A Beginner’s Guide to Dual Diagnosis Rehab

Dual Diagnosis Rehab

Defining Substance Use Disorders

Substance abuse, addiction and dependence were once diagnosed separately. The latest version of the Diagnostic and Statistical Manual groups them together under the umbrella of “substance use disorder.” However, most people -including many medical and mental health professionals- still use the terms substance abuse, addiction and dependence.


Addiction is characterized by compulsive drug or alcohol abuse despite the negative consequences of the abuse. People who are addicted to drugs or alcohol may want or try to stop using, but they find that they can’t.

According to the National Institute on Drug Abuse, good intentions and willpower are rarely enough to end an addiction for the long-term. Professional help is almost always needed.

Addiction develops as the result of changes in the physical structures and chemical functions of the brain. Heavy drug or alcohol abuse may lead the brain’s memory, learning, reward and motivation centers to begin communicating in a way that causes the brain to equate liking drugs or alcohol with wanting them. The result is intense cravings and compulsive drug-using behaviors.

The brain changes that occur with addiction lead to dysfunctional thought and behavior patterns, and the addiction itself causes serious problems in your life.

Addiction, like mental illness, is treatable. Treatment for addiction involves therapy and, in some cases, medication.

Substance Abuse

Substance abuse is the act of using drugs or alcohol in a way that causes problems in your life. These may include relationship, financial, legal or physical or mental health problems.

Using any illegal drug is considered substance abuse, even if you don’t heavily abuse them. That’s because illegal drugs put you at risk for legal troubles, and they can lead you into high-risk or dangerous situations.

The most common form of substance abuse is binge drinking, which is the act of drinking enough in the space of two hours to bring your blood alcohol level up to .08 percent.

According to the Centers for Disease Control, 37.4 million Americans -one in six- binge drink about once a week, with an average of around seven drinks per binge.

Defining Mental Illness

A mental illness is a health condition that causes changes in thinking, emotion or behavior or a combination of these. It affects feelings, moods and thought processes and can interfere with healthy social functioning. Mental illness reduces feelings of good health and wellbeing and can cause relationship and other problems in your life.

Mental Illness is Common

Nearly one in five American adults has some form of mental illness, according to the American Psychiatric Association. The most common are anxiety and depression, with around 40 million American adults suffering from an anxiety disorder and another 14.8 million adults living with major depression in any given year.

Good mental health is the foundation for thinking, learning, self-esteem and resilience. It’s fundamental to healthy relationships, emotional well-being and contributing to the community.

Unfortunately, mental illness is still stigmatized in our society, and many people who have a mental illness are ashamed and embarrassed. But mental illness is a medical condition, just like heart disease or irritable bowel syndrome. The difference is that mental illness affects the brain -and therefore mental functioning- instead of the heart or the digestive system.

Mental illness is a treatable condition, and researchers are learning more about it every day. Treatment for a wide range of mental illnesses includes medication and counseling. Medication can balance neurotransmitters involved in the mental illness, and counseling helps individuals learn skills and strategies for coping and reducing symptoms.


Dependence is characterized by withdrawal symptoms that set in when you stop using drugs or alcohol.

Chronic substance abuse causes the brain to change the way it functions in order to compensate for the presence of drugs or alcohol. For example, alcohol initially increases the activity of the neurotransmitter GABA, which produces feelings of calm and wellbeing.

At the same time, it reduces the activity of glutamate, which is responsible for feelings of excitability. Heavy alcohol abuse leads the brain to compensate by reducing GABA activity and increasing glutamate activity in an attempt to maintain normal function.

These adjustments in the brain lead to tolerance, which occurs when you need increasingly larger doses of drugs or alcohol to get the desired effects. But as you use more, the brain continues to compensate, and at some point, brain function may shift so that it now operates more comfortably when the substance is present.

When you suddenly stop using drugs or alcohol, normal brain function rebounds, flooding the brain with the neurotransmitters that were suppressed and decreasing the function of those that were increased. The result is physical withdrawal symptoms.

Dependence is treated with medical detox, which involves medications that reduce the severity of withdrawal symptoms and prevent or treat dangerous symptoms that may occur.

The Link Between Mental Illness and Substance Abuse

The link between mental illness and substance abuse is well-established. The National Institute on Drug Abuse explains three scenarios that help us understand this link.

  • Abusing drugs can cause the onset of a mental illness or worsen an existing mental illness.
  • People who have a mental illness are likely to self-medicate the symptoms with drugs or alcohol.
  • Overlapping factors for substance use disorders and mental illnesses leave some people at a higher risk of having both.

