Dual Disorders: Counseling Clients with Chemical Dependency and Mental Illness

Dual Disorders: An Overview

Introduction

One of the toughest challenges you will face as a behavioral health professional is treating people who suffer from dual disorders. The term dual disorders, or dual diagnoses, refers to cases in which the individual has both a substance use disorder (also referred to as chemical dependency or addiction) and a coexisting psychiatric illness, such as depression, schizophrenia, borderline personality disorder, social phobia, and other illness. The symptoms of one condition may mask the symptoms of the other or even make them worse. In fact, the use of the word dual may be misleading, since many affected people have three or more concurrent diagnoses. For example, one of our recent studies found that dual-diagnosis clients averaged 3.13 diagnoses, which was twice as high as clients who had psychiatric disorders without an additional substance use disorder.

Psychiatric disorders vary in their severity and effects on the client. While some psychiatric disorders are chronic and persistent with multiple adverse consequences, other disorders are experienced as a single episode and do not have implications for long-term involvement in professional treatment or recovery. Chemical dependency disorders also vary in terms of severity, chronicity, adverse effects on the client and family, and treatment implications.

Seven of the ten leading causes of disability in the world are directly or indirectly related to mental disorders or substance abuse. These seven causes are major depression, road traffic accidents (often caused by substance abuse), alcohol use, self-inflicted injuries (often caused by suicidal gestures), bipolar disorders, violence, and schizophrenia.

While specific types of psychiatric and substance use disorders create specific problems for the client and family, there are many general aspects of dual disorders and recovery. These general aspects apply to various combinations of disorders. Of course, the problems and recovery needs of a particular client will depend on the type and severity of the substance use and psychiatric disorders, ego strength, overall psychological functioning (that is, cognitive functioning, coping skills, strengths, and resiliencies), motivation to change, and the availability of social and family supports. Although everyone can change in some ways, the more chronically impaired clients have more difficulty achieving or maintaining sobriety, managing psychiatric symptoms, and coping with life problems caused or worsened by their dual disorders.

For some people, the substance use disorder dominates the clinical picture. These individuals usually enter the health care system through a chemical dependency program. Unless the dual nature of their problem is known, however, they may find that even after becoming sober, their mood remains low or their feelings of anxiety persist. For others, the psychiatric disorder takes priority, so they seek help through a mental health clinic or hospital. Treatment combining counseling and medications may improve their psychiatric symptoms, but until the chemical dependency issue is addressed, their compulsion to use substances will remain. Therapy must recognize and address both conditions, or the risk of relapse remains high.

It is possible to distinguish subgroups among people with dual disorders:

Those with a primary mental illness whose chemical dependency causes problems serious enough to warrant treatment. This group includes clients who have recurrent or chronic forms of mental illness as well as those who experience one or two acute episodes and function well between episodes. Some clients with chronic forms of mental illness experience persistent symptoms or residual disability, which causes significant psychosocial impairment and makes it more difficult to recover from chemical dependency. The severity of the coexisting substance use disorder may vary from mild to severe.

Those with a primary chemical dependency who experience psychiatric disorders or symptoms, which can interfere with the recovery if not addressed. This coexisting psychopathology may vary from mild to severe.

Those whose histories are so complex that it is difficult to determine which diagnosis is the primary one. Members of this group often have three or more disorders and exhibit severe problems caused or exacerbated by either a substance use disorder or mental illness. These clients may also experience significant residual disability and problems in psychosocial functioning.

On one end of the spectrum are those individuals who accept their conditions, who are internally motivated to change, who function relatively well, and who adhere to and respond favorably to treatment. On the other end are the persistently and chronically ill people who have multiple diagnoses, refuse to admit they have a problem with either or both types of disorders, have multiple problems caused or exacerbated by their disorders, have little or no motivation to change, who resist others' efforts to help them, and who have difficulty adhering to treatment and therefore respond poorly to it. Such people may enter the health care system voluntarily or only under outside pressure from external forces such as loved ones, employers, the legal system, or involuntary commitment to psychiatric care. Despite varying levels of problem or treatment acceptance, this group of multiproblem clients uses a disproportionately large share of treatment resources and often are hospitalized many times, especially those with chronic mental illness. As a treatment professional, you must be prepared to deal with clients from both ends of this spectrum.

