A Complete Guide to Addiction and Dual Diagnosis Recovery for Your Loved One

Watching a family member or loved one struggle with alcohol or drug addiction can be overwhelming, humbling, and exhausting. Not only does it take a toll on the addicted person, it also affects you and other members of the family. There comes a time when it becomes clear that waiting for him or her to ask for help or reach bottom may not be the most effective solution. When family members have reached their bottom or are ready for help, they should consult a professional to learn effective methods to guide both them and their loved one into recovery. Somewhere along the way, society and professionals alike have allowed all the decision-making to remain in the hands of the substance user. In other words, families are led to believe that when the substance user is ready, then and only then can the family be allowed peace and closure. This simply is not accurate.

The motivation to change must be present in order for change to happen. There is always another way to look at a problem and the available solutions. What if rather than waiting for our loved one to reach bottom or ask for help, we look at the environment to see what is creating the impasse. Individuals with a substance use disorder have an additional dependency beyond alcohol or drugs. They have an overwhelming dependency on others and seek to avoid discomfort by choosing the path of least resistance. If the ability to self-medicate and the comfort derived from it are greater than the perceived discomfort of change, then where would one find the motivation to change? Can change happen if substance use is seen as a more comfortable option than seeking treatment? Interventions offer a substance user and the family the ability to look at things differently. This is done by addressing the barriers that may be preventing both family and substance users from finding the motivation to do something different. Changing the family dynamic and the environment that have allowed continued comfort to the substance user can make it possible to consider the 5 dimensions of motivation: desire, ability, reasons, need, and commitment. It truly isn’t about whether family members want help, because most of them do. It is about whether they then ask for help and follow through on it.

The Recovery Process

For most, the recovery process never truly ends. Although over time things become better and easier with continued engagement in recovery, the possibility of relapse for someone with an alcohol or substance use disorder should not be ruled out entirely. Starting the process is almost always the most difficult step. This is where we see the difference between wanting help and having to seek help. There are five categories in the stages of change model. Some form of clinical intervention is required to start the recovery process and then allow the process to move forward. We list them here and encourage you to research each of them in-depth:

1. Pre-contemplation: The substance user lacks ambivalence, e.g., the ability to see both sides of something. At this stage, substance users have zero desire to change nor do they see the need to change. Very few clients are truly in the pre-contemplation stage.
2. Contemplation: Although substance users are often resistant, defensive, and argumentative at this stage, ambivalence is present. It is best to avoid allowing them to argue against change for this will cause them to avoid seeing both the pros and cons of doing something different. 
3. Preparation: Sometimes viewed as the determination phase, this stage is where the pros for change and seeking help outweigh the cons and, as a result, the substance user prepares to take action. The mistake families often make during this stage is clinging to the false hope the substance user will make the change soon. Comments such as “I’ll do something different” or “I will call some places tomorrow” can feel temporarily satisfying to the substance user and the family. Families of addicts are encouraged to take the necessary steps for themselves until their loved one actually starts the recovery process. A decision is only a decision. The next stage of action is where things actually begin to change. 
4. Action: In this stage, behavior modifications become apparent, and experiences or environments begin to change. The substance user may be in some form of treatment and has the intention to engage and stay engaged in recovery efforts.
5. Maintenance: The clinical term may be referred to as the maintenance stage, but we prefer the growth label. We do not believe people turn their lives around by maintaining the status quo. If you’re not growing, then you’re staying stagnant. This stage is one of constant motion, working toward a better life and the prevention of relapse, and not being satisfied with “just getting by.” 

Each one of these steps is part of the path to achieving successful addiction recovery while avoiding common pitfalls. In conjunction with therapy and professional help, family recognition and support along each step of the recovery process can result in changed behaviors that improve conditions for both the substance user and the family. 

Evidence-Based Treatments

Families and substance users face similar challenges and common issues. These commonalities also have effective, recognized solutions that lead both the family and the substance user on a path to overcome alcohol and/or drug addiction. Several different addiction treatment approaches can be effective. With that being said, some treatments work for some people, some of the time. Below are some known and effective evidence-based techniques that are often utilized during the treatment and intervention process. These instruments have proven their efficacy in the treatment of addiction based on scientific testing and clinical judgment. 

Brief Intervention

The goal of the evidence-based brief intervention strategy is to help a substance user move from the contemplation stage to the preparation and action phases of recovery. By changing the environment within the family system and helping the substance user look at the situation differently, the opportunity for both sides to consider different alternatives and solutions that can produce positive outcomes is increased greatly. 

Research shows that early intervention enhances the chance of preventing progression and consequences. Unfortunately, with most cases, we are already past the time for an early or brief intervention. Most people who need intervention services are calling when their loved one is beyond the phase of experimental use or substance use without many problems or consequences. It is never too late to intervene to stop further damage and future consequences. For various reasons, families often inquire as to when their loved one arrived at a diagnosis of “substance use disorder, classification severe.” To help prevent additional damage to the substance user and the family, it is never too late or too early to start the intervention process.

