Until the Eighties, it used to be that clients coming in for treatment were typically corralled into two discrete camps: the mentally ill or the substance abuser. Each had parallel treatment and discrete funding streams. As that decade drew to a close, so appeared the term dual diagnosis, a clinical moniker which appropriately – finally! – acknowledges the reality that those who experience substance abuse disorders were almost always in the throes of one or more concurrent mental health disorders which needed treatment.
Dual diagnosis is when a person experiences a mental health disorder and a comorbid substance abuse problem. There is extensive and ongoing deliberation over the appropriateness of using a single category for a heterogeneous group of individuals with complex needs and a varied range of problems. The concept can be used broadly, for example, it can describe a person with depression and alcoholism, or it can be restricted to specify severe mental illness like schizophrenia and a substance misuse disorder (i.e. someone abusing cannabis or a person who has a less impairing mental illness and drug dependency).
Diagnosing a primary psychiatric illness in substance abusers is challenging, as drug abuse itself often mimics psychiatric symptoms, thus making it difficult to differentiate between substance induced and pre-existing mental illness. Taking a robust social history and creating a genogram, or Family Map, which includes a family’s history of trauma, sudden death, marriages, divorces, sexually acting out, money issues, learning problems, alcohol abuse, drug abuse, in addition to religiosity, etc. helps in the assessment. Taking a bio-psychosocial history of the individual in question helps, although it does not always provide all the necessary clues. Using the research methodology of Portraiture which was developed by the Harvard Qualitative Researcher, Sara Lawrence Lightfoot (The Art and Science of Portraiture) and conducting individual interviews with key stakeholders i.e. family members , business managers, estate attorneys etc. greatly enriches the perspective of the identified patient and aids in the assessment process.
As a seasoned interventionist, I’ve seen clients from both sides of the mental illness/substance abuse spectrum as well as clients with an avalanche of additional problems that I describe as the TRIPLE THREAT, those who experience a tertiary issue either as a result of a prior condition (i.e. disorder or illness) or that one that is exacerbated by additional factors (i.e. physical, legal, traumatic, etc.). These folks and their families present a diagnostic quandary with their kaleidoscope of competing and equally important issues.
Imagine you have a thirty-six year old male client who was in a serious car accident at age sixteen which left him paraplegic. He engages in same sex activities, has disordered eating patterns and has been diagnosed with a personality disorder and has difficulty following through on tasks. Today he is using methamphetamines and while able to drive and is resilient, has failed to launch any farther than the local drug dealer. His family reactively coddles him as they feel the pain of his loss, not allowing him to grow, frozen in the headlights of his endemic grief. This case presents a challenge from many perspectives including and not limited to physical, emotional issues. Finding a treatment center and skilled staff to address the multiplicity of factors becomes an art while simultaneously working with the family.
Likewise, the business manager of a well-known celebrity calls you. The family is a mess and her entourage (business manager, agent, hairdresser, stylist, makeup artist, etc.) is afraid to speak. The house is full of boxes and boxes of unopened merchandise she has purchased. She was seen stealing in a local boutique. She hears voices. Her personal assistants are silent in fear for their employment, as are her parents who have become part of the entourage she must support. In this case as in many like this, the first task for the interventionist is to break through the fear that the team around her has so that a pathway can be created to help this young women towards health and wellness.
An 89-year-old mother calls you, as her New Year’s wish is to save 43-year-old granddaughter and 63-year-old daughter. Her granddaughter houses a methamphetamine lab in her home and surrounds herself with men of nefarious goings- on; their favorite pastime is to break and enter cars. The police are frequent visitors. She has the cognitive abilities of a fifteen year old and the rage of a tiger. Her mother lives in a nearby hotel smoking pot every day and is being supported by the hotel staff that love her and her eccentricities. Neither has had to truly work, and together they are both drowning in the stifling vicissitudes of trust funds, family histories of divorce, religiosity and substance abuse. Both experience anxiety disorders. Here, the hotel staff on the one hand has to be taught that to help their long standing guest, they have to let her go and seek treatment. For the daughter, legal eviction proceedings and the promise of getting her mother help served as a catalyst for change.
A 30-year-old male had traveled through seven treatment centers with the swiftness of an arrow. Each time, he and his parents found fault with the center. For the parents it was never their son’s fault. He was a “country boy” corrupted by the city and wanton women. They turned a blind eye to the arrests, time spent in jail, long absences and disconnections. As interventionists my partner and I worked to use the legal ramifications of his case to help him on a road to health. The Court sentenced him to probation and approved treatment for one year. If he left he would be returned to jail. The court served as a change agent. The family agreed to stay out of micromanaging the treatment team. A “Change Agreement” was developed and signed which specified behavioral changes for all parties not just the IP. Close collaboration between us as case managers and the treatment center ensured accountability.
With each case, my partner, Jeff Merrick, Esq. and I find it essential to be empathetic, compassionate and strategic. We must prioritize intervention strategies that invite and respect the individual and identify therapeutic interventions to help the whole group. This triage includes picking the right treatment center, as not all treatment centers are created equal. By that I mean they have to specifically be able to meet the mental health, substance abuse, physical and legal needs of the client, and be open to collaborating with the case management team. We in turn must be open, flexible and strategic in setting up collaborations both inside and outside the treatment center. We must also be prepared to refer family members to others, when appropriate, for ongoing therapy or intensive workshops.
Our health care system does not always adequately meet the needs of Triple Threat Clients, their eco-systems and substance abuse/mental health issues. Money is always a stumbling block. I believe we must look at the treatment from micro, mezzo and macro perspectives – the individual who needs help, the treatment team supporting their treatment/recovery and the accountability team supporting the individual (i.e. parents, loved ones, their attorney, business manager, or hairdresser etc.). Everyone has to be on board with the client’s treatment path, as well as the health care system which affords treatment and provides for community recovery.
This is a simple, yet terribly complex phenomena: if the threat is triple, our intervening responses have to be as rich and robust as the trauma and neurochemical glitches driving the distress. The era of the Triple Threat is here, presenting with increasingly vocal symptoms that can no longer be sorted through a traditional Dual Diagnosis treatment.
While three may be a crowd, we are at peril if we ignore the needs of this cacophonous threesome with its unique pains and pathologies.
Thank you to Jo Bainbridge MFT, Denise Klein MSW and Sheena Aquino BA for their assistance in bringing this important discussion forward.
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