Overlapping Factors for Dual Diagnosis

Three important underlying factors can lead to both mental illness and substance abuse.

Involvement in similar brain regions

Some regions of the brain are involved in both mental illness and substance use disorders. For example, the dopamine system, which is a key player in developing an addiction, is also a factor in depression and other mental illnesses.

Overlapping genetic risks

Several regions of the human genome are linked to both substance use disorders and mental illnesses. Some of these genetic factors have a direct influence, such as the way substances are metabolized in the body. Other factors have an indirect influence, such as a predisposition for risk-taking behaviors, including abusing drugs or alcohol.


Environmental factors influence both substance abuse and mental illness. High stress, for example, can cause anxiety, and it commonly leads to substance abuse as self-medication.

The Prevalence of Dual Diagnosis

People who have a mood or anxiety disorder are twice as likely as those without to develop a substance use disorder, and vice-versa, according to the National Institute on Drug Abuse. (3)

Around one-third of people who have any type of mental illness, including anxiety or depression, and half of those with a serious mental illness, such as bipolar disorder or schizophrenia, also have a substance use disorder, according to the National Alliance on Mental Illness. (4) Conversely, around a third of people who abuse alcohol and over half of those who abuse drugs also have a mental illness.

Mental Illnesses That Commonly Occur with Addiction

Any mental illness can occur with a substance use disorder, but some more commonly co-occur than others.


Anxiety is characterized by an impending sense of doom, sleep problems and feelings of restlessness. People who suffer from an anxiety disorder often self-medicate with drugs or alcohol in an attempt to feel better. Anxiety disorders include panic disorder, social anxiety disorder and generalized anxiety disorder.

Depressive disorders

Major depression and bipolar disorder are common depressive disorders, and they’re associated with a higher risk of abusing drugs or alcohol as a form of self-medication. Drugs and alcohol may seem to make you feel better initially, but they almost always worsen depression in the long run. A study published in the journal Psychiatric Clinics of North America found that around half of all people who have bipolar disorder have a lifetime history of addiction. (5)

Obsessive-compulsive disorder (OCD)

Obsessive-compulsive disorder is characterized by uncontrollable, recurring thoughts and behaviors that are repeated over and over. According to an article in the Journal of Anxiety Disorders, 27 percent of people who have OCD have a lifetime history of a substance abuse disorder. (6) People with OCD may use drugs or alcohol to relieve symptoms like intrusive thoughts or compulsive, repetitive actions.

Post-traumatic stress disorder (PTSD)

PTSD commonly occurs after a trauma, such as sexual or physical abuse. People with PTSD often use alcohol to relieve symptoms like insomnia, nightmares, intrusive thoughts, troubling memories and flashbacks. According to a study cited in an article published in Alcohol Research & Health,

40 percent of people seeking inpatient treatment for a substance use disorder suffer from PTSD.

Another study found that over half of all combat veterans with PTSD develop an alcohol addiction down the road. (7)

Eating disorders

Eating disorders like anorexia nervosa, bulimia nervosa and binge eating disorder -the three most common eating disorders- often lead to alcohol or drug abuse in an attempt to control the appetite, reduce feelings of depression and cope with low self-esteem. An article in the journal Social Work points out that up to half of all people with an eating disorder engage in substance abuse, compared to just nine percent of the general population. (8)

Diagnosing Co-Occurring Disorders

It can be difficult to diagnose co-occurring disorders since it may not be clear whether certain symptoms are related to a mental illness or substance abuse.

Integrated Screenings Are Key

Due to the high prevalence of dual diagnosis, an integrated screening protocol is used in both mental health care settings and substance abuse treatment settings to help diagnose co-occurring disorders.

The screening is simple and involves a series of questions that are scored to help determine whether a comprehensive assessment is needed to diagnose a co-occurring disorder.


People who seek treatment for a substance use disorder begin the recovery process in medical detox. During medical detox, a variety of medications may be used to reduce the severity of withdrawal symptoms to increase comfort and safety during the detox process.


Once symptoms are under control, medical and mental health providers conduct a series of assessments to determine an individual’s specific needs and issues. The assessments include a medical history, history of mental illness and current symptoms.

A 12-step assessment process is used to evaluate a substance use disorder in the context of a mental illness or vice versa. The assessments give providers a comprehensive picture of the individual’s mental health and the severity of the substance use disorder.

The information gathered is used to develop an individualized treatment plan that addresses both the substance abuse and the mental illness.

Integrated Treatment for Successful Recovery

Mental illness often leads to substance abuse, and substance abuse often leads to new or worsening symptoms of mental illness. Treating both conditions at the same time is central to successful recovery.

