Finding Peaks

Finding Peaks

Episode 33: Behind The Care: Exploring Dual Diagnosis

December 20, 2021

Episode 33
Behind The Care: Exploring Dual Diagnosis

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Episode 33

Our team dives into what Dual Diagnosis truly means and the deep understanding a treatment provider must envelop in order to truly help an individual overcome a mental health or substance use disorder.


  1. What is true Dual Diagnosis?
  2. When calling an addiction treatment center and asking about dual diagnosis, make sure to ask what their specific approach to treating the specific disorders
  3. What are we alleviating when treating an individual when treating dual diagnosis?
  4. Changing the stigma that substance use disorder and mental health disorders are different or should be treated separately, and how they are actually one and the same.
  5. What does a treatment center truly need to be equipped with in order to treat dual-diagnosis successfully?

Select Quotes

If somebody comes into our program and they have depression, an eating disorder, they misuse alcohol and use cannabis, frankly all those things are usually symptoms of the same underlying driving forces and require similar paths towards recovery for all of those. It isn’t that we have separate the eating disorder, separate out the depression, and separate out the addiction, we have to teach the skills and build resilience, and in long term recovery, deal with the etiology of these diagnoses.

Jason Friesema, MA, LPC, LAC Chief Clinical Officer

Episode Transcripts

Episode 33 Transcript

all right hello everybody welcome to another episode of finding peeks i almost forgot how to do this it has been with all the whole said exciting yet yes no i didn’t want to do the exciting thing though i’m trying to be new i’m trying to be new for you the viewer so you can go you know what i’ll watch that guy more often anyways brandon burns chief executive officer for peaks recovery centers chief operating officer clint nicholson chief clinical officer jason friesma jay freeze welcome to the show good to be back fresh out of the holiday season into the holiday season or into the holiday season we are in spirit in the thick of the holiday season we are in spirit here yeah anyways for the viewers in the back i’ve been listening to a lot of podcasts recently and people start with a little a little joke oh a little oh wow little festive fun yeah conversation i’m trying to recreate a little anecdote okay yeah yeah it works for them how’s it going and this is ad-free this is ad-free so that’s your name you have that and we’re working on it brought to you by peaks finding peaks at let us know if you care about our jokes we haven’t actually told a joke yet though happy i know okay give a story you’re going to sell though to start this i had no joke i was really hopeful you guys would be on me i don’t know no stay with us we’re talking about dual diagnosis today i was recently at the natap conference the national association of treatment providers and they do great work at the national level in support of individuals with mental health and substance use disorders and they gather twice per year to bring treatment providers together talk about ethics and a lot of other important things outcomes and so forth in the industry i like to go in there and just talk to the marketers in the crowd just see what’s going on and so um when i go up and i ask people about what they do they’ll say something like well we do dual diagnosis and we’ve talked about this on our prior episodes you can go to addiction treatment center’s websites and they will say something like we do dual diagnosis treatment so i’m sitting with this uh marketer of company x and uh they say they do dual diagnosis and i was like awesome so you do mental health primary and they’re like no no it’s got to have a little bit of the substance use disorder in there and i was like well this is how i i mean i’m going to let you guys explain what tool diagnosis is but in diving into it ultimately my experience is that we don’t really know what that means in this industry and we really don’t know what we’re talking about and this is consistent across treatment platforms um namely that we’re stating that we do it but what i think we’re really doing at the end of the day is stating something more like we do co-occurring disorders so long as there is a substance use disorder primary tied to uh severe anxious disorder or major depressive disorder schizophrenia or whatever it is the substance use disorder has to be at the top for treatment centers to approach it but that’s not the true nature of dual diagnosis nor the approach to it at least in my experience and so let’s just kick this off with what the heck is dual diagnosis because my interpretation of it is that you can have a diagnosis of a substance use disorder somewhere in the past and then a presenting major depressive disorder happening now and it’s dual diagnosis in the fact that they’ve been diagnosed but they’re also not happening at the same time as a co-occurring issue which for me would mean that you could treat mental health primary within that moment under that dual diagnosis lens am i wrong am i the idiot at the conference what’s going on never thank you yeah you’re welcome yeah i definitely don’t