Prevalence of Dual Disorders

There are two large-scale empirical studies documenting dual disorders or comorbidity. The National Institute of Mental Health (NIMH) published results of the Epidemiologic Catchment Area (ECA) survey of more than twenty thousand adults in five communities within the United States (see Robins & Regier, 1991, for a comprehensive review of ECA data). The survey found current or lifetime prevalence of psychiatric and substance disorders to be as in Table 1.1.

As this list shows, two of the top three diagnoses involve a substance use disorder. Overall, 34 percent of the adult population had experienced a form of mental illness or chemical dependency at some time in their lives. While 22.5 percent of those responding claimed a history of psychiatric disorders, 16.4 percent had a substance use disorder.

Nearly three out of ten people with a psychiatric illness have been diagnosed as also having a substance use disorder at some time in their lives. Thirty-seven percent of those with alcohol abuse or dependence and 53 percent with drug abuse or dependence met criteria for a mental disorder. Among drug abusers currently in treatment, 64 percent met the criteria for a coexisting mental disorder. Such numbers show that rates of mental disorders are very high among individuals with any type of substance use disorder, especially those in treatment.

The ECA survey also found that, compared with the general population, the rates of every psychiatric or drug use disorder were higher among alcoholics. The odds are nearly three to one that an alcoholic or a drug abuser will meet lifetime criteria for another disorder. It is also true that high percentages of those with a psychiatric disorder report a history of substance abuse, including 83.6 percent of those diagnosed with antisocial personality disorder, 60 percent of those with bipolar disorder, and 47 percent of those with schizophrenia.

The second large-scale study, conducted by Kessler and colleagues (1996), is the National Comorbidity Study (NCS) of more than 8,000 respondents, which also found high rates of mental health, substance use, and dual disorders. Results of the NCS show the following lifetime rates of disorders among the general population: 26.6 percent have a substance use disorder, and 21.4 percent have a mental disorder. Among those with a mental health disorder, 51 percent have a coexisting substance use disorder. And, among those with a substance use disorder, 41 to 66 percent (depending on the drug of choice) have a coexisting mental disorder.

In addition to these large-scale studies, numerous other sources report high rates of dual disorders. These include studies of clients receiving care in psychiatric or substance abuse treatment settings, comprehensive literature reviews of clinical populations, and publications by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and National Institute on Drug Abuse (NIDA). Considerable empirical evidence is available on the high prevalence of these conditions as well as the adverse effects on the affected client, family, and society.

Origins of Mental Disorders

In order to more effectively treat and prevent mental disorders, a lot of research has been directed toward understanding the origins of mental disorders, chemical dependencies, and dual diagnoses. While we do not yet fully understand how a person develops schizophrenia, panic disorder, or bipolar illness, in recent years there are several important themes that have come out of research in these areas. For clinicians to be most effective with their dual-disordered clients, it is important to understand these themes and use them in developing treatment approaches for their clients.

To begin, it is important to realize that your clients' illnesses evolved over time and across developmental milestones. For example, although a client with schizophrenia may appear withdrawn, disorganized, and poorly groomed when you first meet him or her, this person wasn't always that way. He or she may have started out in life on a relatively normal developmental course. Slowly, the symptoms of the disease emerged as he or she transitioned from, say, adolescence into young adulthood. The pattern of behavior that you now observe in the client is the consequence of the core disabilities produced by the psychiatric illness being shaped and modified over time. Different illnesses have different developmental courses, which result in different clinical pictures, different kinds of disability, and different types of psychological and social problems. For example, schizophrenia typically starts in the early twenties during the transition from adolescence to young adulthood, with some people having an earlier beginning and others having a later onset. Developmentally sensitive stressors such as social or school pressures or military service can trigger a first-break episode of schizophrenia. Depressive illness typically starts in the early adult years but can also start in late middle age. The stress of work retirement can produce a major depressive episode in someone who has had an otherwise uncomplicated history. On the other hand, some clients have been depressed almost as long as they can remember. A whole field of research, called developmental psychopathology, studies how mental disorders develop across time and human development. Understanding the time course for a psychiatric disorder provides an important tool in crafting interventions with clients.

