Specific Treatment Concerns in Working with Co-Occurring Disorders (second in a brand-new, three-part series)

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May 3, 2013 by Dr. Bob Weathers



This is the second in a brand-new, three-part series on working with co-occurring disorders in treating alcohol and other drug addictions…

Here I wish to address three, specific treatment concerns that must be addressed in treating co-occurring disorders: a) the “No Wrong Door Policy,” b) answering the question, “Which came first, the addiction or the psychiatric problem?”, and c) coaching the dual-diagnosis client (with co-occurring disorders), in order that he/she might benefit optimally from 12-step support groups.

First, the “No Wrong Door Policy” basically articulates a clinical approach which aims to be inclusive.  “The goal of this policy is to treat individuals for all their problems at the same time, whether they are initially seeking treatment for a mental health problem or a substance abuse problem” (Gillig & Cingel, 2012, p. 174).

Compartmentalizing clients into categories — for example, as either having a substance abuse or psychiatric disorder — may work on paper.  But as the eminent philosopher of language, Alfred Korzybski, asserted: “The map is not the territory.”.  That is, clear-cut categories (“maps”) may work in the abstract, but often clients (the actual “territory”) present with a unique combination of liabilities (including both substance abuse and psychiatric diagnoses) as well as undeniable strengths (which must not be bypassed, owing to an inordinately psychopathology-biased vantage point).

Second is the question, “Which came first, the addiction or the psychiatric problem?”   Addiction specialists Gillig and Cingel observe: “It appears that either can be the case…Abuse of addictive substances can initiate, exacerbate, mask, or mimic psychiatric problems.  Similarly, psychiatric problems can make one more susceptible to addiction” (p. 170).

What is important is to assess as clearly as possible, in the event of a co-occurring mental health problems and an addiction, which came first — as this will often dictate treatment priorities.  For example, the angry client whose rage attacks occur most often while under the influence will most directly benefit by addressing the substance abuse problem first.  This is not to say that issues around anger will not be needed to be addressed later; only that a clear baseline for that later work will likely presuppose getting the substance abuse under control first.

A third, specific treatment concern in working with co-occurring disorders has to with coaching the dual-diagnosis client in order that he/she might benefit optimally from 12-step support groups.  Think of it: a client with high levels of social anxiety might likely be expected to balk at such group involvement.  Or, another example, culled from a recent conversation with substance abuse expert Dr. Linda Salvucci: a client who has experienced developmental trauma in the context of organized religion might well be anticipated to be wary or so-called “resistant” to 12-step group involvement.

The question then becomes: how can I, the recovery counselor, first assess the client’s capacity and willingness to consider entering into a 12-step (or other) support group for adjunctive treatment?  And, assuming there is both sufficient capacity and willingness, how can I brainstorm, rehearse, prepare, and debrief with my client in a way that facilitates receiving the best results from such group involvement?

In working with the client presenting with co-occurring diagnoses, it is critical to perform an accurate, empathic assessment before self-help group enrollment; and to effectively provide for post-group discussion.

“The debriefing after the first 12-step meeting may be the turning point in recovery. The counselor must help the client overcome any initial obstacles after attending the first group. This may include a discussion of the client’s reaction to the group and how he or she can prepare for future attendance” (Gillig & Cingel, p. 176).

Helpful Resource for Recovery Professionals

Gillig, S.E., & Cingel, P.A.  (2012).  Co-occurring disorders and addictions treatment.  In      Capuzzi, D., & Stauffer, M. (Eds.), Foundations of addictions counseling (2nd ed., pp. 165-188).  Upper Saddle River, NJ: Pearson.





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