In a reader’s survey that we conducted several months ago, many endorsed “co-occurring disorders” (CODs, also called “dual disorders”) as an area of strong interest. This is the first of several articles on this important topic. I will start with a discussion of my father’s experience with CODs followed by a brief review of prevalence and effects of CODs. I will then discuss integrated treatment, recovery from CODs, and the impact on the family (including my family) with a focus on the need for treatment and/or recovery for family members.
A Personal Perspective
My father suffered from chronic alcoholism, depression, and anxiety most of his life, and did not get adequate help until he was sixty-six. I suspect he may have had posttraumatic stress disorder (PTSD) as he was an infantry veteran in WWII wounded in the Pacific, for which he received a Purple Heart. I am pleased to state he lived the last fourteen years of his life sober, and showed a significant improvement in his anxiety and depression. My father was successfully treated by a friend and colleague of mine, a psychiatrist, whom dad and his wife travelled ninety miles to see since they could not find good care in their community. I believe my father’s treatment was successful because this psychiatrist focused on all of his disorders, and involved his wife.
I am less pleased to report that several other medical, psychiatric, and addiction professionals failed in their attempts to help my father. My father and mother, whose death was a major factor in his decision to get help at age sixty-six, told me at different times that his primary care physician and a local psychiatrist both told him on numerous occasions to “cut down” on his drinking, which was not good advice for a man who often consumed over a case of beer per drinking episode and hallucinated during periods of DT’s—signs of serious alcohol dependence. My dad left an addiction rehabilitation program against medical advice because staff did not adequately address his chronic depression and anxiety. He told me that a counselor in the rehab program asked him to write a letter to my mother in an attempt to help him grieve her death. He thought told me it was odd that that he was asked to write a letter “to my dead wife.” Clearly, focusing only on one disorder or telling an alcoholic to “cut down” on his drinking were not effective interventions for a man with CODs.
I know of many other cases in which only one type of disorder was addressed by a treatment team or a professional. I have seen or talked with many families who felt frustrated and upset when treatment of their loved one focused on one type of disorder, which contributed to a poor clinical outcome and relapse to the psychiatric condition or SUD. Fortunately, I know of many cases in which getting the person and family integrated care for the CODs made a significant difference in their lives.
Understanding Co-Occurring Disorders
Epidemiologic and clinical studies show high rates of CODs in community populations and in psychiatric or addiction treatment programs (Kelly & Daley, 2013; Mueser & Gingerich, 2013; Nunes Selzer, Levounis, & Davies, 2010). While SUDs are most common among individuals with antisocial (84 percent) and borderline personality disorders (67 percent), bipolar illness (60 percent), and schizophrenia (50 percent), they are also found with those who have clinical depressive, anxiety, attention deficit, eating, and other DSM-5 disorders. Additionally, many have more than two disorders. For example, depression is common among those with schizophrenia, anxiety disorders, and borderline personality disorder.
Having one type of disorder raises the risk of having the other type, and impacts on treatment and recovery. Substance use can cause, worsen or mask psychiatric symptoms and contribute to relapse. Psychiatric symptoms can lead to substance use and contribute to a SUD or a relapse.
There are many variations of CODs, each with different implications for treatment or recovery. For example, a young man with chronic schizophrenia and dependence on marijuana will have different issues and needs than a middle age woman with mild depression and a prescription opioid dependence, or an elderly man with chronic anxiety and alcoholism. A psychiatric disorder or a SUD can be severe, moderate or mild, so there are many potential combinations. Those with more severe or chronic disorders face more challenges in their recovery.
Numerous studies show that people with CODs have higher rates of noncompliance with treatment, hospitalizations, use of emergency room services, unstable housing or homelessness, depression and suicidality, medical problems such as HIV infection and STDs, legal problems and incarceration, violence, family problems, and financial problems (Daley & Moss, 2002; Mueser & Gingerich, 2013). My colleagues and I found that patients with CODs, compared to those with only a psychiatric disorder, have higher rates of suicidality and homocidality, spend more days in the psychiatric hospital, have higher readmission rates, and have lower rates of entry into ambulatory care following psychiatric hospital discharge (Daley & Douaihy, 2013).
