Treatment Planning for Dual Diagnosis

The presence of a substance use disorder alongside another mental health disorder is an important consideration for treatment planning. We spoke with Dr. Asha Dickerson about how the presence of co-occurring disorders affects the treatment plan and her advice for working with this population.

Can you give an overview of how treatment planning looks different with dual diagnosis?

We use SMART goals . . . get their input. “Tell me what's worked for you in the past. Tell me what kind of things you might do”—and this is the way treatment planning is supposed to be. It's supposed to be in the client's words because it's their treatment plan. It's not yours as the clinician.

What I have seen as a clinical director and a professor for many years is that counselors, when they're doing treatment planning for people with addictions, it has tended to be more cookie cutter. “You are going to go to 12-step meetings. You're going to take your medicine. You're going to come to group three times a week.” And it doesn't give the client a lot of autonomy. To me, when the client doesn't have autonomy, there's going to be a lot less buy-in. So, for me as a clinician, supervisor, and professor, I work a lot with the students on not doing cookie-cutter plans for people who have addictions because there is that co-occurring disorder piece. Let's incorporate that as well when we're doing a treatment plan to make it very individualized.

What should counselors include in their intake forms or intake sessions to get a full picture of a client’s presenting concerns? Is there certain language that is helpful to use or avoid when it comes to assessing for substance use disorders?

I would definitely ask about family history—and these are commonly in the intake—family history, and first age of use, and additional diagnosis. But when considering addictions, you're going to be digging a little deeper. I wouldn't say this can be done on an intake form, but in the formal intake I would ask, if you have these other diagnoses and you've been using substances, which one do you think came first? Because that's the big question—the chicken or the egg. Was the other mental illness there first? Or was the addiction there first? Are you seeing things because you're using substances? Or are you using substances because they help you stop seeing things? I would ask, which one do you think came first? Can you remember the onset of any of these things?

What are some additional challenges or considerations with treatment planning for clients with dual diagnosis?

Definitely environment. We know we always talk to our clients, where the primary issue is an addiction, about are people not drinking around them, are people not using around you? For those people whose primary issue is not addictions, people don't consider as much not using around them. In fact, others may complain that “when you're not drinking, you're no fun” or “if you're not taking these pills, you’re no fun.” So, your environment may not be conducive to recovery, to your wellness, but also your friends and your family as a whole may not be conducive to your recovery and to your wellness.

I want to always talk to clients about defining your own family. It doesn't have to be your blood relatives. What is keeping you connected to these people who could be contributing to the ongoing issues that you have? Or how open are you with them about everything? You may have told them that you have anxiety, but you may not have told them that you smoked marijuana every day to deal with it. Or they know that you smoke marijuana every day because they smoke marijuana every day, but they may think you're doing it for fun. They may not realize that you're doing it because of all the things that happen when you don't have the THC in your system.

Also look at the feasibility of not using certain substances or being or not being in certain situations that make you want to use them. For instance, I have depression or I have bipolar disorder, and my triggers are my parents that I live with. Well, you need to get away from your parents. How, if I don't have money? And I haven't been able to hold down a job because I haven't been able to get my bipolar or depression symptoms under control. Then what kind of sense does it make for me to leave their home?

You mentioned terminology and the line drawn between substance use and mental health. How do you address that with your clients or students?

I try not to say mental health and substance use, because addiction is a mental health issue. So, I say, talk about a mental illness and say specifically which one it is if you have information on that, or just say co-occurring disorders if not.

For my students at Adler Graduate School, we have a co-occurring disorders program, and we have a clinical mental health program, but I try to help the students understand that they're both doing the same thing. We call it specialization, but in my mind it's just an interest. It's the population that you want to work with. You can work in clinical mental health and you're going to work with people who have co-occurring disorders. And you can work in co-occurring disorders and guess what? That's a clinical mental health issue. So, I don't like the separation of the two. I would love for it all just to be together.

Are there treatment modalities that may not be appropriate with dual diagnosis?

So that's again one of those things where I think people try to separate, but all could be appropriate depending on the client. The important thing is individualized treatment. One that's used in co-occurring disorders a lot is reality therapy. You know, we're doing WDEP—Want Doing Evaluate Plan—but I can bring that into anything. We're asking the client what do you want in your life. What are you doing? And let's evaluate that. How is it working for you? And let's come up with a plan. People use that and use reality therapy with co-occurring disorders all the time, but I'm going to use it, period, because everybody, in the end, has something that they want. This part is the Adlerian, which is why Adlerian psych and reality go so well together.

What are you striving to do? That's me asking what you want and what have you been doing to move towards superiority or what you think as superiority? And then let's look at, not how does that work for you, but is it even working for you? And let’s come up with a better plan.

How would you reassess a treatment plan if a dual diagnosis becomes apparent during the course of treatment?