In a dual diagnosis treatment setting, the mental illness is treated in the context of the addiction, and vice versa. According to the Substance Abuse and Mental Health Services Administration,integrated treatment offers better outcomes for people with a dual diagnosis, including:

  • Reduced substance abuse
  • Improved symptoms of mental illness
  • Better mental functioning
  • Decreased hospitalization
  • Increased stability in the client’s living situation
  • Fewer legal troubles
  • An overall higher quality of life

Dual diagnosis treatment is a collaboration between the client and the treatment teams that ensures continuity and a whole-person approach to treatment. Some of the features of fully integrated treatment include:

  • A single program that addresses both disorders
  • The same clinicians treating both disorders
  • An emphasis on trust, understanding and learning
  • An emphasis on a slow pace and a long-term recovery perspective
  • Readily available support
  • Medications administered for either or both disorders
  • A focus on preventing anxiety rather than breaking through denial

Six Principles of Dual Diagnosis Treatment

The Substance Abuse and Mental Health Services Administration identifies six principles that should guide dual diagnosis treatment, based on empirical evidence, clinical experience and a growing understanding of co-occurring disorders. (9)

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1. Employ a Recovery Perspective

The recovery perspective acknowledges that recovery is an ongoing process of internal change that proceeds through various stages. There are two main principles for treatment under the recovery perspective:

The repair stage

This stage finds people in recovery working to repair the damage done by the addiction. Individuals in the repair stage begin to separate themselves from an addiction identity, begin feeling comfortable with feeling uncomfortable and continue to engage in peer support groups.

The growth stage 

In the growth stage, individuals let go of resentments and move forward, set healthy boundaries, begin to give back and continue to maintain a high level of mindfulness of their lifestyle and emotional states.

The abstinence stage 

During the abstinence stage, the main focus of recovery is on coping with cravings and other triggers and abstaining from substance abuse. Individuals are focused on self-care, finding employment, practicing honesty and developing healthy lifestyle habits.  

Developing relevant treatment interventions for each stage of recovery 

Successful recovery is a process of setting and achieving goals at each stage of the process. Relevant therapies, interventions and services are essential at each stage. The stages of recovery include:  

Developing a treatment plan that offers continuity over time

Treatment can occur in various settings over time. A client may start in residential treatment before moving to an intensive outpatient program and then to a standard outpatient program and a sober living residence program. Other recovery settings include services that take place outside of the treatment program or those that follow treatment, such as peer support groups and family and community supports.

2. Adopt a multi-problem viewpoint.

A range of mental, medical, family, social, legal and financial problems often come with co-occurring disorders. In order to be effective, treatment must address the multiple needs of the individual through a variety of therapies, services and interventions.

5. Plan for the client’s cognitive and functional impairments

People with co-occurring disorders may have cognitive and other functional impairments that interfere with their ability to comprehend information or complete tasks. These impairments will be identified during the comprehensive assessment period. Treatment must be tailored to an individual’s level of cognitive functioning and may require using visual aids, repetition and short, highly structured treatment sessions that focus on practical life problems.

3. Develop a phased approach to treatment.

Phases of treatment align with the stages of recovery and include engagement, stabilization, treatment, and continuing care. Differentiating between phases enables care providers to develop and use stage-appropriate treatment protocols, such as motivational therapies during the engagement phase and medications and complementary therapies during the stabilization phase.

6. Use the client’s support system to maintain and extend treatment effectiveness

Support from family, peers and the community is an important factor in long-term recovery. This is particularly true for people with a dual diagnosis, who may not have enjoyed a consistent and supportive environment for many years. Central to successful treatment is engaging clients in a variety of support systems, such as mutual self-help groups and reintegration with family and the community.

Continuity of care is achieved through careful coordination as clients move through various systems and settings during treatment. Continuity includes consistency between primary treatment and other services along with seamless transitions as clients move from one level of care to another.

4. Address specific real-life problems early in treatment

Co-occurring disorders occur in the context of personal and social problems that disrupt an individual’s life. These include situations like family dysfunction, unemployment, homelessness and financial problems. Addressing these problems early on promotes successful ongoing recovery by engaging clients in treatment. Engagement is a critical factor in long-term recovery. Staying in treatment for an adequate period of time dramatically increases the chances of successful recovery. Case management helps providers keep track of the multiple services and interventions that are central to a client’s successful recovery.