Second, in the last few years, the revolution in human genetics has permitted a clearer understanding of the factors that contribute to the origins of mental disorders. Through investigations of the genetics and biology of mental disorders, we have developed a better appreciation of how social and family factors contribute to the development and manifestations of these conditions. We have learned that mental disorders, similar to conditions such as hypertension, asthma, and cardiovascular disease, are what geneticists refer to as complex disorders. Complex disorders tend to run in families, but they are not inherited according to the classical pattern that was first described by Gregor Mendel in his studies of dominant and recessive traits in pea plants. In fact, unlike the color of Mendel's peas, it is unlikely that any single gene causes a mental disorder. Instead, we understand these conditions are due to the complicated patterns produced by many genes at once. In addition, all complex disorders are strongly influenced by environmental exposures and stressors. The environmental exposures help turn on certain genes and turn off other genes, thereby shaping the connections in the brain, the growth of the brain, and the way the brain functions. This is especially true during early development and maturation. The family environment (be it good or bad) tends to make family members more like each other, as does the neighborhood and the culture shared by all family members. Each family member, however, is also exposed to environmental influences not shared by all family members. These include school, work, leisure activities, and the social networks we participate in. These nonshared aspects of the environment tend to make family members more different.

So, now you understand why you and your brother (or sister) are so similar in some ways and so different in other ways. You and your sibling share a lot of genes in common, and you grew up in the same household. These factors make you similar. You each had individual experiences with the world and people around you, however, and that, along with genes that defined you from birth, is what produced your differences. In summary, the environment works on your genes, turning some on and others off, making you the person you are. The same is true of your client. No two individuals with schizophrenia are exactly alike. The signs and symptoms of the disease they carry is altered by environmental exposures that have a different impact depending on when in their lives they experience them. What's interesting is there is also research showing that people with certain kinds of genes tend to gravitate to specific kinds of environments, so the effects of genes and environments are thought to be a two-way street where they actively influence each other but ultimately result in our characteristics as people.

So the environment is pretty important in understanding mental disorders. We have come to learn that the old question Is it due to nature or nurture? isn't really the right question to be asking. Biology and the environment work together in a really complicated way to produce mental disorders. These complex diseases are due to both nature and nurture. When we use medication management, we treat the biological aspect of the illness that is the result of certain genes turning on and others turning off. When we provide psychological and social therapy, we are addressing the way the client responds to the environment (for example, family or social environments) that also has an impact on his or her brain biology. The effective clinician needs to appreciate the roles played by both factors in order to fully understand the client's illness. This is especially true with dual-diagnosed clients, where the impact of alcohol and other drugs has additional biological and environmental consequences.

Relationships Between Chemical Dependency and Psychiatric Illness

There are many possible patterns of interaction between chemical dependency and psychiatric disorders. The following list discusses the many relationships between the disorders. (See Daley & Thase, 2000; Meyer, 1986; Rosenthal & Westreich, 1999; Salloum & Thase, 2000).

Chemical dependency increases the risk of developing a psychiatric illness. The ECA survey and studies of clients in chemical dependency programs strongly suggest that the odds of a chemically dependent individual having a psychiatric illness are higher than would be expected among the general population. For example, the ECA survey found that drug abusers were 4.5 times more likely to develop a psychiatric disorder compared to people who don't abuse drugs.

Psychiatric illness increases the risk of developing a chemical dependency. The ECA survey and studies of clients receiving psychiatric care show higher than expected rates of chemical dependency. For example, the odds of having a chemical dependency are 2.7 times higher for individuals with a psychiatric disorder compared to those without a psychiatric disorder. Rates of substance use disorders are especially high among clients with antisocial personality disorder, borderline personality disorder, bipolar disorder, or schizophrenia.