think you’re the idiot at the conference brandon so you can just take a breath and and feel okay with that okay good thank you um i mean i do think you are right and i do think um your assessment is correct that uh true dual diagnosis um is it can be primary mental health or it could be primary substance use disorder as well i do think at least colloquially when when people mention dual diagnosis it is assumed that one of those diagnoses is uh a substance use disorder is my experience with that word um and actually clint and i are actually dually credentialed we are licensed to be professional counselors which is a mental health license and then we’re licensed addiction counselors um and probably not surprisingly there’s a huge overlap between those two licenses because a lot of the skills and actually a lot of the skills overlap and i think i talked about it at a previous episode of finding peaks but i really think i would like personally and and i hope as a field we can move away even from calling ourselves dual diagnosis because truthfully um the distinction feels arbitrary it feels like it’s still that feels like old language to say you know what you don’t have a true mental health issue if you just are an alcoholic you you just have kind of a characterological problem that you need to quit drinking that’s that’s where it just feels like antiquated uh conceptualization of people with mental health issues right absolutely i think it comes from this idea that somehow substance use and mental health are different like there is this like grand distinction that if you have a substance use disorder then you don’t have a mental health issue which by definition substance use is a mental health diagnosis so it’s again i think arbitrary in a way i think it’s actually kind of confusing and can kind of conflate treatment to a certain degree um i think when you the fact is that if a dual diagnosis can be to mental health i mean it can be i don’t know depression and anxiety i mean that’s technically a dual diagnosis isn’t it a co-occurring disorder would be any two diagnoses that are occurring and presenting it the exact same time it doesn’t so this idea that substance use you have to have this special sort of substance use disorder in order to to activate these other mental health disorders in order to treat them doesn’t it really it goes back like jason said to sort of old thinking um old definitions and really this this separation that you know we’ve talked about in length uh but that somehow mental health diagnoses and substance use disorders are different and i think that again getting rid of that language is um one good way to help try to to eliminate this sort of barrier that actually doesn’t really exist yeah and the the the project here for the the viewers at the end of the day of course is just to familiarize yourself for how this industry works at least when i’m in this host seat that’s what i’m really trying to get at in as many ways as i possibly can to inform you and help you when you call an addiction treatment center and they and you say my son and daughter is dually diagnosed can you help that they’re gonna say yes but it’s not clear to me that when i talk to treatment centers particularly their marketers that they’re aware of like what that really means and what they’re actually treating in whether or not there’s an actual approach to that at the end of the day other than phrases on websites to get phone calls to ring and so what i’m advocating for here is certainly education and also to responsibility on the part of treatment centers that if you’re going to put this stuff on your website you better do it and take it seriously because they’re our family’s desperate out there for dual diagnosis care and approaches uh at the end of the day so off my soapbox that’s my soapbox well while playing appreciate it thank you um so and it’s also too that i think um i think we were talking about this a little bit uh earlier as well too but it it does seem to be like um that we’re just gonna work on this major depressive disorder thing that’s in the brain we’re gonna work on this sud thing that’s causing the alcoholism and things at the end of the day but that’s not really how treatment works right we’re working on a variety of different features that are helping and supporting the individual live a better life not necessarily curing those ailments within 45 day episodes 90 or even 6 months to a year long but gradually and slowly but surely making their lives better and so within dual diagnosis approach to you know treatment if we’re treating somebody with major depressive disorder for example that’s going to take a while to really nurture and treat as a diagnosis so i was hopeful that maybe we could talk a little bit about what we’re actually trying to alleviate in between in that time period to improve the life you know maybe it starts with getting out of bed and putting you know getting sunshine on your face and these sort of things but it seems like in a very clinical sense that the project is greater than just these diagnosed things at the end of the day yeah i mean i think i think you’re exactly right i think i think it’s really important you know when we consider treating somebody with uh depression um i think there are things that need to occur medications usually uh you