First thing I'm probably going to look at is what medication they're on. Because one thing that's missed a lot in co-occurring disorders is medication interactions. We're wondering why your antidepressant isn't working or this isn't working, it’s because you're mixing it with alcohol and other things. And even then, we can look at what is the purpose of your drinking or the purpose of you using this drug. And if it's because you're self-medicating, we can look at tweaking or changing the medication that you're already taking. A lot of that is going to be looking at the continuum of care and making sure that we're collaborating across different professions. I work directly with a psychiatrist who helps me with medication-assisted treatment.

Especially when it comes to people who have been diagnosed with depression or anxiety, that's the most frequent time. I'll see some substance use because you're trying to feel better, and your medicine’s not working. And first of all, your medicine is barely working because you're doing all this other stuff to feel better, but also maybe if your medicines worked a little better, you wouldn't be doing all this stuff to try to feel better. So, it’s a lot of medication management.

At what point should a counselor consider providing a referral to a client with dual diagnosis?

I think as soon as you start hearing a lot of terms that you're not familiar with. It's not necessarily refer out immediately; I would always say consult, because no one should ever practice beyond their scope of competence, but also you cannot become competent in an area if you don't practice in that area.

I have a lot of supervisees, and when they are focused too much on one group or they don't want to see a client because they feel uncomfortable, I will encourage them see that person because, I say, “This type of client is going to come in your office again and you need to try now while you are under supervision. I know what I'm doing so I can help you to try, and if you don't like it, don't make that your specialty. But I'll know that when you're done with me in 2 to 3 years, if a client just like that comes into your office, you will know the terms and you will have some tools in your toolbox.”

Right when you graduate, most of the time you don't get to do what you want to do. You get a job where you can get a job. So, if you're finding yourself coming in contact with a lot of people who have issues you're not familiar with, again, don't run. Find you some training, go to a conference, go to a symposium, look for a webinar. The information is there. And, again, expand your scope of competence. You may be the only person available in their area, and their insurers may not pay for telehealth. Technically, you can keep turning people away, but why? You could stop being mediocre and learn a little bit more.

Could you speak some more on how a counselor can improve their addiction treatment skills and expand their scope of competency to work with co-occurring disorders?

I would say get comfortable by getting outside. One thing I will say about people who work in co-occurring disorders is you may have more clientele who are indigent, who are on the streets, and so I don't think that you can go get a degree or a certificate and think that you're going to sit in your office all day. You're not. You need to be out under the bridges, checking in the tents. If you're trying to recruit or even retain your clientele, you go to the shelters, to the soup kitchens.

There are people whose family members don't deal with them anymore. And they're not going to be at the AA meeting. If they go AWOL and they just walk away and don't do treatment anymore, you're not going to find them at work. You're not going to be able to call them at the office or at their grandmother's house and say, “Hey, just checking on Billy.” No. Billy is somewhere in the streets. Are you willing to go out there and, not necessarily look for him, but for my Billies that I work with, they may call and say, “OK, look, I'm out here. I fell off. Can you come get me?”

I've gone and gotten them. I've gotten women from trap houses. I've gotten young girls from some pimp’s house, and sometimes I've had to bring the police.

But how comfortable are you with that? Part of getting comfortable with that is going to be providing service. I always ask students when they're interviewing, I'm looking at their résumés, “What community service do you have under your belt?”

Are you already out getting in touch with these people who you claim you want to work with, who you claim you're passionate about? Are you really passionate, or does getting the master's degree seem like a good idea and this one seemed doable?

Dr. Asha Dickerson is an Atlanta-based educator of counselors, social workers, human service professionals, addictions specialists, and other helping professionals. She is a National Certified Counselor (NCC), Licensed Professional Counselor (LPC), Master Addiction Counselor (MAC), and Approved Clinical Supervisor (ACS). Dr. Dickerson is a native of Montgomery, Alabama, and alumna of the University of Alabama at Birmingham. She received a doctoral degree from Auburn University.

 Dr. Dickerson is currently an Associate Professor at Adler Graduate School in Minnetonka, Minesota, and Clinical Director at Someone Cares Atlanta. Although she’s made her home in Georgia, Dr. Dickerson provides workshops, training, and other services throughout the United States and in other countries. She is very active in several community, state, and national organizations; currently serving as the Co-Chair of the Southern Association for Counselor Education and Supervision Emerging Leaders Program, Past-President of the Association for Multicultural Counseling and Development (AMCD), and Past-Chair of the American Counseling Association of Georgia. Dr. Dickerson has received numerous awards and is an inaugural NBCC Foundation Minority Fellow.

Her clinical and academic specialties include social and cultural diversity, addictions, and blended family issues. Her goal is to educate, encourage, and enrich the lives of her clients, students, employees, and the community through her commitment to advocacy, mental health, family wellness, and leadership.

**Opinions and thoughts expressed in NBCC Visions Newsletter articles belong to the interviewees and do not necessarily reflect the opinions or practices of NBCC and Affiliates.