Psychiatric symptoms may affect the onset, duration, or response to treatment of chemical dependency. Cloninger (1987) characterized alcoholics into two subgroups, male-limited (25 percent of sample) and milieu-limited (75 percent). Members of the male-limited group appear more likely to be influenced by biological factors and to develop substance abuse problems earlier (usually before age twenty-five) than members of the other group. They are also more likely to get into trouble with the law and more likely to have biological fathers who have problems with substance use and antisocial behavior. Members of the milieu-limited group are thought to be more influenced by environmental factors in developing alcoholism, and they develop it at a later age. McLellan and colleagues (1983) report that clients with higher ratings of psychiatric severity on the Addiction Severity Index are more likely to relapse to substance abuse than other clients are. Psychiatric impairment has a strong association with relapse to drug use among opiate addicts. Clients who have both chemical dependency and antisocial personality disorder drop out of treatment at a higher rate and thus have a poorer prognosis than other diagnostic groups do.

Chemical dependency affects adherence to psychiatric treatment and clinical outcome. Psychiatric clients with an additional chemical dependency disorder show much worse treatment adherence rates and higher rates of relapse and hospitalization in a psychiatric facility. As a result, clinical outcome is worse.

Psychiatric symptoms may arise as a direct result of chronic substance abuse or withdrawal. Drugs and alcohol may directly impair mood, cognitive functioning, or behavior. Depression, mania, anxiety, panic, paranoia, delusions, and hallucinations are some of the specific symptoms that may result from chronic use of substances or as part of an acute or protracted withdrawal syndrome. For example, users of PCP, hallucinogens, or stimulants may become psychotic and present a clinical picture that sometimes resembles schizophrenia. Alcoholics and cocaine addicts may experience depression and suicid-ality during withdrawal. Individuals who abuse tranquilizers may show agitation and anxiety symptoms when they cut back or stop using these substances. The preceding examples generally involve chronic or heavy substance abuse. Keep in mind, however, that even small doses of alcohol or other drugs can cause difficulty in the client who has a chronic or persistent mental illness.

Symptoms of psychiatric illness may result as the indirect consequences of chemical dependency. Many individuals suffer tremendous personal consequences as a result of their chemical dependency. Disturbed family and interpersonal relationships, increased health problems, trouble on the job, loss of dignity, and squandered potential are common among the chemically dependent. Use of illicit drugs can lead to trouble with the legal system, resulting in loss of freedom as well. Any of these circumstances can contribute to depression or anxiety. Chemical dependency can also produce antisocial behavior such as selling drugs, stealing to support an addiction, aggressiveness toward others as a result of impaired judgment, or suicidality.

Over time, symptoms of chemical dependency and psychiatric illness may become linked or interrelated. In some cases, it may be difficult to distinguish which disorder is primary and which is secondary. Many of those with chronic disorders come to treatment with a very complex set of symptoms and problems. The specific symptoms may even vary from one episode of an illness to another.

The dual disorders can develop independently at different times. Alcoholics or drug addicts who have been sober for many months or years can still develop an episode of psychiatric illness such as major depression. Individuals with schizophrenia or panic disorder may abuse or become dependent on alcohol or other drugs while their psychiatric symptoms are in remission. It is not always easy to determine if dual diagnoses are present because a psychiatric disorder can mask chemical dependency, and chemical dependency can mask a psychiatric disorder. Even after you have established the diagnoses, it may not be clear which problem should be treated first. Some believe the psychiatric illness takes precedence, while others believe the chemical dependency should have priority. Depending on circumstances, either position may be correct. In any case, treatment must address both conditions at some point, either sequentially or simultaneously. Untreated chemical dependency may contribute to a relapse of the psychiatric disorder, and untreated psychiatric disorders may contribute to an alcohol or drug relapse.