Motivational Interviewing

Motivational interviewing is a complex style of counseling designed to orient a substance user’s thinking and verbal communication toward change. One of the many goals of an intervention is to help the substance user and the family see things differently and to help remove barriers to change. The wise use of motivational interviewing strategies by a trained professional allows substance users to see things differently and to be their own catalyst for decision-making. In other words, change becomes their idea, not someone telling them what to do.

Interventions are an invitation to join hands in recovery among family members and substance users. They also represent an opportunity for both sides to see the benefits of changing current behaviors and understanding the source of those behaviors. When delivered professionally and effectively, the end result should be acceptance from both sides, regardless of the substance user’s decision. It is not the job of the family or the professionals to tell the substance user what to do. Families, however, have the right to ask for acceptance of their boundaries and their changed approach in addressing the situation. Should the substance user decide to stay on a path of destruction, we ask that he or she respect the family’s decision to move forward in their own recovery and also to understand the boundaries and accountability set forth by the family. Utilizing motivational interviewing while addressing the family roles that may be preventing the substance user from moving through the stages of change has resulted in many successful outcomes. 

Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy combines Behavioral Therapy and Cognitive Therapy. CBT focuses on addressing learned behaviors thought to be inherited through modeling as well as operant and classical conditioning. This is also known as the ABC model. Behaviors (B) are driven by learning or previous experiences or events called Antecedents (A) and influenced by the Consequences (C) that ensue. We believe that consequences (C) need to be recognized as a result of the behavior in order for a substance user to find the motivation to begin the journey through the stages of change.  

With interventions, we can tie together some of the learned behaviors that may be causing the situation to stay the same for both the family and the substance user. On one hand, the family has learned how to behave and act toward the substance user in order to avoid confrontation. At the same time, the substance user has taught the family that if anything changes, the family will face consequences. This manipulation of family members is what allows the substance user to maintain a level of comfort and avoid consequences. The family learns that enabling fills a void and provides some level of comfort to them, i.e., the feeling of being needed in the relationship. Over time, the substance user achieves a sense of entitlement, and both sides start to learn how to cope maladaptively with the situation. Families are told their only options are to wait for the substance user to hit bottom or to ask for help.

Behavioral Couples Therapy (BCT)

This evidence-based treatment was previously referred to as Behavioral Marriage Therapy (BMT). Research shows that substance use disorder treatment that involves the spouse or significant other has greater positive outcomes than treatment involving the substance user alone. BCT has two primary goals in the substance user’s treatment plan; the first is to hold the substance user accountable to someone other than themselves, and the second goal of BCT is to improve the relationship over time. When family members enter recovery and are involved in the change process, the positive results of addiction treatment increase, too. 

Although Behavioral Couples Therapy refers to a spouse or significant other, we also see successful outcomes when the family is involved in their own recovery while setting boundaries and holding their loved one accountable. Substance use is not a victimless crime, contrary to what some are led to believe. Those who use substances often do so selfishly with little to no regard for others affected by their actions. Gaining self-awareness on how behaviors by both substance users and family members can compromise recovery efforts is beneficial. Both sides entering recovery and learning all they can about addiction and associated behaviors produces far better outcomes than individual recovery efforts. This is not to say that it only works if both family members and substance users enter recovery at the same time. Research shows that when one side gets better first, that often can allow the other side to change and improve, too. A healthy family makes it difficult for a substance user to be comfortable and avoid the necessary consequences that result from motivation and change. 

Relapse Prevention

Unfortunately, relapses can and do occur for substance users. Relapses do not just happen by accident as they are usually in the making over time. In our experience, relapses almost always happen after a person starts doing well in recovery or has the illusion of doing better. The reason this occurs is the addict or alcoholic bases his or her recovery efforts on whether the symptoms have been addressed. In other words, the focus shifts to winning back the things that have been lost and away from the behaviors that caused the losses (symptoms). When addiction recovery focuses on paying off debt, reinstating driving privileges, getting the job or the wife and kids back, the tendency is to gloss over what caused those losses to occur in the first place. Addressing the behaviors and gaining self-awareness, in addition to addressing maladaptive behaviors and coping skills are almost always a more successful approach. This approach can also help retrieve things lost in the addiction while addressing the cause. It has been said that if substance users’ only focus is “getting their stuff back,” then they are just setting the stage for the next relapse. With alcohol or substance use disorder, there are three stages of relapse:

1. Emotional Relapse:

This is the first phase of a relapse. It will often manifest itself while the loved one is not actively thinking about using drugs or alcohol but is nonetheless opening him or herself to the danger of exposure. Actions posing risks can include internalizing negative thoughts, not going to therapy, isolation from others, and other destructive behaviors not centered around alcohol or drug use. Recognizing the emergence of patterns that could lead someone to turn back to alcohol or drugs for respite is critical, and communicating about these risks can be lifesaving. This stage is very insidious in nature and is almost never seen as such by the substance user. This is why ongoing recovery efforts and being around people who can alert the loved one to the warning signs can be helpful.