know alternative um or or kind of new and progressive treatments like like tms like we’ve talked about or um other ideas uh are important and then there is an entire set of behaviors that i think that need to be encouraged and installed with people in education around how to manage depression and how to notice warning signs of relapse of depression that’s i mean i i really it’s interesting that we are talking about this because it has been on the forefront of our mind lately of how do we really begin to nurture um the language we use at peace to say uh to merge these mental health issues with substance use and depression and how do we begin to say like there are signs you can tell when maybe you’re you’re not sleeping uh as you should you’re over sleeping or you’re not eating as you should you’re not getting the nutrients you need you’ve stopped exercising these are warning signs that your depression is likely beginning to relapse and it’s fascinating how similar it is if you just overlay alcohol heading all in the same direction because ultimately if somebody comes into our program and they have depression and they have an eating disorder and they misuse alcohol and cannabis um frankly they’re all those three things are usually just symptoms of the same kind of underlying and driving forces and literally require very similar paths toward recovery for for all of those it it isn’t we have to separate out eating disorder and separate out depression and and separate out addiction like we have to kind of teach skills and build resilience and also um probably in long-term recovery you know in long-term recovery from all those like deal with kind of the ideology of it so yeah i think that what we’ve in the past kind of looked at is treating symptoms right like you have this one specific symptom that is presenting itself with major depressive disorder so so we go after that one symptom but that again kind of keeps us at the surface level and doesn’t necessarily invite the clinician or the doctor to go further beyond that and kind of look at the systemic issues that are going on and it doesn’t necessarily um you know mean that it’s all about insight though and developing insight into you know where these like deep seated feelings are coming from it’s also the systemic issues that come from just daily living like how do i live my life how do i uh how do i actually change and adjust my my day-to-day behavior to support my long-term recovery and whether that’s in um again like jason said recovery is it’s a mental health thing too it has i think that we use that term and we automatically jump to this idea of substance use but it’s not i mean you can relapse from depression you can relapse from schizophrenia you can relapse from anxiety i mean all of these things happen because the again the behaviors that have been uh or coping strategies that have been addressed or adopted um essentially stop working or you stop using them so and i so this is all my beliefs all of everything that i’ve you know certainly wanted before i’m really energized by this discussion um so you know in that regard it it seems actually very accessible to actually provide dual diagnosis treatment right i mean take it seriously with licensures and you know the the people actually equipped to be able to handle you know the complexity of such uh diagnoses at the end of the day but so what are some of the you know so somebody comes into peaks and they have major depressive disorder and maybe they smoke pot 30 days ago but it’s not a primary concern but it is a thing that you know kind of gets entangled within that depressive disorder um you know at the same time at peaks we’ve got somebody coming in with you know significant heroin or opioid use disorder on this side and maybe several months ago they felt you know depressed as an episode so you’re treating these individuals kind of at the same time and um and then in our industry i think in the way at that service level wants to kind of just push them off into their own centers and say they’re two independent things but what i hear and what i experience here certainly is that we’re still looking at a brain disorder of some sort and it feels reasonable and manageable to actually have them in the same group stop talking about the darn diagnosis and what’s contributing to the diagnoses themselves but the relapse potential for them and i mean call me out if i’m wrong here but sometimes it feels like the thing that’s going on for the major depressive disorder you know can’t get up out of bed motivated and so forth is also happening with the opioid use disorder and so the underlying behavioral issues often look the same and makes it manageable to have them in the same group and operate from that direction i mean what i thought of when you were saying that brain and like if somebody comes in um and sits and does counseling with me for instance and they have a heroin addiction you would be shocked at how little times a word heroin comes out of my mouth you know what i mean like we don’t you know maybe an intake just to kind of get the background and all that like we’ll talk about it but like that isn’t the thing right like there’s all the other things there’s there’s grief there’s resilience there’s shame there’s all these other things that that are truly what we talk about and