Traditional Therapies

Traditional “talk” therapies used in dual diagnosis treatment are those that have been shown through research to be effective for treating addiction. These include:


Cognitive-Behavioral Therapy
Cognitive-behavioral therapy helps individuals identify and replace dysfunctional thought and behavior patterns, address underlying issues behind the addiction and develop coping skills for dealing with stress, negative emotions and symptoms of mental illness. Cognitive-behavioral therapy is the most effective and commonly used therapy in treating both a mental illness and a substance use disorder.
Family Therapy

Family therapy helps to restore function to the family system. Family members learn healthy communication skills and other skills that help improve relationships and restore damaged trust.



Pharmacotherapy is the use of medications to help treat a substance use disorder or a mental illness -or both. Medication-assisted treatment for an alcohol or opioid use disorder helps to restore normal brain function, reduce cravings and block the effects of opioids or alcohol if these are used while in recovery. Medications may also be given to help control symptoms of mental illness.

Psychoeducational Classes

Psychoeducational classes help clients better understand mental illness, substance use disorders and the various aspects of these. The better clients understand how addiction and mental illness develop and how they’re treated, the better the chances they’ll enjoy long-term recovery.

Complementary Therapies 

 Complementary therapies used in dual diagnosis treatment are those that have been shown through research to be effective for treating addiction when they’re used along with traditional “talk” therapies.

Art Therapy
Art therapy helps people express difficult emotions and work through unhappy experiences through creative self-expression. Art therapy decreases denial, improves self-awareness and reduces stress and feelings of shame. 
Equine Therapy

Equine therapy involves working with horses. Equine therapy increases self-confidence, helps clients set healthy boundaries and improves awareness of emotional states.

Biofeedback helps clients learn to control their body’s stress response and reduce cravings through relaxation techniques like deep breathing, meditation and progressive relaxation. 
Yoga improves self-awareness and promotes physical and mental balance, strength and flexibility. 
Mindfulness Meditation
Mindfulness meditation reduces the body’s stress response and helps practitioners respond better to outside stressors.

Other Interventions and Services

Successful treatment depends on addressing all of an individual’s needs and issues. Other services and interventions used in dual diagnosis treatment are provided as needed and may include:

  • Housing assistance to help clients find safe, stable housing once treatment is complete.
  • Medical care to get medical problems under control.
  • Vocational or educational assistance to help clients return to the job force or go back to school.
  • Legal assistance to help clients navigate the court system.
  • Financial counseling to get finances back on track.
  • Life skills classes to help clients develop essential life skills that support recovery, including domestic and relationship skills.

Choosing the Best Treatment Program for Dual Diagnosis

Some treatment programs specialize in dual diagnosis, while others offer it along with standard substance use disorder treatment. Either way, choosing a program that addresses co-occurring disorders is crucial for the best possible outcomes of treatment. Here’s what to look for in a high-quality dual diagnosis treatment program.

A proven track record

A reputable treatment program will make claims about the effectiveness of the program and back it up with numbers. It will be happy to provide you with documentation showing its success rate.


A treatment program that’s accredited has been through a rigorous evaluation process by a third-party accrediting body. An accredited treatment program will use industry best-practices protocol and research-based therapies. It will have exceptional staff, administrative and management personnel. CARF International and Joint Commission are two of the largest and most respected accreditation organizations for addiction treatment programs.

Qualified, licensed providers

All providers at a reputable treatment program will be licensed by the state and fully certified in the therapies they provide. They will be well-versed in professional standards of conduct.

Family programming

Family involvement in treatment is an important factor for successful recovery. Choose a program that has a family component, which will include family therapy, psychoeducational classes and workshops to educate family members about addiction, recovery and the best way to support their loved one during and after treatment.

A holistic approach to treatment

A holistic approach involves a variety of therapies that address all of an individual’s issues of body, mind and spirit for whole-person healing. Both traditional and complementary therapies will be used in a high-quality dual diagnosis treatment program.


A treatment center should be warm and welcoming rather than cold and institutional. The center should be clean and pleasantly decorated for a calm, nurturing environment.

There is Hope

The Substance Abuse and Mental Health Services Administration stresses that hope is the foundation of recovery. Hope is the belief that a better future is possible.

Dual diagnosis treatment works for most people who engage with their treatment plan and stay in treatment for an adequate amount of time -anything less than 90 days is of limited effectiveness, according to the National Institute on Drug Abuse. (10)

Dual diagnosis treatment helps with the development of the skills, strategies and techniques you need for successful long-term recovery from both a mental illness and a substance use disorder. It can help improve your quality of life by leaps and bounds and find joy and happiness in your life once and for all. Treatment works, and it can work for you, too.