Posted by: counselorcarmella | May 24, 2012

The Challenges of Co-occurring Disorders and the “Double Trouble” Program

SC SHARE is a non profit organization  that supports, advocates for, and educates those with   mental health issues.  One of SHARE’s focusses is  helping those with co occurring disorders (mental health problems and  substance abuse issues). Co occurring  used to be called  MICA (mentally ill and chemically addicted.  Then, the term was dual diagnosis.  Whatever you call it, this is a common problem  (research says at least 50% of those with  mental illness are also abusing substances.) Many experts believe it is a much higher number.
Despite how common  it is, this is also a very neglected  problem. many therapists and  treatment facilities   deal with  either mental health problems or substance problems but few are able or willing to  address both. In most cases,  therapists  are not equipped by training or experience to   address both sets of issues. There is even controversy about whether you can treat a  substance problem and a severe mental health issue at the same time. Usually, one is going to  take priority and its going to be the one that seems to be causing the biggest problem at the moment.  That doesn’t mean the  other problem can be ignored, though.   These issues feed off each other and    it will be extremely difficult to maintain   healthy changes in one area if the other is  still  not being  dealt with. 
Those  with co occurring disorders are a challenging population for several reasons.  One is that so many  never seek help in the first place. Many don’t realize they have a problem or minimize the extent of the problem.  Others  don’t want help or still think they can  “handle it” themselves. Many people with a mental illness do these things and many people with substance abuse issues do these things; combine the two and you have people even less likely to seek help. A depressed person who is drinking may  not have hope that they would benefit from treatment, as depressed people are often hopeless  that they will ever feel better in the first place. Motivation is also an issue with depression so this person will be unlikely to take the initiative to seek treatment. If someone is  abusing pain  pills and also experiencing symptoms of schizophrenia, for example, paranoia may keep them from  admitting their problem to someone who could help.
Honesty is a problem with co occurring disorders. Someone with a mental illness may hide the fact that they’re drinking or abusing street drugs or prescription medications, even when prescribed psych meds that may  interact badly with other substances.  They put themselves at risk  by doing this.  At the very least, the alcohol or other drugs will  prevent the  psychiatric medication from working properly. At worst, the substances can  work together in ways that are lethal.   Those treating these individuals can’t address what they don’t know and are often left to wonder why  prescribed meds aren’t working or why   the client isn’t  progressing in counseling.  Professionals commonly ask about  substance use patterns, but clients  often lie and deny  use entirely or claim to  use  occasionally or rarely and in moderation.  The truth may be the exact opposite.  They also may hold out about the fact that they are drinking and  using other drugs.  They may say they drink  sometimes, but will leave out other substance use entirely.        
If a clinician picks up on the substance problem, or is told about it by  a family member or other loved one involved in  the session, the  individual  with the  co occurring problems often says, “That’s not why I came here.  I came here about my depression/marriage problems/temper.  That’s what I need help with.”  If I  say  I believe the substance issue  needs to be dealt with first, they often get defensive and do not   make use of  the referral options I give them.  They want to feel better, but they do not want to  change their substance  use/abuse patterns.  
Initial diagnosis can be  difficult. Substance use makes it difficult to tell what  is a mental health  symptom and what is a  side effect or  result of drugs and/or alcohol. Many people begin using substances to “self medicate” for mental health symptoms.  This can happen whether they’ve already been diagnosed with a mental illness or not. This can ultimately lead to   substance overuse or dependence and  delayed treatment for the mental health disorder they’re trying to cope with because it is either covered up or   not being treated properly  (or at all) in terms of an appropriate medication. Oftentimes,  the person has to be off substances for a period of time before  clinicians can  say for sure if there is an underlying mental health  problem and what it is. It can be very upsetting and frustrating for someone who thinks their problems are because of substances to get clean and then  realize they still have symptoms  that aren’t going away  and that “something else”  is wrong.
Substances  also  keep people from learning  better coping skills since the person is looking to something  external  rather than  developing internal resources.  They   have trouble with insight  and often   can’t see  the reality of their situation at all. Insight can also be more difficult for those with certain types of mental illnesses.  
Also,  if a person has had an addiction, there can be  concerns around prescribing them certain medications for their  mental illness.  Xanax for anxiety or  adoral for ADD/ADHD  may be too risky for someone who  is known to become addicted, or at the very least to abuse,   substances.   People can  begin  taking more of these medications than they’re supposed to and become dependent. This doesn’t mean they shouldn’t take psych meds any more than  someone who used to abuse pain medication should never be given pain medication of any  kind when undergoing a painful medical procedure. It does mean choices have to be made  with the person’s previous history in mind and that   risks and benefits of  medication options have to be weighed.
Those with  co occurring disorders need to be treated by therapists and psychiatrists who  understand   the unique needs of this population.  They may need in patient treatment  to  gain initial sobriety or  baseline emotional stability.  There are intensive outpatient programs for both sets of issues, as well.  One problem may take a backseat to  the other for a time, but ultimately, both must be addressed to avoid significant gaps in treatment. Those with co occurring disorders also need to be involved in a 12 step group that  believes in the reality of  mental health diagnoses and is not hostile to the appropriate use of psych meds. Twelve step programs provide accountability  and support, as well as structure and  some coping skills. These programs are   free and available in  every community.
Unfortunately,  many AA and NA programs are opposed to  medications for mental health issues. This is beginning to change, but it is still  a common  attitude and many people with co occurring disorders don’t talk about their mental health problems at these  group meetings.  They are not able to  be completely honest and  can’t receive peer support for their mental health concerns.   They can’t talk about  counseling or medication use. If they do  talk about taking medications, they may be  encouraged to stop them because God and the 12 steps are supposed to be enough and because  using  “mind altering” substances means they aren’t  seeking sobriety. . It is always unwise to take medical advice from someone who is not trained to provide it, but such advice is  handed out in 12 step programs  far too often when it comes to psych meds. 
Fortunately, SC SHARE offers a program called “Double Trouble” that is a 12 step program designed to address   the needs of those with co occurring disorders.  The program was not developed by  SC Share.  Materials are provided through Hazelden Treatment  Centers, which also publishes materials on  addiction recovery.  Like AA or NA, the program has  both  12 steps and 12 traditions. They are slightly modified to fit  the needs of those with co occurring disorders. This program allows openness  about the mental illness aspect, as well as the   substance aspect, of their struggles.  The stigma of mental illness is addressed and  group members learn that mental illness is a “no fault” illness.  They learn that  what they have is a  medical problem like diabetes or  high blood pressure  and that taking medication for  the problem is an okay thing.  They learn that they  can be accepted for who they are  and not be judged.  They can begin learning that its okay to ask for help and to trust others who  know how they feel  because they’ve had similar experiences. 
As with AA or NA,  members learn to   own their mistakes  so they can  work through the guilt, resentment, or other feelings.  They  learn about how to handle blame of self and others and how to  try and mend  and strengthen relationships.    The group environment allows  people to  be vulnerable in a supportive setting so they can tell their complete story, including the challenges of both a mental illness and a substance abuse problem.  The group setting  and working through the steps with others  also helps with  insight.  Members learn about co occurring disorders and learn skills and attitudes that will help them  achieve and maintain  health.  As with  AA or NA,  the strength and help of God/a Higher Power is an integral part of the program.
This does not mean other 12 step programs should not be utilized.  NA and AA still have their place and  the baby  should not be thrown out with the bathwater.  They are good  programs and  are more widely available  than programs like  Double Trouble. Even when a DTR program is available, clients still may want to participate in AA or  NA groups, as well. Sometimes,  people in these groups  discover through sharing  with  another person in a more private conversation outside of  the group that  they both have mental health concerns.  They can support each other on this level, as well, even if the group as a whole doesn’t  provide such support.    

