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Evidence-Based Reviews

5 keys to improve counseling for dual-diagnosis patients

An empathic approach can be effective when treating psychiatric patients with substance use disorders

Vol. 2, No. 9 / September 2003

Psychiatrists frequently encounter dual-diagnosis patients (Box) and may often wonder which to treat first—the substance abuse or the psychiatric comorbidity. Five principles can help you counsel dual-diagnosis patients more effectively. Briefly, they are to:

  • appreciate this population’s heterogeneity
  • adopt a longitudinal treatment approach, reassessing patients’ progress and adjusting interventions as needed over time
  • be empathic rather than confrontational
  • realize that treatment often proceeds in stages—not on a smooth, linear path
  • recognize the importance of medication compliance.


Different patients, different problems. All counseling of dual-diagnosis patients begins with a thorough assessment aimed at making an accurate diagnosis and understanding the relationship between the co-existing disorders. Although some people refer to “dual-diagnosis patients” as a single entity, these patients differ according to:


Dual-diagnosis patients: Twice the clinical challenge

The National Institute of Mental Health’s Epidemiologic Catchment Area study documented high rates of substance use disorders in patients with psychiatric disorders. 1 Lifetime prevalence of co-occurrence was 61% for bipolar disorder (the highest of any Axis I disorder),47% for schizophrenia, and 36% for panic disorder.

Dual-diagnosis patients face a more bleak prognosis than those with a single disorder, including higher rates of relapse, hospitalization, violence, incarceration, homelessness, and serious infections such as hepatitis and HIV. 2 Unfortunately, these findings have not always led to effective treatments.

These patients represent a heterogeneous group and require individualized treatment. For example, abstinence from alcohol or drugs may worsen psychiatric symptoms in a patient with posttraumatic stress disorder and substance abuse. On the other hand, abstinence would be expected to improve the symptoms of a patient with comorbid major depressive disorder and substance abuse.

  • diagnosis, with a myriad of potential combinations of substance use and psychiatric disorders
  • severity of disorder, with some having a predominant psychiatric or substance use problem and others experiencing severe courses of both problems
  • causes of their substance abuse and psychiatric disorders, based in part on which problem is primary and which is secondary
  • level of motivation for treatment and their treatment goals.

Primary versus secondary disorders. How to distinguish “primary” from “secondary” disorders in dually diagnosed patients has prompted much research and debate.

A psychiatric disorder is typically called primary when it can be viewed as independent from the substance use disorder. The term “secondary psychiatric disorder” connotes that the substance use disorder is causing the psychiatric symptoms. For example, alcohol-dependent patients in detoxification programs often have depressive symptoms, some of which abate with abstinence. They are frequently diagnosed as having “secondary depression,” or—in DSM-IV diagnostic terms—substance-induced mood disorder.

Unfortunately, distinguishing primary from secondary disorders is sometimes difficult because of patients’ poor memory, recall bias, and inadequate periods of sobriety (“I’ve been drinking for a long time and have been depressed for a long time, so I don’t remember what I was like when I was sober”). Thus, the diagnostic assessment is generally accomplished over time, rather than in a single interview.

Our research 3 and clinical experience have taught us that patients’ recall about the relationship between their substance use and psychiatric symptoms often changes over time. Determining the “primary” disorder may also have limited validity in predicting treatment response. 4

Stages of Change model. The Stages of Change model 5,6 is useful for assessing a dually diagnosed patient’s motivation to change, although its use in addictive disorders has been challenged. 7,8 According to the transtheoretical model developed by Prochaska et al (Table 1), 5 people generally make behavioral changes in stages defined by their level of willingness to make these changes.

When counseling the dually diagnosed patient, it is useful to assess readiness to change and to suggest behavioral steps the patient is able and willing to make. Thus, it would not be appropriate to discuss drug refusal methods with a patient who does not see his substance use as a problem. Rather, addressing this patient’s ambivalence would be more useful.

Table 1

5 stages of change: The transtheoretical model of behavior change

Stage of change

Patient behavior


No intention to change behavior in the foreseeable future; little or no awareness of problems


Aware that a problem exists; seriously thinking about overcoming it but no commitment to take action


Intends to take action within the next month; has tried unsuccessfully to take action in the past year


Modifies behavior, experiences, or environment to overcome problems


Works to prevent relapse and consolidate gains attained during action stage; for addictive behaviors, maintenance extends indefinitely from 6 months after the initial action

Source: Prochaska JO. Transtheoretical model: Stages of Change. Cancer Prevention Research Center, University of Rhode Island.

