One of the major challenges for clinicians and psychiatrists is assessing mental health disorders when a substance use disorder is present. Although different sources of data state various statistics, it is undisputed that many people in treatment for substance use present with mental health disorder symptoms as well. The available information confirms that, on average, approximately 50% of people with a substance use disorder also meet the criteria for a concurrent mental health disorder. Meeting criteria for mental health concerns does not necessarily mean that it can be diagnosed accurately due to current or recent substance use. It means symptoms are currently present, but the cause of the symptoms cannot be accurately determined at the specific time. When substance users receive proper treatment, clinicians in dual diagnosis treatment centers can determine if a mental illness is present and which symptoms result from substance use.
Many families we assist regarding substance use problems often suggest their loved ones’ issues derive from a mental health disorder, not substance use. Families often reference that even during short periods of abstinence, their loved ones’ behaviors are still questionable, although not as severe. This is important information for several reasons. It shows that many behaviors that drive addiction can be misdiagnosed as mental health disorders, especially when the diagnosis happens shortly after detox and within the first thirty days of treatment. Or it could mean that the substance use is worsening the symptoms of a mental health disorder. Many affected by a substance use disorder can greatly reduce behaviors that were diagnosed as mental health concerns with time, behavioral change, cognitive behavioral therapy, twelve-step programming, acquired coping skills, mindfulness, and self-awareness. Whenever substance use is present and accompanied by various psychosocial concerns, it is suggested that the clinician should assume these concerns result from the substance use until such time it can be determined they do not.
Many other factors can cause symptoms of a mental health disorder to be present. Often, these symptoms are the result of substance use, and just as often, they result from actual mental health issues. As stated above, the primary cause of misdiagnosis occurs when the clinician or psychiatrist determines the mental health disorder prematurely. This happens when substance users are diagnosed while actively using substances or shortly after they stop. Other factors that cause misdiagnosis of mental health disorders include misdiagnosed medical concerns, for example; someone diagnosed with a mental health condition finds out that it was something else, perhaps a thyroid condition, that caused lack of motivation, brain fog, anxiety, or depression.
The point is that mental health disorders are often present and need to be addressed. Another point is that clinicians and psychiatrists should be considering everything and not rushing to judgment to offer an immediate mental health diagnosis, as they often do. And although investigating sleep, diet, and exercise in and of themselves will most likely not fully address substance use or mental health disorders, they can and should be addressed. By putting the client first and really listening and observing, we can help to identify a dual diagnosis and provide effective treatment. There should not be a rush to judgment early in the process.
Families considering addiction treatment for a loved one but who have not considered the mental health aspects of treatment could benefit by educating themselves about proper dual diagnosis programs for addiction. Most treatment centers offer similar services and similar programming. Families will want to consider:
Accreditations such as JCAHO or CARF
JCAHO is the Joint Commission on Accreditation of Healthcare Organizations. It confirms the centers have been vetted and comply with the highest standards nationwide. CARF stands for the Commission on Accreditation of Rehabilitation Facilities. In order to receive a CARF accreditation, a facility must demonstrate its commitment to strive to provide the best quality of care at all times.
Evidence-based care offers a menu of treatment and intervention strategies that have proven their efficacy in providing positive treatment outcomes and results.
A legitscript certification must be obtained in order for a treatment center to present itself for online drug and alcohol treatment searches. Treatment centers or intervention companies that have obtained this certification have gone through a rigorous process that ensures they are delivering quality services and care. This certification also weeds out unethical practices and deceitful websites.
This is an area where many professional interventionists and counselors fall short. The client/counselor relationship is one of if not the greatest predictor of outcomes in substance use treatment. An interventionist has an obligation to the family of the substance user to see the case through. Providing ongoing family recovery coaching and support services while acting as a bridge to the treatment center greatly increases positive outcomes. Interventionists who just talk someone into treatment and tell the family to go to Al-Anon are not offering a proper intervention; they are doing 12-step service work and should not charge for that service.
Below, we will cover helpful information for families regarding dual diagnosis and its treatment.
Substance Use and Behavioral Health
Whether a mental illness is driving the substance use or the substance use is presenting mental health symptoms, the common denominator is substance use. There are several different models and theories on comorbidity which occurs when two or more disorders are present simultaneously. As previously mentioned, the challenge has always been addressing both effectively. Today, clinicians have moved away from primary and secondary diagnosis and often address the comorbidity together. Here are some of the challenges to consider.
How does a clinician determine what mental diagnosis is also in play when someone has used crystal methamphetamines or Adderall? Some substance users are hearing voices, are paranoid or manic, and some can’t carry a conversation that is clear and concise. Even if clients present with a history of mental illness, is it because of the drugs or could they have been previously misdiagnosed due to some other problem? Unresolved trauma and negative experiences can cause one to behave erratically (a temporary coping mechanism) prior to finding methamphetamines or Adderall as an ineffective coping mechanism. And whether there is a history of mental illness or not, Adderall and crystal methamphetamine present symptoms that are listed in textbooks associated with mental illness.
