Dueling Disorders: The Battle Inside

No, the title is not a typo. I know that Dual Disorders and Co-occurring Disorders are the correct terms for the combination of substance abuse and mental health disorders. I think a better term to bring home the power of this co-morbid brain and body chaos is “Dueling Disorders.” That’s what killed my brother. The mental health issues and addictions battled within him, each fueling the fight until he finally surrendered. The treatment he was given did not help him stop the battle.

I do not believe he had any hope that the behavioral health and medical system could help him. Maybe it was the lack of hope for healing that really killed him and not the Dueling Disorders? Our family will never know for certain.

In our work, I ponder if we too easily compartmentalize people’s needs and address only their parts we are most comfortable with? If yes, does this impair our ability to see the whole person in front of us—their strengths, their joys, their dreams, their level of confidence, their history of trauma, their facade or “curtain” that they put forth to hide behind, as well as the parts of themselves with addictions and mental health challenges? Humans hide in plain sight so what does it take to create a good therapeutic relationship so you can have a chance to see the whole person and engage them in treatment?

Obviously, my brother is always on my mind. But also because the title of an article in the August 2013 publication of Counselor: The Magazine for Addictions Professionals stopped my breath: "Dual Diagnosis: Expectation, Not Exception." The point being that we should expect that our clients come to us with a Dual Diagnosis and not just expect a single diagnosis. And working at a school of social work with a trauma-informed curriculum and trauma continuing education programs, I am acutely aware of the need to see the whole person through a trauma-informed lens. I don’t know if any care provider ever saw the whole of my brother. I think they only saw his successful facade and the little bits he would reveal as needed.

According to SAMHSA, approximately 8.9 million adults have co-occurring disorders. Approximately 90% of those seen in public behavioral health settings have a trauma history. I find these numbers horrifying, a sad statement about the world we live in.

• Is your agency or practice current with evidence-based treatment for co-occurring disorders? Does it adhere to the principles from SAMHSA for an integrated screening and assessment process?

• Does it offer a trauma-informed environment that follows the guiding principles of safety, trustworthiness, choice, collaboration, and empowerment? Are services person-centered? Is there universal trauma screening? How do staff effectively build  therapeutic relationships?

• If your organization has clinicians who are highly skilled in working with those who have a co-occurring disorders, is there anything more that can be done to share their skills with less experienced clinicians?

• If your clinicians lack sufficient skills and knowledge to best meet the needs of this population, what is one step you could take to begin to address this need?

• Is lethality assessed and if there is risk, is it part of the treatment plan?

• If you or your agency are in state of “overwhelm” from workloads, complex client needs, and rapidly changing regulatory expectations, what is one step you can take to best serve this population? If you woke up tomorrow, and clients were better served, what would be different?

• if your services are not where you want them to be and you do not know what to do first, start by asking the “5 Whys” to get to the root issue.

• Have you reviewed your strategic plan  for needed updating to better serve people’s needs?

• Do you collect program evaluation data so you know what service  outcomes are?

Some days, we just need to stop and take a breath to celebrate how much we already do to effectively help people heal, and identify the steps to get us to enhanced skills in evidence-based and best practice so that even more people can have that chance. And remember that hope is one of the most powerful things we can give our clients in a therapeutic relationship. Resource information is listed below.

TIP 42 Substance Abuse Treatment for Persons with Co-Occurring Disorders

Effectively serving individuals with co-occurring mental and substance use disorders requires integrated screening and assessment processes.

Integrated Treatment for Co-Occurring Disorders Evidence-Based Practices (EBP) KIT

Jacobs, D. & Brewer, M. (2004).  American Psychiatric Association Practice Guideline: Provides recommendations for Assessing and Treating Patients with Suicidal Behaviors. Psychiatric Annals 34:5 (373-380). Available online.

National Center on Trauma-Informed Care  

Trauma-Informed Assessment and Screening PowerPoint

Scott D. Miller, PhD. Session Rating Scale and Outcome Rating Scale.

Evidence-based therapy relationships: research conclusions and clinical practices.

Therapeutic Relationship vs. Treatment Model blog post by Ricky Greenwald, PsyD

Video from TedX: 11 minutes of a powerful story from a young man who tells a “stop in your tracks” story about what depression feels like.