It is important to note that many patients move back and forth between stages of readiness to change. For example, a patient in the action stage (entering treatment and pursuing a goal of abstinence) may revert to contemplation and again question whether he or she has a serious substance abuse problem. We recommend that clinicians reassess patients regularly and continue to match interventions with the current level of motivation.


Three approaches are used for treating the coexisting problems of dual-diagnosis patients—sequential, parallel, and integrated.

Sequential treatment addresses the more acute disorder first; the other disorder receives greater attention later. This model is commonly used with hospital treatment, in which comparatively little attention would be paid to substance use in a patient who is acutely psychotic.

Parallel treatment addresses each disorder contemporaneously but in different settings (such as at a substance abuse program on Monday and a mental health center on Thursday).

One limitation of the sequential and parallel models is that psychiatric and substance abuse programs typically have different orientations. A lack of comprehensive assessment may leave the substance abuse or psychiatric disorder underdiagnosed, depending on the setting. Staff members may also project negative attitudes toward patients with psychiatric or substance use disorders if they know comparatively little about the diagnosis and treatment of the other type of disorder. Treatment in two settings also can lead to communication problems and differences of opinion among the treating clinicians.

Integrated treatment, in which both disorders are treated simultaneously in the same setting, has shown favorable outcomes in several initial studies. 9 11 Different integrated treatment models have been described, which vary according to the psychiatric disorders’ nature and the treatment’s theoretical orientation. Integrated treatment strategies include:

  • focusing on psychiatric and substance abuse issues simultaneously or in alternating sessions
  • providing intense case management
  • stressing the importance of medication compliance. 12


As mentioned, a careful history and thorough assessment are the keys to effectively treating the dually diagnosed patient.

Assess how the patient perceives the relationship between his substance use disorder and psychiatric symptoms. For example, ask, “What do you see as the relationship between your drinking and your depression, if any?”

As part of this process, explore both the immediate and long-term relationships between the two phenomena. For example, some patients will say that drinking offers them immediate relief from their depressive symptoms but exacerbates their depression the following day. Encouraging patients to look beyond the immediate—often positive—effects of their substance use may help them understand the negative consequences of continued use.

Review previous periods of recovery and relapse. For patients who have had substantial periods of recovery, it is important to acknowledge these successes and to ask in an upbeat and admiring way, “How did you do it?” This approach may remind patients of past successes and counterbalance their frequent feelings of discouragement and hopelessness.

Table 2

4 phases in treating the dually diagnosed patient


Therapeutic goals


Build an alliance
Attract patient to treatment program


Convince engaged patient to accept longer-term, abstinence-based treatment

Active treatment

Help patient develop attitudes and techniques essential to maintain sobriety

Relapse prevention

Help patient maintain gains made in active treatment and cope with lapses/relapses should they occur

To help clarify the relationship between coexisting disorders, ask patients about psychiatric symptoms they have experienced during periods of substance use and recovery. Taking a relapse history can help you and the patient identify decisions and behaviors he or she must avoid (such as stopping medication, failing to attend treatment, or engaging in high-risk activities as in going to bars).


Four phases of dual-diagnosis treatment—engagement, persuasion, active treatment, and relapse prevention—have been described, along with their therapeutic goals (Table 2). 13 Consider these phases when treating this population, even though most patients do not proceed through them in an orderly, linear fashion.

Engagement. At the onset, the therapist tries to build an alliance and begins to establish trust and credibility.

Persuasion involves helping the patient comprehend the need to seriously address his or her substance use. It is important during engagement and persuasion stages to be empathic, using reflective listening and validating techniques.

Helping the patient see the discrepancy between his or her long-term goals and current behavior can create the impetus for change. Linking the substance use and psychiatric symptoms and exploring their impact on each other may help the patient understand the problem.

Ambivalence and resistance are normal reactions to this process of change, so avoid arguing with the patient. Confrontation—long a common strategy in substance abuse treatment—is losing favor and is being supplanted in many cases by a more supportive, empathic approach. 14 Indeed, patients with co-occurring psychiatric illness generally respond particularly poorly to confrontation.