2. Mental Relapse: 

During this stage of relapse, loved ones will rationalize old behaviors and unhealthy actions. Resentments start to build; they become critical and judgmental of others and start to believe they can stay sober on their own. This is where bad behaviors such as dishonesty, infidelity, and other unhealthy habits start to come back. This can also include reconnecting with old acquaintances who are negative influences and possibly with whom they used drugs or drank alcohol. You may not always know when they are using substances, but you will always know when they are not. If not addressed promptly, behaviors that start during the mental relapse stage almost always end in a chemical relapse. The behavioral changes that occur during the mental relapse phase are often referred to as the pre-lapse stage. The behavior is also much more obvious at this stage than at the emotional relapse stage. 

3. Physical Relapse: 

The common understanding of relapse is resuming use of the substance itself. The reality is that by the time an addict begins drinking or drug use again, the relapse has been triggered by ignoring the red flags of the prior two stages. At this point, it is critical that action be taken again and a new plan and support system be put in place. If you have ever spoken to a person who has relapsed, you are aware that the drug or alcohol use increases well beyond where it ended prior to getting sober. 

One silver lining of relapse is what can be learned from it. The experience of relapse can be used to help fine tune or strengthen a new treatment plan. When individuals relapse, they can almost always identify where and when the behaviors changed that culminated in the physical relapse. Identifying relapse triggers can significantly reduce the likelihood of another relapse down the road. 

Dual Diagnosis Treatment Approaches

Dual diagnosis treatment plans have the highest efficacy when an integrated treatment team is involved. Integrated treatment centers and teams mean that all the professionals work together and collaborate on solutions and methods to improve the delivery of care. When treatment centers outsource services to other professionals at different agencies with little to no collaboration among them, the client can be at risk of misdiagnosis or improper medication. Drug and alcohol use can reveal underlying mental health issues that make it appear one has mental health issues when that is not the case. Just the same, mental health concerns could be causing one to self-medicate. Drug or alcohol use can exacerbate the symptoms and cause an improper diagnosis of mental health issues. 

Mental health issues can certainly be worsened by drug and alcohol use. When a substance user is experiencing mental health symptoms, it can be difficult for even the most seasoned professionals within an integrated treatment team to make an accurate diagnosis. Put another way, it is difficult to hear the noise in the engine while the radio is turned to maximum volume.  When professionals are able to stabilize and detoxify the patient, they allow themselves a greater opportunity to treat the client more effectively. 

American Society of Addiction Medicine (ASAM)

ASAM criteria are most often used to help professionals determine client needs in 6 different areas. Most treatment centers follow ASAM criteria to ensure their clients have all their problem areas addressed. ASAM criteria can also be helpful in determining continued treatment needs to the satisfaction of an insurance carrier or funding source such as state-supported treatment centers. ASAM can also be used to help clients build upon areas where they appear strong and competent. Knowing a client’s strengths and liabilities while addressing any possible relapse potential can help determine effective treatment and discharge plans. 

Intervention professionals should be doing their best to gain as much knowledge as possible from the family to address problem areas the loved one may be facing. Knowing the patient’s drug or alcohol use history as well as any medical or behavioral challenges can help determine the level of care and address specific needs in problem areas. This information can help the intervention counselor gauge the substance user’s readiness to change. Once the substance user arrives at treatment, the interventionist, upon being listed on a release of information, can collaborate with the client’s treatment team. The interventionist then becomes part of the client’s integrated treatment team while at the same time engaging the family in the recovery process. This can help address relapse concerns or potential problems undisclosed by the substance user or the family. It can also help in determining the safest discharge environment for the client, such as sober living, for example. 

Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

The DSM manual is used by professionals to diagnose and determine Mental Health and Substance Use Disorders. A Substance Use Disorder assessment gauges the severity based on what the person is doing, what happens as a result of drug or alcohol use, and what occurs when someone is using substances in spite of the consequences. For addiction professionals, the DSM helps with treatment planning and level of care placement. This is achieved by addressing 11 different concerns to determine the severity of the disorder. When 2 or 3 symptoms occur, it is classified as a mild substance use disorder. Four or 5 symptoms are classified as moderate, and 6 or more symptoms are classified as severe. 

The DSM recognizes substance use disorders in 10 different categories. These are: alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, and stimulants such as amphetamines, methamphetamines, cocaine, crack, and even tobacco. 

Seeking Professional Help 

As with other medical illnesses and diseases, there is much oversight and many professional minds that go into treating substance use disorders and mental illness. Unlike other medical problems, many families and substance users continue to look at addiction treatment as a problem they can address without professional help. It also appears to be the only fatal illness where families and substance users fight to stay sick or believe that it will just go away on its own. With all we know about addiction and the dysfunctional family system that enables it, how do we help a family understand the importance of surrendering to professional guidance? Every path to recovery is unique, and consulting professional interventionists or therapists is an effective way to receive positive results. This is especially true when families and substance users seek a solution on their own. An intervention specialist can work with you and your family to create an integrated support system with your loved one, providing the greatest opportunity for long-term behavioral change and growth. Professional interventionists can increase successful outcomes at treatment centers when used in conjunction with and as part of the integrated team. Consistent family support has overwhelming data indicating it is an important part of addiction recovery. Please reach out to a professional if your family or loved one is in need because the change will make many lives better.

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