Double Trouble

Historical Perspective

Traditionally, those with mental health and addiction problems have had, in addition to their illness, the additional burden of shame due to a societal stigma that viewed addiction problems as moral weakness and mental health problems as a result of weak motivation. In spite of this stigma, mental health professionals have historically viewed psychiatric disorders as treatable illnesses. However, while mental health professionals have helped reframe the societal view of mental problems from that of an individual weakness to an illness, many still viewed addiction as a symptom of a mental disorder. Conversely, addiction professionals saw addiction as the primary illness with many firmly believing that once the individual was in recovery, the psychiatric-like symptoms would disappear. It is now known that co-occurring disorders are quite complex, have no common etiology, and, in many cases, are developed independent of each other.

Assessment and Diagnosis

While assessing for a substance use or a mental disorder, the practitioner must be prepared for a majority of cases to be assessed as "double trouble." Therefore, assessments in any mental health or addiction setting must be performed with the assumption that the clients being diagnosed as having co-occurring disorders are the expectation, not the exception. However, accurate diagnoses for co-occurring disorders are complicated by the fact that it is difficult to distinguish between symptoms that are characteristic of a mental disorder and those that are generated by a substance use disorder. Although mental and substance use disorders may occur independent of each other, their bidirectional interaction further complicates the ability to accurately diagnose. Therefore, a precise and thorough differential diagnosis can only be performed over time and under a measured and vigilant approach.

Effective assessments of co-occurring disorders are those that include a welcoming and safe atmosphere with a high degree of empathy and hope. A practitioner who provides an engaging environment can successfully gather information from the client and hence has a better chance of collecting the ingredients necessary to accurately assess the existence of a co-occurring disorder, establish the client's readiness for [Page 296]change, determine strengths as well as challenges to the client's recovery, and engage the client in the development of an appropriate and continuous treatment relationship. Thus, the practitioner is performing an integrated assessment and providing the best means to effectively work with the client to mutually develop a meaningful treatment plan.

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