Receiving additional support for mental health concerns  can and should be  sought after, but there are various ways to do so.   If  a 12  step group for co occurring disorders is not available,  such support can be  obtained by  attending a peer-to-peer support group that deals with mental illnesses, such as those provided through the National Alliance on Mental Illness (NAMI).  In these settings, the focus would be on the mental illness aspect rather than the substance  use aspect, which is being addressed in   NA or  AA.

Support can also be obtained from a counselor. Many counselors are comfortable continuing to help  clients address mental health concerns once their substance  problems are   under control and will encourage ongoing participation in  AA or NA.  Individualized support and interventions provided by one-on-one counseling can be helpful in addition to 12 step groups in most cases anyway and can be  “customized” in a sense for each person’s  needs.

I am one of many counselors who does not treat co occurring disorders; I do not have the training in substance abuse treatment and  don’t have a lot of interest in addictions work.  Every counselor has   met clients who have both mental health concerns and substance problems, however, and  we have to know enough to be able to  make a solid referral and treatment recommendations.  The client’s I’ve  met in this situation  were experiencing significant depression or anxiety  problems and drinking excessively, but that is just one of many combinations that are possible.  I applaud SC SHARE, the original creators of Double Trouble and Hazelden, and the private therapists I know who specialize in co occurring disorders, for taking on a particularly challenging population  with needs that are often  overlooked or  not adequately addressed.  It is my hope that awareness of this  problem will continue to grow so that treatment and appropriate support is more widely available.
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  1. love this!!

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