Getting the Most out of Dual Diagnosis Treatment through Active Involvement

Here is a brief guide to help you get more active and involved in the diagnosis and treatment-plan process, read on to learn more about:

1. How clinicians come up with a diagnosis.
2. Why you need to be honest with your clinician.
3. What to do if you don't agree with your diagnosis.
4. Why you should guide the treatment plan (you have to state what you're actually willing/able to do).
5. How to prioritize and how to make a specific plan of action.
   

Diagnosis - Subjective Vs. Objective

Mental health and addiction are generally not objective in the way that most medical conditions are. If you have a broken leg, you could visit ten different doctors, all of whom will almost assuredly come to exactly the same diagnosis, prognosis, and course of treatment. Go see ten different dual diagnosis clinicians and there’s a very good chance you’d see a variety of diagnoses and a variety of treatment options and prognoses.

So there's no single right way.

Traditional dual diagnosis treatment has flaws:

• It tends to place the provider in the role of “expert” and the client into a passive role of recipient.
  
• Amongst “experts” is an ongoing debate as to whether substance abuse/addiction or mental health conditions should be treated first.
  
• In far too many practices, choice of treatment options rarely incorporates meaningful input from those being served.
  

Therefore, the more knowledgeable we are about the processes and our options, the better equipped we are to choose practitioners and approaches that best fit us.

Diagnosis Guides Treatment...So Be Honest!

Mental Health diagnoses are based on a biological/psychological/social (and sometimes spiritual) assessment, which is meant to be an holistic view of a person’s life – where we’re at and how we got here.

Diagnosis is important:

• Diagnosis dictates prognosis (likelihood of improvement) and treatment selection. Unfortunately, a very high percentage of clinicians rush this process. More accurate mental health diagnoses are achieved when we are forthcoming and candid in answering the myriad of questions posed in the assessment process.

So take your time:

• I urge my clients to take time to get comfortable and establish rapport before answering very personal questions. In most cases, a clinician has 30 days to complete this process. Take all the time you need and be aware of how your emotions in the moment may hinder you from being totally honest.

And tell the truth (don't minimize):

• Substance abuse and addiction assessment are based on Chemical Use Assessments and hinge on accurate reporting. Don’t understate your drug & alcohol use. Minimizing and rationalizing are a big part of how we came to be in harm’s way.

Understanding the Results

A completed assessment uses five Axis of treatment to organize multiple conditions. They are:

1. Axis I – Addiction, substance abuse and most mental health conditions
2. Axis II – Personality disorders, pervasive developmental disorders
3. Axis III – Known medical conditions
4. Axis IV – Major life stressors – financial, relational, occupational problems, problems with primary support group
5. Axis V – Global assessment of functioning - A ridiculously subjective numerical scoring of a person’s overall functioning. It runs from 0-100. Yet you’ll almost never hear of a person below 25 and it would be an exceedingly rare person in need of more than very short term treatment if their score is much over 75

What If We Disagree with the Diagnosis?

Don't blindly accept a diagnosis:

• I encourage my clients to seek thorough explanations in layperson language (accept nothing less).
  
• I also urge them to listen for what resonates (sounds true and feels true). In most cases, accurately diagnosing a person with less than six months of abstinence from drugs and alcohol is largely a guessing game.
  
• It’s further problematic when clinicians get bogged down trying to determine which came first - the chicken and the egg scenario of mental health condition or substance abuse.

(Hint: happy, well adjusted people don’t often develop addictions).

• Seek a second opinion. Consult with your primary care physician (especially before taking psychotropic medications).

We can recognize that many of us were self medicating when we used. We can consider whether we were a mess before we ever took the first drink or the first hit. We can also acknowledge that conditions or at least temporary states of depression and anxiety are inevitable for those active in addiction or in early recovery.

It doesn’t mean you’re crazy. It means you’re an addict/alcoholic.

Work for a Treatment Plan You'll Actually Follow

The final piece of the assessment is recommendations for treatment and other services that may be beneficial. In the midst of being overwhelmed and at a low point in our lives; it’s very tempting to simply accept these as a set of directions and follow them accordingly.

I urge my clients to set their own agenda for a very simple reason – what they’re willing to do is vastly more important than what I think would work best. If your clinician is recommending something you know you’re not willing to do at this time, tell them. Anything else is a waste of your time and theirs.

Need help choosing options?

Try the Keep It Simple System (K.I.S.S.). Treatment isn’t really about what we want. It’s about what we need. Start with your physical health and move your way up Maslow’s Hierarchy. If the house is on fire it doesn’t make sense to water the lawn. Prioritize.

I’ve joked for years that I’m going to write a scholarly article “Clinical Applications of Common Sense.” I find it conspicuously lacking amongst a lot of my colleagues. In the absence of a psychotic disorder or otherwise extremely debilitating condition, sobriety should always be the highest priority in treatment. Continued drug and alcohol abuse compromises a person’s ability to retain the gains they might make in treatment. Revisiting the same topics and feelings without the willingness and ability to make changes is like tearing off a scab every week and wondering why it’s not healing.

Prioritize and Make a Specific Plan

If we’re going to move beyond a place of being chronically overwhelmed then we require fractionating and accountability. I often ask my clients, “How many dragons are we going to slay at once?” They’ve identified twenty (overwhelmed) and I want to get down to one (manageability attained through fractionating).

The next piece is developing a highly specific plan for how we get from where they are to where they want to be. Vague notions and ideas do not result in action. Who, what, where, and when do result in action and accountability.

We have every right to support and treatment. We have the right to work with clinicians and other providers who are “client centered.” If the provider is truly invested in empowering others then they practice their profession in such as way as to solicit and respect the identified goals of the client. Being passive as a recipient of services means that we get to experience what someone else thinks we need. We tend not to be invested in what others want for us. Reconceptualizing treatment is as simple as setting our own agenda and choosing what matters most.