Active treatment focuses on techniques to achieve abstinence, including alcohol and drug refusal skills, methods to deal with craving, and ways to recognize and avoid situations that present a high risk for relapse.

Relapse prevention reinforces gains made in previous stages. Here, the patient learns how to identify and deal with risky situations and how to handle a “slip” if it occurs.


Self-help groups. Ask whether the patient has attended self-help groups for addiction or psychiatric illness. If so, then ask, “What did you think of the meetings? What did you like and dislike?”

Self-help groups such as Alcoholics Anonymous (AA) or the Manic-Depressive and Depressive Association (MDDA) can help enormously in the recovery process. These groups are free, readily available, and can offer patients a support network. Although many dual-diagnosis patients are reluctant to attend self-help groups, they may benefit from the support, role modeling, practical advice, and structure that these meetings offer.

Drug therapy for the dual-diagnosis patient focuses on the psychiatric disorder and is usually combined with psychosocial approaches. There is little evidence that one medication is more effective than others for these patients.

Because medication compliance is key to their effective treatment, be sure to ask patients at each visit, “Have you been taking your medication as prescribed?” Because dual-diagnosis patients have been shown to take more or less medication than prescribed, 15 asking how much medication they are taking can be revealing.

Related resources


Dr. Manwani receives research support from Abbott Laboratories.

Dr. Weiss is a speaker for Abbott Laboratories and Eli Lilly and Co.


Supported by grants K0200326, DA09400, and DA15968 from the National Institute on Drug Abuse and a grant from the Dr. Ralph and Marian C. Falk Medical Research Trust.


1. Reigier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) Study. JAMA 1990;264:2511-18.

2. Drake RE, Essock SM, Shaner A, et al. Implementing dual diagnosis services for clients with severe mental illness. Psychiatr Serv 2001;52:469-76.

3. Griffin ML, Weiss RD, Mirin SM, et al. The use of the Diagnostic Interview Schedule in drug-dependent patients. Am. J Drug Alcohol Abuse 1987;13(3):281-91.

4. Mason BJ, Kocsis JH, Ritvo EC, et al. A double-blind, placebo-controlled trial of desipramine for primary alcohol dependence stratified on the presence or absence of major depression. JAMA 1996;275(10):761-7.

5. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors. Am Psychol 1992;47:1102-14.

6. Connors GJ, Donovan DM, DiClemente CC. Substance abuse treatment and the stages of change. New York: Guilford Press, 2001.

7. Carey KB, Purnine DM, Maisto SA, et al. Assessing readiness to change substance abuse: a critical review of instruments. Clinical Psychol 1999;6:245-66.

8. Sutton S. Back to the drawing board? A review of applications of the transtheoretical model to substance use. Addiction 2001;96:175-86.

9. Drake RE, McHugo GJ, Noordsy DL. Treatment of alcoholism among schizophrenic outpatients: 4-year outcomes. Am J Psychiatry 1993;150:328-9.

10. Hellerstein DJ, Rosenthal RN, Miner CR. A prospective study of integrated outpatient treatment for substance-abusing schizophrenic patients. Am J Addict 1995;4:33-42.

11. Drake RE, Yovetich NA, Bebout RR, et al. Integrated treatment for dually diagnosed homeless adults. J Nerv Ment Dis 1997;185:298-305.

12. Weiss RD, Najavits LM, Hennessy G. Overview of treatment modalities for dual diagnosis patients: pharmacotherapy, psychotherapy, and twelve-step programs. In: Kranzler HR, Tinsley J (eds). Dual diagnosis: substance abuse and comorbid disorders. (2nd ed). New York: Marcel Dekker. In press.

13. Osher FC, Kofoed LL. Treatment of patients with psychiatric and psychoactive substance abuse disorders. Hosp Community Psychiatry 1989;40(10):1025-30.

14. Miller WR, Rollnick S. Motivational interviewing: preparing for change (2nd ed). New York: Guilford Press, 2002.

15. Weiss RD, Greenfield SF, Najavits LM, et al. Medication compliance among patients with bipolar disorder and substance use disorder. J Clin Psychiatry 1998;59(4):172-4.

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