Dual Diagnosis

The term dual diagnosis in the addictions field usually means that a person is chemically dependent and also has a psychiatric disorder. The most common of these disorders are schizophrenia, major depression, and manic-depression. Patients are often called MICAs (mentally ill chemical abuser). No doubt the dual diagnosis phenomenon is as old as alcoholism and mental illness. But the treatment programs of the past few decades have noted that these clients are unsuccessful when treated with either a substance abuse or a mental illness model alone.


The symptoms of each disorder can mask or mimic the other. In the past chemical dependency programs would miss the mental illness, while psychiatric and mental health workers might miss the substance abuse.

Chronic relapse, medication abuse, failure to progress, disruptive behaviors, criminal behavior, and incarceration all pointed to the need for better treatment for these patients. Therapists needed a lot more training.


There are many programs available for the patient who is chemically dependent and schizophrenic. They are more obvious than other combinations. Some states have specialized programs and groups for the dual diagnosed client.


Counselors, social workers, psychiatrists, and nurses need special training to deal with this population. Dual diagnosis programs must have an integrated approach, combining all the knowledge and skills needed to treat each problem individually, with special strategies for dual diagnoses.


Interventions for this patient population are different from conventional chemical dependency treatment. Patients’ thinking may be fragmented and egos may be fragile. Traditional methods of education and confrontation may be ineffective. A New Hampshire model reported in Addiction and Recovery magazine (“Integrated Services for the Dually-Diagnosed Client,” June 1990) addresses the special vulnerabilities and slow progress of these clients. There are four stages to the process:

  • Engagement. Patients must be convinced of the need to become involved.
  • Persuasion. Clients must learn to want long-term abstinence.
  • Active treatment. Teaching skills and attitudes to maintain abstinence, often linked with NA and AA.
  • Relapse prevention. These clients are relapse prone, need daily reinforcement for clean time, and benefit from monitoring abstinence.


People with chronic depression and chemical dependence may have a chemical imbalance that suggests antidepressants. They may not appear disoriented or be disruptive, but they will find little joy in their recovery unless the depression is treated. For these patients, the depression is not related to what is going on their lives, and the Steps or gratitude lists do not help much. This condition should be diagnosed by a psychiatrist who knows about addiction.


This disorder is more than the dramatic mood swings that occur with addiction. They can wreak havoc for a person in treatment or trying to recover. If there is a history of it in your family, or symptoms continue months into recovery, see a psychiatrist.


A person with a borderline personality may have trouble recovering from addiction. Craigjohnson (1987) has done a lot of work with borderline bulimics and anorexics. He does not call bulimia an addictive disorder, but his suggestions are applicable when working with a borderline addict of any kind.

Borderlines do not know how to make effective use of human contact. Early caretakers were often perceived as trying to injure them. This sets up a harsh, punitive, sadomasochistic inner world, which they act out in relationships most of their lives. Borderline addicts will probably have more serious illnesses, suicide attempts, self-mutilating behavior, and more substance abuse accompanying other addictions.

These clients wear out both counselors and friends. You have to know how to avoid getting hooked into what Johnson calls projective identification. They try to set up an empathic link with you and carry you along with whatever rage or impulsivity they are feeling. With borderlines you feel “damned if you do and damned if you don’t.” Borderlines are best treated by teams. Johnson warns that they can make progress if you are willing to have a client for life.

Note that this psychological approach to the treatment of borderlines sounds a lot like some popular descriptions of codependency. It may be that Johnson is treating severe codependency, or that some people who are identifying with the codependency movement are indeed borderline. Either way, professional treatment of these individuals requires skilled diagnostics and therapy.


Multiple personality disorder (MPD) may also coexist with addiction. For more details refer to the Psychological problems module. When severe, this mental illness is likely to take priority over a person’s recovery. Many MPDS who are chemically dependent end up in prison. This disorder should be treated by programs with highly trained professionals.


Many hard-line AA members tell everyone they know that any use of a drug is relapse. This can cause problems for vulnerable, sensitive addicts who have dual diagnoses. Even Bill and Dr. Bob were aware of their limitations in the medical and psychiatric area, and they sought to work with doctors and psychiatrists for mutual understanding about alcoholism. The right answer for one addict can be the wrong solution for another.

Dual dianosis, see also: Anorexia nervosa, Codependency, Core functions, Counseling, Disease concept, Employee assistance programs, Energy levels, Impaired professionals, Intervention, Proression, Psychological problems, Therapy & treatment.

Updated 8 Sep 2015

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Addictionary 2 by Jan & Judy Wilson

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