Three Perspectives on Dual Disorders

Client

A single psychiatric illness or substance use disorder can be trouble enough. People with dual disorders, however, are in a kind of double bind because they have multiple disorders, often accompanied by problems in various areas of functioning. Problems associated with dual disorders include (1) higher rates of disability with more total DSM-IV-TR diagnoses, days in the hospital, ER visits, and use of psychiatric and substance abuse services; (2) higher rates of unstable living arrangements or homelessness, medical problems, HIV infection and sexually transmitted diseases, violence, legal problems, and incarceration, and social problems including family burden; (3) poorer treatment response, lower rates of adherence to treatment, and higher relapse and rehospitalization rates; and (4) higher rates of depression and suicide.

Certain subgroups, such as the chronically mentally ill, often have difficulty in daily functioning. They may be unable to find or keep a job, live independently, or develop satisfying interpersonal relationships. Many have trouble complying with treatment and are at higher risk of relapse. Sicker clients with more symptoms need more care, but unfortunately they are less likely to remain in treatment.

Some clients with dual disorders get caught up in a vicious cycle. They enter either the mental health or the chemical dependency treatment system (or both). Professionals may react negatively to a client's slow progress, the inability to abstain from substances, disinterest in abstinence as a treatment goal, poor adherence with therapy or medications, and reluctance to engage in self-help programs. Try to understand each client from the inside out. Think about what it feels like for the client to have two or more disorders, as well as the impact it has on a client's self-esteem, ability to function, relationships, and quality of life.

Family

Psychiatric illness, chemical dependency, or the combination of the two can have a significant adverse impact on the family system as well as individual members, including children. On the other hand, the family has a tremendous influence on the client as well. Try to understand the family's unique experience having a member with dual disorders. Think about the family member's relationship with the ill member, and personal reactions (thoughts, feelings, concerns, worries, and behaviors). Chapter 3 is devoted specifically to the family and will review family issues with which the clinician should be familiar. The chapter will also discuss ways you can help family members even if you are not a family therapist or social worker.

Counselor or Therapist

Chemical dependency counselors must learn to recognize psychiatric disorders and to deal with them in an appropriate and timely manner. Similarly, mental health counselors need to recognize and deal with clients who have chemical dependency problems, and they must be prepared to offer the full range of treatment options, including support groups and Twelve Step programs.

For these reasons, you will need to be ready to carry out many different functions in the course of your client's care: assessment, treatment, referral, and advocacy. Although you will not necessarily provide treatment for clients with whom you are not properly trained, you will encounter dual diagnosis clients and therefore may need to rely on other professionals and treatment programs to ensure the client gets the treatment needed. You should be aware of all the resources available in your community: treatment centers, self-help groups and their locations, social services, case management, economic assistance, housing, vocational training, and so on. Since psychiatric hospitalization may be needed with some dual-disordered clients, familiarize yourself with the procedures and community standards for voluntary and involuntary hospitalization. You should also have a working knowledge of various intervention strategies used for influencing clients with chemical dependency to seek the proper treatment if you or your agency are unable to provide it.

Be aware of your own limitations and do not attempt to provide treatment to clients if you lack knowledge of or experience with their disorders. For more seriously impaired clients, establish goals that are realistic and achievable. You may have to modify your view of what constitutes success or failure for clients whose dual disorders significantly impair their judgment and functioning.

Your attitudes and perceptions are critical influences on the process and outcome of clinical interventions. Some mental health professionals, for example, tend to regard clients with substance use disorders less sympathetically than those with psychiatric illness. Similarly, some chemical dependency professionals are skeptical about the impact (or even the reality) of certain psychiatric illnesses; they may tend to assume that all of their clients' problems stem from chemical dependency. Like their mental health counterparts, they may judge or negatively perceive clients who have certain disorders. For example, when confronted with a person who has been diagnosed as having borderline or antisocial personality disorder, the caregiver may label the client as problematic before treatment has even started or before it has been given a fair chance to work. Some clinicians look unfavorably on clients who relapse to substance abuse during treatment or shortly afterward. They tend to judge less harshly those clients who show symptoms of their psychiatric illnesses after a period of remission. Such attitudes and perceptions may affect your involvement in the treatment process or lead to undue pessimism about its potential results.