Treatment of CODs
Mental health professionals need to assess patients for substance use and, when a SUD is diagnosed, include this in the treatment plan. Similarly, addiction professionals need to assess patients for psychiatric symptoms and include any psychiatric disorder in the treatment plan. In some instances this may require collaborating with other professionals to address the patients’ disorders, as not all systems are able to provide integrated care to all types of patients. For example, many addiction programs are not staffed to treat patients with SUDs who have schizophrenia or bipolar illness, so an integrated program in a psychiatric system is more appropriate.
Counselors and other providers need to convey helpful attitudes towards patients with CODs. I am aware of many instances in which professionals in psychiatric and medical systems have said or conveyed negative statements to patients with SUDs. I am also aware of situations in which addiction professionals have minimized or even ignored the psychiatric disorder. I am also aware of situations where a patient had trouble finding a program that would treat the CODs. For example, I received a desperate call from the director of United Mental Health, now called Mental Health America, who told me a woman with alcohol dependence, major depression, and agoraphobia called five addiction or mental health programs only to be shuffled back and forth between systems. Mental health professionals told her to get her alcoholism treated first and addiction professionals told her to get her psychiatric disorders treated first. She did not get well until we treated her in one of our integrated programs that addressed all of her disorders. I believe all of these systems had good intentions when suggesting she get help elsewhere, but as a colleague once told me “the road to hell is paved with good intentions.”
Treatment of CODs may require a combination of psychiatric and addiction services offered in hospitals, rehabilitation programs, community residential programs, ambulatory programs or specialty programs. Other services are often needed for more severe cases such as case managers, vocational counselors, outreach workers, peer mentors or others. In addition to treatment programs or therapy, many individuals with CODs need medications for their psychiatric illness or dependence on nicotine, opioids or alcohol.
Integrated treatment refers to receiving care for both disorders from the same treatment team or professional. There are many approaches to integrated care. Some approaches focus on any combination of disorders while others focus on specific categories of psychiatric illness combined with SUDs (Mueser & Gingerich, 2013; Daley & Thase, 2003; Nunes et al., 2010).
Individuals with chronic or severe psychiatric disorders should be treated in a mental health system that can also address their SUD. The goals of treatment of CODs are to help patients manage their disorders, engage in recovery, reduce relapse risk, and make personal or lifestyle changes that lead to an improvement in the overall quality of life.
Recovery from Co-Occurring Disorders
Recovery may involve any of these domains: physical, lifestyle, psychological, family, social, and personal growth (Daley & Douaihy, 2014; Daley & Thase, 2003). Each patient’s recovery plan is unique. While some are involved for a brief period, others are involved life-long, especially those with more chronic and persistent psychiatric disorders or substance addictions.
Patients need to identify recovery goals and steps they can take to reach these goals. Recovery is an active process that may involve a combination of the following:
- Information: Learning about alcohol or drugs; causes, effects, and treatment of both types of disorders; the role and limitations of treatment; and the processes of recovery and relapse.
- Increasing self-awareness: Understanding the impact of the disorder(s) on self and others, motivation to change, personal coping mechanisms, and personal barriers to change.
- Learning and using coping skills: Developing or strengthening behavioral, cognitive, and interpersonal skills to manage symptoms of the CODs, and making changes pertinent to treatment goals.
- Involving the family or significant others: Including others in treatment and the recovery processes to reduce family burden, elicit their support, and provide them an opportunity to address their feelings and problems.
- Engaging in mutual support programs: Engage in MSPs to provide the patient with help and support from peers, and exposure to a program to manage the disorder(s).
- Reducing relapse risk: Anticipating and reducing risk through early identification and management of relapse warning signs and personal high-risk factors.
- Having a safety plan: Addressing self-harm behaviors, suicidal thoughts or feelings, and not acting on a plan, or controlling desires to harm others.
CODs and the Family
Family units and individual members may experience negative effects from exposure to a loved one with CODs (Daley & Sinberg, 2004; Mueser & Gingerich, 2013). Specific effects vary from one family to the next or among members of the same family. Factors determining the impact on a family or member include who in the family has the disorders, how they act and function, whether they are receiving treatment, support available to the family member dealing with a loved one’s CODs, and coping skills of the family member. Some people are more resilient and able to manage stressful situations than others.
