Until the '80s, it used to be that clients coming in for treatment were typically corralled into two discrete camps: the mentally ill or the substance abuser. Each had parallel treatment and discrete funding streams. As that decade drew to a close, so appeared the term dual diagnosis, a clinical moniker which appropriately -- finally! -- acknowledges the reality that those who experience substance abuse disorders were almost always in the throes of one or more concurrent mental health disorders that needed treatment.
Dual diagnosis is when a person experiences a mental health disorder and a comorbid substance abuse problem. There is extensive and ongoing deliberation over the appropriateness of using a single category for a heterogeneous group of individuals with complex needs and a varied range of problems. The concept can be used broadly -- for example, it can describe a person with depression and alcoholism -- or it can be restricted to specify severe mental illness like schizophrenia and a substance misuse disorder (e.g., someone abusing cannabis or a person who has a less-impairing mental illness and drug dependency).
Diagnosing a primary psychiatric illness in substance abusers is challenging, as drug abuse itself often mimics psychiatric symptoms, thus making it difficult to differentiate between substance induced and pre-existing mental illness. Taking a robust social history and creating a genogram, which includes a family's history of trauma, sudden death, marriages, divorces, sexually acting out, money issues, learning problems, alcohol abuse, drug abuse, in addition to religiosity, etc. helps in the assessment. Taking a bio-psychosocial history of the individual in question helps, although it does not always provide all the necessary clues.
As a seasoned interventionist, I've seen clients from both sides of the mental illness/substance abuse spectrum as well as clients with an avalanche of additional problems that I describe as the TRIPLE THREAT, those who suffer from a tertiary issue either as a result of a prior condition (i.e. disorder or illness) or that one that is exacerbated by additional factors (i.e. physical, legal, traumatic, etc.). These folks and their families present a diagnostic quandary with their kaleidoscope of competing and equally important issues.
Imagine you have a 36-year-old male client who was in a serious car accident at age 16 which left him paraplegic. Today he is using methamphetamines and while able to drive and is resilient, has failed to launch any farther then the local drug dealer. His family reactively coddles him as they feel the pain of his loss, not allowing him to grow, frozen in the headlights of his endemic grief.
The business manager calls you of a well-known celebrity. The family is a mess, her entourage is afraid to speak. The house is full of boxes and boxes of unopened merchandise she has purchased. She was seen stealing in a local boutique. She hears voices. Her personal assistants, hairdresser stylist are silent, as they fear for their employment, as do her parents who have become part of the entourage she must support.
An 89-year-old mother calls you, as her New Year's wish is to save 43-year-old granddaughter and 63-year-old daughter. Her granddaughter houses a methamphetamine lab in her home and surrounds herself with men of nefarious goings-on; their favorite pastime is to break and enter cars. The police are frequent visitors. She has the cognitive abilities of a fifteen year old and the rage of a tiger. Her mother lives in a nearby hotel smoking pot every day and is being supported by the hotel staff that love her and her eccentricities. Neither has had to truly work, and together they are both drowning in the stifling vicissitudes of trust funds, family histories of divorce, religiosity and substance abuse and both experience anxiety disorders.
With each case, as an interventionist, my partner and I find it essential to be empathetic, compassionate and strategic. We must prioritize intervention strategies that invite and respect the individual and identify therapeutic interventions to help the whole group. This triage includes picking the right treatment center, as not all treatment centers are created equal. By that I mean they have to specifically be able to meet the mental health, substance abuse, physical and legal needs of the client, and not just pay them glancing lip service.
Our health care system does not adequately meet the needs of Triple Threat Clients and their eco-systems substance abuse issues. I believe we must look at the treatment from micro, mezzo and macro perspectives -- the individual who needs help, the treatment team supporting their treatment/recovery and the accountability team supporting the individual (i.e. parents, loved ones, their accountant, or hairdresser), everyone has to be on board with the client's treatment path, as well as the health care system which affords treatment and provides for community recovery.
It's simple, but complex: If the threat is triple, our intervening responses have to be as rich and robust as the trauma and neurochemical glitches driving the distress. The era of the Triple Threat is here, presenting with increasingly vocal symptoms that can no longer be sorted through a traditional Dual Diagnosis treatment.
While three may be a crowd, we are at peril if we ignore the needs of this cacophonous threesome with its unique pains and pathologies.
Thank you to Jo Bainbridge MFT, Denise Klein MSW and Sheena Aquino BA for their assistance in bringing this important discussion forward.
Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.