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National Alliance on Mental Illness
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Dual Diagnosis: Adolescents with Co-occurring Brain Disorders & Substance Abuse Disorders

Adolescents are often referred to treatment for substance abuse, but are not referred to a qualified mental health professional for appropriate diagnosis and treatment of any underlying cause for their drug and alcohol abuse. However, many teens have symptoms of a mood disorder that may in fact have led to self-medicating with street drugs and alcohol.

Families and caregivers know how difficult it is to find treatment for an adolescent who abuses drugs or alcohol, but who also is diagnosed with a brain disorder (mental illness); i.e., ADHD, depression, or bipolar disorder. Traditionally, programs that treat individuals with brain disorders do not treat individuals with active substance abuse problems, and programs for substance abusers are not geared for people with mental illness. Adolescents are often caught in this treatment or services gap.

Is dual diagnosis common?

The combination of mental illness and substance abuse is so common that many clinicians now expect to find it. Studies show that more than half of young persons with a substance abuse diagnosis also have a diagnosable mental illness.

What causes these disorders?

Mental health and addiction counselors increasingly believe that brain disorders and substance abuse disorders are biologically and physiologically based.

What kind of treatment works?

Families and caregivers may feel angry and blame the adolescent for being foolish and weak-willed. They may feel hurt when their child breaks trust by lying and stealing. But it's important to realize that mental illness and often substance abuse are disorders that the adolescent cannot take control of without professional help.

Teens with difficult problems such as concurrent mental illness and substance abuse disorders do not respond to simplistic advice like "just say no" or "snap out of it." Psychotherapy and medication combined with appropriate self-help and other support groups help most, but patients are still highly prone to relapse.

Treatment programs designed primarily for substance abusers are not recommended for individuals who have a diagnosed mental illness. Their reliance on confrontation techniques and discouragement of use of appropriate prescription medications tend to compound the problems of individuals with mental illness. These strategies may produce stress levels that make symptoms worse or cause relapse.

What is a better approach?

Increasingly, the psychiatric and drug counseling communities agree that both disorders must be treated at the same time. Early studies show that when mental illness and substance abuse are treated together, suicide attempts and psychotic episodes decrease rapidly.

Since dually diagnosed clients to not fit well into most traditional 12-step programs, special peer groups based on the principle of treating both disorders together should be developed at the community level. Individuals who develop positive social networking have a much better chance of controlling their illnesses. Healthy recreational activities are extremely important.

What's the first step in treatment?

The presence of both disorders must first be established by careful assessment. This may be difficult because the symptoms of one disorder can mimic the symptoms of the other. Seek referral to a psychologist or psychiatrist. Local NAMI affiliates are happy to refer families to mental health professionals their members recommend. (Call the NAMI HelpLine at 1-800/950-6264 for a local contact).

Once a professional assessment has confirmed a dual diagnosis of mental illness and substance abuse, mental health professionals and family members should work together on a strategy for integrating care and motivating the adolescent.

What do model programs for treating mental illness and substance abuse look like?

There is a growing number of model programs. Support groups are an important component of these programs. Adolescents support each other as they learn about the negative role that alcohol and drugs has had on their lives. They learn social skills and how to replace substance use with new thoughts and behaviors. They get help with concrete situations that arise because of their brain disorder (mental illness). Look into programs that have support groups for family members and friends.

If your teen has a substance abuse disorder ...

  1. Don't regard it as a family disgrace. Recovery is possible just as it is with other illnesses.
  2. Encourage and facilitate participation in support groups during and after treatment.
  3. Don't nag, preach, or lecture.
  4. Don't use the "if you loved me" approach. It is like saying, "If you loved me, you would not have tuberculosis."
  5. Establish consequences for behaviors. Don't be afraid to call upon law enforcement if teens engage in underage drinking on your premises. You can be held legally responsible for endangering minors if you do not take timely action.
  6. Avoid threats unless you think them through carefully and definitely intend to carry them out. Idle threats only make the person with a substance abuse disorder feel you don't mean what you say.
  7. During recovery, encourage teens to engage in after-school activities with adult supervision. If they cannot participate in sports or other extracurricular school activities, part-time employment or volunteer work can build self-esteem.
  8. Don't expect an immediate, 100-percent recovery. Like any illness, there is a period of convalescence with a brain disorder. There may be relapses and times of tension and resentment among family members.
  9. Do offer love, support, and understanding during the recovery.

Reviewed by Patrick C. Friman, Ph.D., A.B.P.P., Director of Clinical Services & Research at Father Flanigan's Boys' Home and associate professor, Creighton University School of Medicine.

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