How do clinicians diagnose an alcoholic’s depression even as the substance use continues? After the alcohol use has ended, how do they determine if it is clinical depression that drove the alcohol use, or is the alcohol user experiencing depression due to the problems amassed by the use of alcohol? Could the alcohol use not be self-medication due to the inability to cope effectively with negative feelings or experiences? Even when families tell us their loved ones have had mental health issues all their life, have they been accurately and properly diagnosed and treated? If they are still consuming alcohol, then the answer is probably no. Were they given medication by a family doctor with no experience in mental health or by a psychiatrist who spoke to them for thirty minutes and then wrote a prescription?
Alcohol in and of itself does not create anger. It reveals the deep feelings one truly feels. Is the anger from a mental illness or unresolved traumatic experience that could be better addressed with treatment and counseling instead of a psychiatric medication? One would have to work seriously with the alcohol user before making an accurate determination.
The same applies to any drug and the solution it brings the user. Whether it be opioids, benzodiazepines, or inhalants, people are self-medicating with something. It may be mental illness, but it may also be unresolved feelings and experiences that presented as mental illness prior to the use of substances. Long-term treatment in an integrated setting with clinicians willing to listen and work with the substance user often provides the greatest opportunity for a positive outcome.
Mental Illnesses and Addiction
Two models offer the greatest support for clinicians in determining whether the substance use is a result of self-medicating a pre-existing mental illness. Clients in these two categories are also at greatest risk for developing a substance use disorder when a pre-existing mental disorder is present. These two models are:
This model suggests that biological vulnerabilities are precursors to the onset of mental disorders and the development of substance use disorders. These vulnerabilities are believed to be related to family genetics and events that occurred to the child during pregnancy and shortly after birth. Later in life, these implicit memories are thought to be evoked by environmental stresses and triggers. An interesting observation of the super sensitivity model focuses on the amount and frequency of substances used that bring about consequences. This is what separates a substance use disorder used to medicate a pre-existing mental disorder from a substance use disorder that leads to symptoms of a mental disorder. The model suggests that those with pre-existing mental health issues experience severe consequences brought on by substance use, even if mild or moderate. A substance use disorder without a pre-existing mental disorder typically sees severe consequences when much larger amounts of substances are used and with greater frequency.
Antisocial Personality Disorder (ASPD) Common Factor Model
This model suggests that clients with ASPD are at a far greater risk of developing a substance use disorder. ASPD is also more common in dual diagnosis clients than in clients with a mental health disorder but no substance use disorder. ASPD is most often followed by a childhood diagnosis of a conduct disorder. Clients with ASPD experience symptoms such as dishonesty, dislike for authority, lack of compassion for others, inability to hold onto relationships, putting up walls to prevent others from getting close, and engaging in conflict and chaos. What is most interesting about ASPD is we have not worked with even one client with a substance use disorder, moderate or severe, who did not check every (or almost every) box on the ASPD symptoms list. We also know many of these symptoms do not necessarily represent a mental health concern. The majority of people with ASPD who use substances go on to live great lives with astounding transformation in their behavior. This is often achieved without a mental health diagnosis, without psychiatric medications, and with evidenced-based treatments of Cognitive Behavioral Therapy and 12-Step Facilitation.
Can Drugs and Alcohol Cause Mental Health Illnesses and Symptoms?
Borderline Personality Disorder (BPD)
Symptoms of BPD include unstable relationships with others, problems with self-image and self-perception, and impulsive behaviors. This volatility in behavior can worsen when substances are present. Alcohol or drug use can cause or worsen many of the characteristic symptoms of BPD including: intense fears of abandonment or rejection, engaging in impulsive and risky behavior, and losing one’s temper with random outbursts of intense anger. Whether an individual had BPD before drug and alcohol use, he or she is now displaying the symptoms. With effective dual diagnosis intervention and treatment strategies, those with BPD symptoms can receive appropriate care to address the behaviors and concerns.
Characterized by mood swings, fluctuation in energy, and difficulty in daily task management, the symptoms of bipolar disorder may also result from substance use and addiction.
Key symptoms shared by bipolar disorder and alcohol use disorder are mania and hypomania. While alcohol use disorder can exacerbate existent bipolar, there are many types of bipolar disorder including Types 1 and 2 as well as diagnoses that are tied directly to alcohol and drug use. Bipolar disorder is by far the most over-diagnosed and misdiagnosed mental disorder found in substance use disorder clients. It is extremely difficult for a clinician or a psychiatrist to diagnose bipolar disorder effectively during active substance use or shortly after abstinence begins.
Alcohol and substance use disorders are common with people who have been diagnosed with anxiety disorders. They often turn to alcohol or drug use as a coping mechanism. The main symptoms of alcoholism, alcohol withdrawal, and alcohol detox are acute, intense anxiety and panic attacks. In other words, alcohol and substance use disorders can cause anxiety disorder symptoms. Alcohol and drug use present co-occurring disorders that should be treated with evidence-based, dual-diagnosis intervention and cared for by integrated treatment teams.
