for convenience, and there is an open and transparent dialogue between addiction specialists and psychiatric care providers (note that psychiatrists working with drug rehab centers may also have addiction specializations).
The potential treatment complexity that a dual diagnosis presents can be frustrated by services that are not already integrated. As any American with two health conditions and separate medical providers knows, one medical office does not always seamlessly communicate with the other office. There is a minimized risk of providers having incomplete information when treatment for a client with a dual diagnosis is brought under one roof.
A parent with a teenage child with a dual diagnosis will likely want to understand both the approaches taken to treat the child’s particular drug abuse issues as well as the methods used to treat the co-occurring mental health disorder. Regarding substance abuse treatment, as the National Institute on Drug Abuse explains, there are two main pillars supporting the architecture of rehab programs: pharmacological interventions (i.e., targeted medications) and therapy.
Therapy, the other mainstay of recovery treatment, is an umbrella term for the various psychological and/or behavioral approaches that may be employed. Therapy in rehab centers typically occurs in both one-on-one sessions and separate counselor-led group sessions. In some instances, research has been conducted to evaluate the effectiveness of a specific one-on-one therapy approach vis-à-vis specific drugs of abuse or a specific age group, such as adolescents in recovery.
All of these approaches complement one another and may be used in conjunction. Therapy is responsive to client needs. As client needs change over the course of treatment in a rehab program, different therapies may be applied during different phases. For instance, MET has been shown to be effective in the early stages of recovery to motivate clients to commit to recovery and remain in a program. Recovery centers will explain their policies as well as the local laws governing the rights of parents to keep their minor children in the recovery facility.
Based on the principles of Motivational Interviewing, MET can help adolescent clients to overcome their inner obstacles to engaging treatment services. After an initial assessment to identify the adolescent clients’ level of motivation, follow-up sessions involve the therapist explaining the need for treatment and working to bring the adolescent on board by soliciting self-motivational statements. MET is generally not a standalone treatment and is most often used in conjunction with another therapy approach, such as CBT.
As NIDA explains, CBT can be used either in an individual session or a therapist-led group session (in either inpatient or outpatient programs). CBT was not specifically developed for adolescents in recovery, but it has been adapted to use in this group. In session, therapists and adolescent clients explore both the positives (such as a feeling of supreme confidence) and the many negatives of drug abuse (such as its impact on health, social standing, and relationships).
As CBT is a largely pragmatic approach, the clients’ insights into their drug use triggers and patterns provide them with real-world guidance. Clients learn how to recognize the impulse to use drugs and transform it into a healthy decision, such as going for a walk or leaving a party where drugs are present. Skills taught include self-control tactics, anger management, emotional regulation, pragmatic problem-solving skills, and strategies to refuse drugs if they are offered.
According to NIDA, the goal of 12-Step facilitation therapy is to introduce adolescent clients to group recovery meetings – such as Narcotics Anonymous or teen-specific groups, like Teen Addiction Anonymous – with the hope that they will engage these groups after the intensive phase of inpatient or outpatient rehab ends. According to research, the benefits of 12-Step programs extend to adolescents. Studies also show that 12-Step facilitation therapy in adolescents can help to improve attendance rates in outpatient therapy. There are philosophical and pragmatic tenets involved in 12-Step philosophy, but a main hallmark is that participants take responsibility for their substance abuse and recovery process while at the same time receiving support from others in recovery.
It is critical to point out that a rehab program that accommodates a dual diagnosis should provide exemplary services for both the substance use disorder and other mental health disorder. Bringing treatment under one roof is intended to improve outcomes and not compromise the depth of services each issue requires. For this reason, the prevailing approaches that are used to treat a particular mental health disorder (according to its severity grade in the individual client) are used in treatment programs that accommodate a dual diagnosis. As with substance abuse treatment, the two main components of treatment for other mental health disorders are targeted prescription medications and therapy; however, for some mental health disorders, the prevailing practice is to use therapy alone.
The specific mental health disorder that is diagnosed determines which medication, if any, will be prescribed for treatment. The U.S. Food and Drug Administration approves mental health disorder treatment medications for use in specific conditions. However, operating under an exception, prescribing doctors may use medications for other mental health disorders, provided doing so will have a reasonable therapeutic benefit (known as using a medication “off-label”). According to the National Institute of Mental Health, the following types of mental health disorder may be treated with the medication types indicated:
As discussed above, medication is used to treat addiction in specific cases. For this reason, there is not generally an issue regarding the interaction of substance use disorder medications and other mental health disorder medications. However, in the case of a teen who has concurrent opiate/opioid abuse and another mental health disorder for which a prescription medication is indicated, the parent and child will need to discuss any possible interactions or complications with the prescribing psychiatrist. Regarding therapy approaches, as a general rule of thumb, the approaches that may be used to treat substance abuse disorder may also be tailored to the other co-occurring mental health disorder, and vice versa. Therapy can occur in one-on-one sessions and separate therapist-led group sessions in either an inpatient or outpatient setting.
According to the National Alliance on Mental Illness, the following are some of the most common types of therapy that are used to treat a range of mental health disorders:
For illustrative purposes, this discussion will take a closer look at DBT. According to the American Institute for Cognitive Therapy, DBT has been shown to be particularly helpful for adolescents for whom standard treatment does not appear to be effective. DBT can be effective especially for adolescents who experience one or more of the following issues:
DBT is a staple form of treatment in individuals who have a mental health disorder, such as borderline personality disorder, and who experience symptoms such as identity issues, impulsivity, risky behaviors, emotional dysregulation, and conflict with parents. DBT for adolescents aims to help them learn how to manage seemingly overwhelming emotions, strategically work through difficult situations, and improve interpersonal relationships. Additional topics that may be addressed in DBT sessions include low self-opinion/image, social isolation, bullying, peer pressure, self-punishing behaviors, depression, academic troubles that arise from emotional instability, sibling rivalry, romantic relationship, and feelings around parental divorce.
Other therapy approaches are designed around the symptoms associated with particular mental health disorders or have been shown to have general applicability. During a stay in a rehab center that accommodates a dual diagnosis, teen clients may receive blended therapy sessions that address both the substance abuse and symptoms associated with the co-occurring mental health disorder. As no two clients present with the same drug abuse or mental health history, an individualized model of care is beneficial.
Tailoring a recovery plan to clients with a dual diagnosis includes optimizing the process by selecting the research-based therapies that are shown to be most effective for the particular drugs of abuse and mental health disorders involved. A recovery plan, however, must also be responsive to the adolescent clients’ reactions.
An initial treatment plan is a blueprint for recovery and can be modified or augmented as necessary in the interest of optimizing the process for the adolescent client.