If you are a chemical dependency professional, you may need to reexamine your attitudes concerning the use of medications. Medications are a necessary and effective therapeutic option for many individuals with certain psychiatric disorders. Do not assume that the need for these medications indicates that the client is not really sober or clean and is still dependent on drugs. Failure to facilitate an assessment of a client's need for medication and to make appropriate prescriptions available is unethical; it can prolong suffering and interfere with or prevent recovery from a psychiatric disorder.

This example illustrates the point: a forty-four-year-old male alcoholic named Ned became severely depressed a few months after achieving sobriety. Although aware of Ned's depression, his counselor told him that she did not believe in medications for alcoholics (she also made this statement to one of the authors involved in this case). For some time, she continued to treat Ned with supportive therapy only. There were some modest improvements in his symptoms, but overall his depression remained severe. Finally, Ned insisted something else be done. Only then did the counselor refer him to us for psychiatric evaluation. We designed a course of treatment that combined antidepressants with psychotherapy. Within a few weeks, Ned reported significant relief in his depressive symptoms. Had the counselor accepted the need for medications, Ned's suffering could have ended much sooner.

Again, by the same token, some mental health professionals may need to evaluate their beliefs and attitudes regarding the value of self-help programs in promoting recovery. Some therapists are saddled with serious misconceptions and erroneous beliefs about what self-help programs do and how they function. Consequently, they either fail to inform clients that these programs are available or they discourage anyone from taking advantage of them. Another example from our clinic makes this point: Stuart, a twenty-eight-year-old drug addict with a long history of multiple psychiatric disorders, told us his previous outpatient therapist had said that Narcotics Anonymous (NA) was a religious program and that there was no evidence it was effective in helping addicts stay off drugs. We took the time to correct Stuart's impressions. Certainly NA, like all related Twelve Step programs, has a spiritual component, but this is not the same as it being a religious program or a religion. We also told him of reports from tens of thousands of addicts, some of whom were participants in our own treatment program, who believe that their lives may very well have been saved as a result of participation in NA. Surely such evidence supports the notion that the NA program can be effective.

If you have not already done so, we recommend that you attend several open meetings of Alcoholics Anonymous (AA), Cocaine Anonymous (CA), Narcotics Anonymous (NA), Dual Recovery Anonymous (DRA), or mental health self-help groups to see recovery in action. Witnessing a meeting will give you a clear image of the dynamics of recovery and provide a sense of the powerful effects of the fellowship available in such a setting. Attending meetings broadens your perspective: in clinical situations, you may see only those addicts who are struggling with problems; sitting in on a self-help meeting, you have the opportunity to see those who are doing well. The healing forces at work in self-help programs often apply equally well in addressing psychiatric disorders. People can help each other recover by sharing strategies for managing their mental disorders and supporting each other in their efforts to overcome the impact of the disorders on their lives.

Some caregivers tend either to overdiagnose or underdiagnose cases of dual disorders. We caution against both tendencies. For example, getting drunk on alcohol or high on pot does not automatically indicate that the person doing so has a substance abuse or substance dependence disorder requiring treatment. Such behavior may represent instead an incident of substance misuse. On the other hand, you are no doubt aware of cases in which alcoholism or drug addiction was clearly present but was not diagnosed.

The same problem exists with regard to the psychiatric aspect of dual disorders. In our practice, we have treated clients who clearly met criteria for a major depressive illness or anxiety disorder but who were told by other caregivers that their symptoms were merely the result of substance use, as in this example: Betty, sixty-five years old, had a long history of alcoholism. She also reported symptoms of phobia and panic. Several therapists in a substance abuse clinic had told her that drinking was the cause of these symptoms. She reluctantly agreed to attend an inpatient rehabilitation program, but her phobic symptoms led her to leave after just one day, saying, I could not stand being closed in. Eventually Betty was referred to our clinic. We consulted with staff members of the rehabilitation program, who told us Betty had left because she was thirsty. No, they said, they had not even considered the possibility that she suffered from some form of psychiatric illness. Since receiving treatment for her anxiety and phobia, Betty has done quite well. She is sober, and her psychiatric symptoms have stabilized.