Alcohol use disorders can lead to anxiety and a diagnosis of anxiety disorder. The two disorders feed off each other and the most effective approach is to treat both simultaneously when both are present. During alcohol detox, the alcohol is slowly removed from the body. As this occurs, the anxiety symptoms and a possible risk of seizures can be medically treated to keep the patient as safe as possible. Once the detox is complete and an alcoholic has recovered physically, it is time to start working on the mental component. It is not uncommon for the anxiety to subside when symptoms of anxiety are no longer present. While the alcohol or substance user may not have an anxiety disorder or other mental health disorders at this time, he/she did present with symptoms that needed to be treated at the time of intake. Close monitoring of behavior and symptoms should continue and be addressed as they arise. Clinicians and medical professionals have a menu of options to choose from to handle each specific situation as it arises.
Post-traumatic Stress Disorder occurs when someone is exposed to or witnesses extreme, disturbing events causing death or serious injury. PTSD is more common in women than in men with substance use disorders. Symptoms of PTSD include reliving the traumatic event, increased arousal, and avoiding the feelings of the event or similar events that trigger the intense emotions. Some of the re-experiencing includes nightmares, unwanted memories, and reminders that trigger thoughts and feelings of the trauma reoccurring. Some of those with PTSD turn to substances to cope with the feelings in what is termed horrification recall. There are many different therapeutic intervention strategies to help clients with PTSD, including healthy and effective coping mechanisms.
Cognitive Behavioral Therapy (CBT) for Substance Use and Mental Health Treatment
Cognitive Behavioral Therapy is an evidence-based treatment that combines cognitive therapy with behavioral therapy. Behavior therapy is based on classical and operant conditioning. Cognitive therapy is based on self-awareness to identify thoughts that cause psychological distress. CBT is often used as a treatment for alcohol use disorder or drug addiction and is helpful in treating underlying mental illness diagnoses; it is also frequently used for relapse prevention.
CBT has shown great success in treating alcohol use and even the most severe forms of alcoholism. It allows substance users to re-think their behaviors, implement positive changes to those behaviors, and reap more positive outcomes from changed behaviors. It is a very helpful tool in addiction recovery, and it grows in value later where it is used as a tool to mitigate triggers such as sadness or depression and the urge to relapse.
Cognitive Behavioral Therapy has several different approaches or techniques that fall under its umbrella. One of these is Rational Emotive Behavioral Therapy (REBT) which holds that the way we perceive an event may be the problem, not necessarily the event itself. Another CBT instrument is Cognitive Therapy (CT). It was developed by Dr. Aaron T. Beck who believed that people with disorders such as depression can be helped by addressing their negative views of themselves and also addressing their pessimistic or hopeless views of the future. A third CBT model is called Strengths-Based Cognitive Behavioral Therapy, SB-CBT. This model encourages clients to develop new ways of solving problems rather than changing old behaviors.
Regardless of the method of CBT used, several similarities help clients improve their conditions, behavior, and thinking.
- Client/Counselor Relationship – This is one of the greatest predictors of positive outcomes in treatment.
- Problems are a Matter of Perception – Things are as bad as our ability to cope effectively.
- Changing the Perception – Is there another way of looking at the problem, and is there another way to go about addressing it?
- Here and Now – During counseling, each strategy is designed to have the client look at the problem here and now.
- More Involved Therapist – In CBT approaches, the therapist or counselor takes a more involved and directive approach than what would be traditional in other methods.
- Focused Treatment – CBT takes a goal-oriented approach. It targets specific problems more than other forms of counseling and psychotherapy.
The goal of any interventionist, therapist, counselor, psychiatrist, psychologist, or psychotherapist is to have a menu of options available to them. The more trained and versed the professional is, the greater the opportunities for their clients and patients.
Family First Intervention Can Help
At Family First Intervention, we believe in a team-based rehabilitation and recovery for your family and your loved one. Our goal is to help you meet your goals. We hope one of those goals is to have us be a bridge between your family and the substance user. Families who surrender to professionals, just as they expect the substance user to do, achieve better results than when they try to fix the problem without professional involvement. Dual diagnosis treatment is very effective in helping families and their loved ones. When an intervention or treatment team helps the family in addition to the facility helping their loved one, the opportunities for positive outcomes increase greatly.
If you would like to learn more about our intervention process and dual diagnosis treatment care, please reach out today for a free consultation – we’d love to hear your story.
The most formidable challenge we professionals face is families not accepting our suggested solutions. Rather, they only hear us challenging theirs. Interventions are as much about families letting go of old ideas as they are about being open to new ones. Before a family can do something about the problem, they must stop allowing the problem to persist. These same thoughts and principles apply to your loved one in need of help.