building a support system and and um and really those those all apply to whatever malady brings somebody like if somebody needs inpatient treatment for mental health issues they’re they’re in jeopardy too their life is in jeopardy just as much as somebody who uses fentanyl or something like it may look different it does look different but but like i said you know it’s not like 45 days of heroin treatment means all we talk about are war stories and needles and and black tar and all that that that is not the case at all there’s all the other things that are underneath that the the human that’s underneath all that and and that so and all of in in both of those issues whether you struggle with depressive episodes or you struggle with opiate addiction there’s a similar fallout in your life that has to be also addressed right like all of those those two those two diagnoses impact life in the same way they destroy relationships they interrupt stability they they completely um they create barriers to self-growth and self-insight all of those same things happen at the same time they just happen for different reasons but the reality is like jason said that uh you’re always talking about the sort of underlying motivations and the underlying things that are happening and rather than just going in it’s just similar similarly with depression you don’t just sit there and just talk about depression i mean that’s depressing absolutely worst counseling session in the world so tell me how depressed you are right now it doesn’t make any sense yeah so similarly you’re not gonna just say this so tell me about all the heroin you did like that is not gonna get anybody better you know there it’s everything around it that is actually what you’re focusing on and the reality is that life around any diagnosis is um really similar in the sense that it’s it’s interrupted it’s disruptive and it needs a different approach and intervention strategy to help it sort of be redirected and re-vigorized and reinvigorated rather yeah love it we’re on fire right now i feel like it i hope i hope it’s burning on the other side of the screen yeah yeah absolutely this is good stuff with words yeah what i what i think i want to uh i’m in a lane of curiosity here now so okay so we have these underlying things so i was i was thinking about it on my drive back from natap thinking about like cocaine use disorder right that somebody has these underlying conditions for which they’re operating under and somebody with major depressive disorder has these underlying you know things behavioral or otherwise that are happening and it just seems like at the level of cocaine use you hear there’s all types of war stories about people who have very similar traumatic backgrounds you know happening at different times for different reasons and so forth but two traumatized people can go to the party in the club at night both engage in cocaine use significantly that night one will put it down and never come back and the other one gets fired up about it shoots off in the you know the difficult direction of having a cocaine use disorder but it seems like one person is just more vulnerable or susceptible to that in the way that the other person isn’t and so the drug use or the addiction actually takes place out of that vulnerability rather than two individuals who still need to nurture these underlying behaviors this one just didn’t get addicted and so maybe it goes you know unseen but this individual is still struggling deeply as much as this individual over here and if we’re vulnerable to drugs are we also vulnerable to those major depressive disorder states in anxious states as well too differently than other people who experience similar symptomology well i think in in kind of this theme of dual diagnosis like um i did a lot of work with uh guys in the army coming back from iraq and afghanistan before uh fort carson here locally uh got you know kind of got the wounded warrior project and all the other things going um so i was just a community therapist and all of a sudden i i was inundated with all these guys coming in um from the field and you know i like to say like with with ptsd you know if six guys in an armored personnel carrier gets blown up two people die two people get ptsd two people shake it off and keep going it it has it and it’s kind of unpredictable um to your point in there probably are factors but like we can’t describe we can’t predict i at least last i knew we can’t really predict who’s going to get ptsd out of it and who isn’t but to your point like people are differently susceptible to the same the literally the same stimulus event that occurs that’s what i observed happened um and i think it absolutely applies to the same thing like some people to your point try a hard drug we’re like okay that could take or leave that and other people are like that is uh a glove going on to my hand that that is a natural fit for me um and and it’s the parallels are just remarkable i think when you and and you mentioned a minute ago like why would this be so hard to treat these two things but because our entire industry bases upon we have two different licenses for mainly overlapping skill sets to be honest with you yeah um and i think it’s just an antiquated if you ask me an antiquated thing and now yeah i don’t know go ahead well i