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The benefits of a dual diagnosis therapist for those struggling with both substance abuse and mood disorders

Q: Last winter, I got really depressed around the holidays; it was my first holiday season as a single mother after a divorce that I didn’t want. I was drinking more than usual at times, and long story short, I drank too much one night and made a half-hearted suicide attempt. Fortunately, my parents took the kids for a while, and I was treated in a psychiatric unit and started on antidepressants.

At this point, I am feeling much better emotionally (I think the antidepressants are really helping), and my doctor and I agree that I should see a therapist to make sure I continue to do and feel better. I thought the therapy would focus on my depression, so I was surprised when my doctor referred me to a “dual diagnosis therapist” (I had never heard of this before) to talk about both my alcohol use and my depression. I’m not sure this is really necessary. I do tend to drink more when I’m depressed (this is not my first go-around with depression), but never to where I’m drinking daily or passing out or anything, so I really don’t think the alcohol is the problem or that I need help from a substance abuse specialist. I feel that if my depression is treated, the drinking part will take care of itself. On the other hand, I like my doctor and generally trust her judgment.

Can you explain what a dual diagnosis therapist is and why someone who isn’t a full-blown alcoholic might need one?

A: Most people have never heard of a dual diagnosis therapist (also known in some areas as dual disorder therapists or co-occurring disorders therapist). I think you are fortunate, though, that your doctor is aware of this clinical specialty. Here’s why this kind of referral can make sense for some people.

Substance abuse (whether or not it rises to the level of addiction ) and mood disorders such as depression often go together in complicated ways. Often it takes a therapist who not only understands both conditions, but knows about the various ways that one can lead to or contribute to the other, to formulate an effective treatment plan. Although the term “dual diagnosis” suggests someone has been diagnosed or meets criteria for having both a mental health disorder and a substance abuse disorder, it is not at all unusual for a dual diagnosis therapist to evaluate and treat clients who don’t fully meet criteria for two separate disorders. You might think of a dual diagnosis therapist as a person with expertise in evaluating and treating the interplay between a client’s substance use and his or her mood problems.

You wrote that you have struggled with depression more than once and that you tend to drink more when you’re depressed. This suggests a relationship between depression and drinking that needs to be better understood. The fact that you drink more when you’re depressed suggests that feeling depressed increases your likelihood of drinking to excess. If bad things happen as a result of your being intoxicated (such as, say, being arrested for driving under the influence, or losing your temper with someone you care about), these experiences can contribute to your becoming more depressed. There is also the fact that when you drink alcohol, you are consuming a depressant, which in and of itself can make depression worse. Add the fact that alcohol is a disinhibitor, impairing judgment, and when you combine it with depression, that can put you at increased risk of impulsive behavior, such a suicide attempt. (I don’t know the circumstances of your suicide attempt or if suicidality has been a long-standing issue, but the fact that you described it as a “half-hearted” attempt suggests to me that you might have been less likely to act on the urge if you had been sober.) And, last but not least, your antidepressant medication regimen may call for changes in your drinking habits.

A dual diagnosis therapist can develop an integrated treatment plan that takes both problems into consideration and help you understand how you can move forward without one problem making the other worse. Sometimes people with unrecognized dual conditions relapse more often into mental health crises or substance abuse because treatment or self-help that is geared exclusively to one problem or the other does not adequately help them prevent relapse. For this reason, many people who see a dual diagnosis specialist experience a sense of validation and relief that somebody really understand the complexity of what they’re dealing with.

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