Proper Assessment and Diagnosis for Dual Diagnosis Clientele

T.V. Boscarelli, C.A.D.A.C., C.C.S.; Director of Adult Treatment Services – The Council on Alcoholism and Drug Abuse Santa Barbara

So much has been written and wrangled about treatment for dual diagnosis clients. Recently, over a two month period, the topic, ?Which Came First, the Chicken Or the Egg? brought tremendous response to a national dual diagnosis website. The debate centered, of course, on whether substance abuse caused mental illness, or mental illness caused substance abuse in dual diagnosis clients. It soon became apparent that those submitting opinions were from two distinct camps ? those with, primarily, a mental health treatment background, and those with, primarily, a substance abuse treatment background. As the discussion wound down, little was resolved. Each faction proved their point ? to themselves!

The rhetoric pinpointed the fact that, once again, professionals in this field lose sight of one of the key elements in proper assessment of any substance abusing population ? dependence vs. abuse. The two diagnoses are bandied about in discussions and research as if they are synonymous, and nothing can be further from the truth. Until a client is properly diagnosed in this area, effective treatment is accidental. With proper diagnosis, the practitioner?s bias becomes moot.

Too often, clinicians treat dual diagnosis as if there is one primary diagnosis and one secondary diagnosis. If there is a correct assessment of addiction, or alcoholism, these diagnoses indicate a primary disease, one that is not caused by any mental illness. Research today has isolated those genes that cause addiction and, although mental illness may be the catalyst that activates drug and/or alcohol usage, the addiction itself is a separate issue, the drug and/or alcohol usage a current symptom of that disease. Treating the mental illness as the primary disease, and expecting the addiction to dissipate without also treating it as a primary disease is contra-indicated. Conversely, if the mental condition were truly a primary diagnosis, not a series of symptoms caused by the abuse of chemicals, treating the substance abuse as addiction, and minimizing the mental illness would also not serve the client. Further, two primary diagnoses of mental illness and addiction (not substance abuse) need to be treated in an integrated or parallel manner, with both conditions being treated as primary, without one being seen as the cause of the other.

Semantics kill in this profession. Due to comfortability within a specific discipline, some providers prefer to diagnose all substance abusing mentally ill clients as addicts and alcoholics, and formulate their treatment plan accordingly. This wastes time, effort, and understanding that would be better served with a more cognitive-behavioral approach to curtail drug/alcohol usage. Other professionals minimize the addiction/alcoholism, calling it ?abuse,? and their treatment plans do not deal with the obsession and compulsion, as well as the emotional or spiritual aspects of true addiction and/or alcoholism.

The time has come for those professionals who have dedicated their lives to helping others to take a better look at the clients for whom they are working. ?Abuse? and ?Addiction and/or Alcoholism? are not interchangeable terms, any more than ?Depression? and ?Schizophrenia.? Until we take the time to properly diagnose clients and to differentiate in our writings, communications, and publications between addictive diseases and abuse, we will continue to do a grave disservice to the clients and patients that we propose to be helping.

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