Sometimes therapists or counselors mislabel their clients because they lack complete information about the condition. A client who has one or two episodes of antisocial behavior may be slapped with a diagnosis of antisocial personality disorder, even when he or she does not meet the stringent criteria for this diagnosis. Such inappropriate or careless labeling only hurts clients. It is difficult, if not impossible, to develop a healthy therapeutic alliance if the counselor prejudges the client negatively.

Professional Enabling

Mental health professionals who lack knowledge or skill, or who carry negative attitudes and perceptions about certain conditions or clients, may directly or indirectly perpetuate or exacerbate a person's chemical dependency or psychiatric illness. This is known as professional enabling. Such enabling may be passive, such as ignoring a serious mental health or chemical dependency problem, or active, such as giving inappropriate advice or treatment. Examples of enabling behaviors or attitudes include the following:

Failure to gather an accurate and detailed history of alcohol and other drug use, as well as of psychiatric symptoms.

Failure to address the chemical dependency or the psychiatric illness in the treatment plan.

Waiting for the person with a chemical dependency to hit bottom or to ask for treatment.

Assuming that the client must acknowledge a psychiatric illness in order to benefit from treatment.

Giving oversimplified advice, such as telling a substance abuser to stop drug use without suggesting a professional treatment program, a self-help recovery program, or both; advising a client with serious clinical depression or anxiety to attend AA or NA meetings without considering other options such as medication or psychotherapy.

Assuming that major or multiple problems must exist before the client can be considered chemically dependent or psychiatrically ill. As with any type of illness, there is a range in the severity of, and degree of impairment from, chemical dependency or psychiatric illness.

Viewing the chemical dependency as merely symptomatic of a psychiatric illness or viewing psychiatric symptoms as merely caused by chemical dependency.

Excluding the family from the assessment or treatment processes when their involvement is indicated.

Assuming recovery is in motion simply because a client stops using alcohol or other drugs.

Assuming that each of the dual disorders requires treatment by separate clinicians or in separate programs.

Taking a rigid stance against the use of medications to treat psychiatric illness.

Assessment of Dual-Diagnosis Clients

DSM-IV-TR Multiaxial Assessment Process

A comprehensive assessment is needed to determine diagnoses and treatment needs of the client. According to the American Psychiatric Association (APA), domains of this comprehensive clinical evaluation include the following:

Reason for the evaluation (chief complaint, reasons for seeking treatment or for hospitalization)

History of the present illness (symptoms, problems, factors leading to changes in symptoms or illness)

Past psychiatric history (past syndromes and treatments and the effects of those treatments)

General medical history (current and past illnesses, medical problems and treatments)

History of substance use (amount, frequency, quantity, methods, and consequences of use of both licit and illicit substances)

Psychosocial and developmental history (developmental milestones, education, work, sexual history, cultural and religious influences, history of abuse, trauma or experiences in war or natural disasters, legal or criminal history, and history of relationships and functioning in family and social roles)

Social history (living arrangements, relationships, involvement in social agencies or criminal proceedings)

Occupational history (jobs held, reasons for changing jobs, stress or environmental problems associated with jobs, military status and experiences)

Family history of illness (medical, psychiatric or substance use disorders among relatives)

Review of systems (sleep, appetite, pain, fatigue)

Physical examination

Mental status examination

Functional assessment (activities of daily living such as eating, shopping, managing money, caring for a family)

Methods of attaining information include interviews with the client or collateral sources (family members, friends, and other providers of services), observation of the client, structured interviews, questionnaires and rating scales, psychological or neuropsychological tests, and physical examination or laboratory tests.

The clinician should become familiar with the APA's multiaxial system of recording