i agree i think that you know you have two people that come in with ptsd and then you when the especially when they’re coming into treatment what you’re seeing are just maladaptive responses to that right so one person’s maladaptive response might be to use heroin another person’s maladaptive response might be to restrict food you know or to maybe goes maybe they start to develop and go into these depressive states where they’re completely detached from the world and their relationships start falling apart um you know it’s the reality is that when it that’s really what we’re treating we’re just treating maladaptive behavioral responses to triggers in the world right um so i think that again it this idea of having these that were we live in these sort of separate treatment worlds of mental health or addiction it’s just not true i mean it’s in the end it’s just you know i i’ve responded to something in a maladaptive way and it’s destroying my life regardless of what that presentation or behavior is i’m falling apart and so i need help and that’s what we do right yeah to be clear too like there’s there are nuances of treatment that do need to be specific right like you can’t everybody just can’t walk in and you’re like oh you have anxiety here’s prozac you have depression here’s prozac you have a heroin addiction here’s prozac there has to be nuanced treatment for all these things and certainly in individual therapy um some form of relapse prevention or whatever there will be individualized aspects of it but you know the overall core um i think is remarkably similar on the treatment of all these things with some little pieces of nuance absolutely certainly more similar than we ever really talk about or giving credit yeah but again yeah to jason’s point like it is more complex than that or else this would be a cakewalk right yeah but there is definitely um there is definitely nuance and uh and specificity and specialization um but ultimately as i think clinicians you recognize that really you’re just treating people in pain you know yeah what it comes down to yeah it it it’s a fascinating hyphenated like is it hyphenated dual diagnosis or is it just good words two i think co-occurring is called coca-cola or you can like smush it together you can do it by the way yeah yeah cocaine yeah later we’ll figure out the spelling of this but it’s it’s a it’s it’s language that’s used all across the board i think as a society we’re very familiar with it as a language and kind of what it means but it’s it’s interesting that it is all the little things you know sort of below the surface of the language that’s taking place at the end of the day and how still within the framework of addiction treatment centers and to be absolutely charitable this is not all treatment centers of course i’m just talking about the ones i picked on at this conference uh you know and their marketers bless their hearts they do phps the uh at the end of the day uh where do i wanna how do i wanna take this out on is that though we’re saying we do this how quickly it’s treated as this binary thing that the sud has to be this presenting factor or else substance use disorder treatment or as a substance use disorder treatment or as an addiction treatment center we can’t treat anything else that’s going on if we can’t minimally tie it to that sud language and so the my point here to the family systems that are watching this if you haven’t tuckered out yet in that regard is to be mindful of that when you’re calling places and ask those thoughtful questions about that uh at the end of the day because if your loved ones presenting with mental health as a primary major depressive disorder and they smoke pot you know or whatever the case was 30 days prior that on those excited admissions line they’re going to say yes we treat dual dino yes we can handle that oh and i heard that that that substance use disorder thing in the background yeah we can definitely do that but it’s not about the pod in that condition right we’re treating something unique and you want to find a center that can commit to that as a project or all of its underlying features and treat those individuals equally in a room with opioid use disorders and everything else that’s going on so that’s kind of my general takeaway here they want to leave the crew with any final words from you guys about this though i thought you guys were well spoken oh thank you very good that’s usually what i say at the end of things full stop full stop yeah gold stars gold stars gold stars yeah cool yeah yeah there’s green and red too but gold’s the best yeah okay that’s my joke you guys got it the viewers got it too that’s it for us here at finding peaks um regarding dual diagnosis hopefully we were able to dive a little bit deeper into that elaborate it on a little bit pull out some of the frustrations from that language and give you all um greater information to guide treatment for your loved ones your family members and so forth finding peaks at questions thoughts ideas hated your jokes brandon send it all to that space find us on the facebooks the twitters the instagrams

what else is out there youtubes yeah itunes itunes a podcast yeah i’ll get it right one day i appreciate you all for joining us until next time we are out


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