Please read about the dual diagnosis model (below) and discuss its strengths and weaknesses.

DUAL DIAGNOSIS MODEL

Substance abusers who present with depression or social problems are commonly encountered, as discussed above. Some of these individuals will insist that their depression or other problems should be the focus of treatment, rather than their substance abuse. Their belief is in either the self-medication model or the social model. In order to simplify the following discussion, we will use as an example those substance abusers who complain primarily of depression, while minimizing their substance abuse. These are substance abusers who believe in the self-medication model. Essentially, they state that they use substances because they are depressed. Their treatment will depend on the beliefs of their therapists. The need to address that too and let me tell you why. Any attempt I make to determine the type of depression you have will be confounded by further chemical use. Also, any treatment that I can give you for your depression will be sabotaged by further chemical use.

This is because we know that regardless of which came first (the depression or the chemicals) and regardless of why you use, chemicals make depression worse over long periods of time. In short, you have two problems, they both require treatment, and the best way I can treat your depression right now is to give you treatment for chemical dependency. After that treatment is begun, we will be better able to see if other treatments for your depression are needed." If the therapist also believes in the self-medication model, then treatment will focus primarily on the depression.

The potential pitfall here is a treatment match based on collusion (see Table 4), in which both the therapist and substance abuser believe in depression as a focus of treatment but mutually deny the importance of substance abuse. By contrast, if the therapist believes in the disease model, then statements such as "I use substances because I am depressed" are interpreted as rationalizations. Substance abusers may become defensive when their use of substances is explored. The therapeutic task is then formulated by the disease model therapist in terms of breaking through the defensiveness and denial. The potential pitfall here is a mismatch of beliefs resulting in an antagonistic relationship, instead of an alliance in which treatment can occur (Table 4). In essence, the substance abuser is invited to believe in the dual diagnosis model (see Table 5) in which the argument about what is the primary problem requiring treatment is replaced by the idea that treatment is required for both problems.

In this way, the therapist and substance abuser can build an alliance around a common goal, which is to treat depression, without denying the importance of treating chemical dependency. The way out of this clinical dilemma is first to assess carefully everyone's beliefs in order to guard against either collusion or a mismatch, both of which are counter therapeutic.

Next, the substance abuser is invited into an alliance without collusion by the following intervention: "I agree that you appear depressed and this is certainly a problem for you. We need to address that. It is also true from what you have told me that you have a diagnosis of chemical dependency.

We Like the self-medication model, the dual diagnosis model views the coexisting mental disorder as a primary problem that may require its own psychotherapeutic or pharmacotherapeutic intervention. This helps to build an alliance with the substance abuser and prevents the minimization of coexisting mental disorders by the therapist. Like the disease model, the dual diagnosis model also views substance abuse as a primary problem requiring its own treatment. This helps to prevent collusion with the substance abuser and insures that the importance of substance abuse treatment will not be overlooked.

Properly applied, the dual diagnosis model integrates elements of both the self-medication and disease models in a way that avoids the disadvantages of adhering to only one or the other. In the dual diagnosis model, substance abuse and other mental disorders can be seen as coexisting without necessarily attributing one etiologically to the other. Both are considered primary disorders that can exacerbate one another. The strategy for treatment is to focus on both disorders, although substance use must first stop in order to diagnose and treat the coexisting mental disorder. If an initial period of abstinence proves to be sufficient treatment for the coexisting mental disorder, then a shift from the dual diagnosis model toward other models can be made, as appropriate.

In this discussion, we have alluded to the value of assessing the respective beliefs of the therapist and the substance abuser regarding treatment models. When both the therapist and substance abuser believe in a common explanatory system that does not deny important problems requiring treatment, then a treatment match based on a healthy alliance has been achieved (Table 4). Obviously, this type of match is preferred, but cannot be expected to occur by accident. Only by carefully monitoring our own beliefs and those of the substance abusers we treat can we insure this type of match. Furthermore, substance abusers may require the use of integrative models in order to establish a therapeutic alliance, as exemplified by this discussion of the dual diagnosis model. In other words, integrative models may provide the optimal clinical strategy for bridging discrepant belief systems between therapists and substance abusers.

References

Brower et al. (1989) Treatment impications of chemical dependency models: An integrative apporach.Journal of Substance Abuse Treatment, (6) 147-157.