In a survey of over 120 patients with CODs that I conducted in one of our treatment programs, patients reported the following effects on their families or significant others:
- Caused an emotional burden (91 percent)
- Neglected their family (84 percent)
- Acted irresponsibly towards family (74 percent)
- Created an economic burden (64 percent)
- Physically abused a family member (45 percent)
- Lost a child, usually to child welfare, due to problems created by their disorders (25 percent)
This shows that patients recognize that their families experience multiple negative effects of their CODs. Family involvement in treatment and/or recovery are ways to help members learn to support and deal with their loved one while getting help and support for themselves to deal with their emotional burden and problems caused or worsened by the SUDs. If clinical depression, an anxiety disorder or a SUD are experienced by the family member, professional help is needed. Participation in mutual support programs can help as well.
A Personal Perspective on My Family
Our family lived in public housing or rundown houses much of the time, had no phone or car for years, and depended on public assistance off and on. We moved seven times by the time I was a teenager, had utilities cut off several times, and sometimes lived from day to day or even meal to meal—mother was creative and resilient in feeding us. There were six children in our family: five were academic underachievers with three dropping out of high school, four had SUDs, five had psychiatric disorders, and five were juvenile delinquents with three spending time in jail or prison. In a book I wrote entitled Addiction and Depression, I stated that “one of the most significant experiences I had was growing up in a family with parental alcoholism and depression. I experienced firsthand the negative impact of these disorders on my family and saw that every single member was emotionally hurt. I also saw how this pain showed in unique ways in our behaviors and relationships. Anger, anxiety, worry, and fear were my companions for many years. Academic underachievement and juvenile delinquency were just a few of the ‘side effects’ that I personally experienced” (Daley, 2006).
I go on to say that “I feel fortunate that my hurts have been healed and that understanding and forgiveness have replaced my anger and bitterness” (Daley, 2006). Most of my siblings also rebounded from negative effects they experienced from our family. I know many colleagues and family members who have also done well as a result of treatment, mutual support programs or both. This shows how many of us are resilient and able to survive difficult experiences. And, we often grow from these experiences.
Integrated care for CODs is the preferred method of treatment when possible to insure that all disorders are addressed in the treatment plan. Otherwise, the individual with the CODs may not receive the maximum benefit from treatment and is at increased risk for relapse to either disorder. In my previous role developing and overseeing a large continuum of services for patients with SUDs and CODs, I encountered large numbers of individuals who reported they improved more when their treatment addressed all of their disorders.
When possible, families or significant others should be included in treatment. They can help support their loved one’s recovery, but just as important, they can address their own reactions and needs. In a future article, I will discuss the family perspective in greater detail, and include results of several family surveys that are currently being conducted.
Daley, D. C. (2006). Addiction and mood disorders: A guide for clients and families. New York, NY: Oxford University Press.
Daley, D. C., & Douaihy, A. (2013). Co-occurring disorders. In A. Douaihy & D. C. Daley (Eds.), Substance use disorders (pp. 283–310). New York, NY: Oxford University Press.
Daley, D. C., & Douaihy, A. (2014). Recovery from co-occurring disorders (rev. ed.). Murrysville, PA: Daley Publications.
Daley, D. C., & Moss, H. M. (2002). Dual disorders: Counseling clients with chemical dependency and mental illness (3rd ed.). Center City, MN: Hazelden.
Daley, D. C., & Sinberg, J. (2004). A family guide to coping with dual disorders: Addiction and psychiatric illness (3rd ed.). Center City, MN: Hazelden.
Daley, D. C., & Thase, M. E. (2003). Dual disorders recovery counseling: Integrated treatment for substance use and psychiatric disorders (3rd ed.). Independence, MO: Independence Press.
Kelly, T. M., & Daley, D. C. (2013). Integrated treatment of substance use and psychiatric disorders. Social Work in Public Health, 28, 388–406.
Mueser, K. T., & Gingerich, S. (2013). Treatment of co-occurring psychotic and substance use disorders. Social Work in Public Health, 28(3–4), 424–39.
Nunes, E. V., Selzer, J., Levounis, P., & Davies, C. (2010). Substance dependence and co-occurring psychiatric disorders: Best practices for diagnosis and clinical treatment. Kingston, NJ: Civic Research Institute.