dualdiagnosis509.doc - Winona State University by pengtt


									                                                               Dual Diagnosis   1

Dual Diagnosis: Definitions, Related Counseling Issues & Treatment

                           Kelly J. Kuehl

  A Capstone Project submitted in partial fulfillment of the

     requirements for the Master of Science Degree in

                   Counselor Education at

                  Winona State University

                        Spring 2009
                                                                               Dual Diagnosis   2



Abstract                                                                  3

Introduction and Rationale                                                4

Review of Relevant Literature                                           4-16

       Defining Dual Diagnosis                                           4-6

       Statistics of Those With Mental Health Issues and Abuse Issues    6

Commonly Abused Drugs and their histories                               7-11

       Stimulants                                                        7-9

       Narcotics                                                        9-10

       Sedatives                                                        10-11

Brain chemistry                                                         11-13

Treatment Options                                                       13-16

Summary                                                                  16

Personal Reaction                                                       16-18

References                                                               19

Appendix A                                                              20-21

Appendix B                                                              22-23
                                                                               Dual Diagnosis       3


This paper defines dual diagnoses and explores related counseling issues and treatment options.

It identifies commonly abused drugs, their history and effects that these drugs have on the brain

functions of people with and without diagnoses. It also discusses the importance and difficulty in

distinguishing between and treating symptoms of individual diagnoses.
                                                                                       Dual Diagnosis         4

                                       Introduction and Rational

       I chose this topic for my paper because I see everyday the hardships and concerns that

over the counter drug and alcohol abuse can cause those with a dual diagnoses. Many of the

chronically mental ill clients I work with have a dual diagnosis and it has become evident that

many are only treated for one of their disorders. Many agencies like the one I work for treat

mental illness and attend to health issues but either does not or is unable to treat addictions. I feel

that many concerns for clients can be attended to if both diagnoses were first acknowledged. I

believe there are limitations to accomplishing these ideas including lack of funding, lack of

collaboration between agencies, lack of cooperation from clients and the readily available supply

of legal over the counter medications that are being abused. I hope that this project will allow me

to gain a wealth of knowledge in the interest of improving treatment of dual diagnoses.

Dual diagnosis

         A dual diagnosis occurs when an individual is affected by both chemical dependency and a

 psychiatric illness (Dual Recovery Anonymous World Services Inc, 2008). Both illnesses may affect

 an individual physically, psychologically, socially, and spiritually. Each illness has symptoms that

 interfere with a person‟s ability to function effectively and relate to themselves and others. Not only is

 the individual affected by two separate illnesses, both illnesses are interacting with one another. The

 illnesses may exacerbate each other and each disorder predisposes to relapse in the other disease. At

 times the symptoms can overlap and even mask each other making diagnosis and treatment more

 difficult (Dual Recovery Anonymous World Services Inc). (Henderson, 2000) states that the people

 who have had the most difficulty with the split between addiction and mental health treatment delivery
                                                                                   Dual Diagnosis     5

 systems are those who suffer from the major psychiatric disorders. These disorders are chronic and

 significant functional impairment.

       Dual diagnosis is often used interchangeably with the terms co-morbidity, co-occurring

illnesses, concurrent disorders, co-morbid disorders, co-occurring disorder, dual disorder, and,

double trouble According to Dual Recovery Anonymous World Services, (2008) professional

literature has used a confusing array of terms and acronyms to describe co-occurring disorders or

a dual diagnosis. Individuals who experience a dual diagnosis often face a wide range of

psychosocial issues and may experience multiple interacting illnesses (more than two). The term

"co-occurring disorders" is becoming a common term used to refer to dual diagnosis, or co-

occurring substance abuse disorders and psychiatric or emotional illnesses (Dual Recovery

Anonymous World Services Inc).

       There is no single type of dual diagnosis. There are numerous forms of psychiatric

illnesses. There are also many patterns of alcohol or drug abuse. As a result, a variety of different

forms of dual or multiple disorders are possible (Dual Recovery Anonymous World Services Inc,

2008). For example: psychiatric symptoms may be covered up or masked by alcohol or drug

use, alcohol or drug use or the withdrawal from alcohol or other drugs can mimic or give the

appearance of some psychiatric illnesses, untreated chemical dependency can contribute to a

reoccurrence of psychiatric symptoms, and untreated psychiatric illness can contribute to an

alcohol or drug relapse. Other problems and consequences that are associated with dual disorder

include: family problems or problems in intimate relationships, isolation and social withdrawal,

financial problems, employment or school problems, high risk behavior while driving, multiple

admission for chemical dependency services due to relapse, multiple admissions for psychiatric

care, increased emergency room admissions, increased need for health care services, legal
                                                                                   Dual Diagnosis     6

problems and possible incarceration and homelessness (Dual Recovery Anonymous World

Services Inc).

        Currently the most common mental illnesses linked with substance abuse according to the

DSMIV include, antisocial personality disorder, anxiety disorder, bipolar disorder, depressive

disorders, generalized anxiety disorders, major depressive disorder, mania, mood disorders,

panic disorders, phobia, post-traumatic stress disorder and schizophrenia, (Mogil, 2001 ). Seven

percent of the general population in the United States falls into the dual diagnosis category.

National mental health resources suggest that fifty to seventy percent of those who are addicted

to mood altering chemicals also suffer from psychiatric disorders (Mogil). Chemical dependency

is found in 56% of people with bi-polar disorder, 47% of people with schizophrenia, 32% of

people living with mood disorders other than bi-polar and 24% of people with anxiety disorder

(Mogil). According to a report published by the Journal of the American Medical Association;

thirty-seven percent of alcohol abusers and fifty-three percent of drug abusers also have at least

one serious mental illness and of all people diagnosed as mentally ill, 29% abuse either alcohol

or drugs (Mental Health America, 2009). Estimates of the prevalence of substance use disorders

among psychiatric patient populations vary widely, reflecting factors such as the use of samples

with acute versus nonacute illnesses, the geographic site of studies (for example, urban versus

rural or West versus East), and the availability of illicit drugs in the study location. Studies in the

United States confirm that the prevalence of substance use disorders among patients with severe

mental illness is higher than in the general population (Mental Health America).
                                                                                 Dual Diagnosis       7

Commonly abused drugs and their history
       The definition of medication abuse is the use of any prescription medication not

specifically prescribed for you or the use of a prescription or over-the-counter medication that is

different in any way that is different from the instructions given by the doctor or printed on the

label of the medication (Mogil, 2001). The most addictive medications, whether they are

prescription or over-the-counter fall into three categories: stimulants, narcotics and sedatives.

Scientific research has shown that when these addictive or abusable drugs bombard the system,

they change the biochemistry of the brain (Mogil).

       Many pills like ephedrine, diet pills and body enhancement products are sold over the

counter and contain amphetamines. Amphetamines, or stimulants, date back as far as 1887 when

they were first synthesized by a German scientist (Bayer, 2000). It was then ignored until the

1930‟s when scientists discovered its many uses. It was first used to increase blood pressure and

in treating lung congestion. By 1932 it was marketed as a nasal inhaler, and later this formula

(Benzedrine) was sold in tablet form to treat allergies, colds, hay fever and asthma. Three years

later it was also discovered that amphetamines were useful in treating narcolepsy and

Parkinson‟s disease. According to Bayer, (2000 ) for the next 11 years the drug became more

popular and was used in treating for smoking, low blood pressure, persistent hiccups, and

morphine addiction. As these different uses were discovered, additional forms of the drug were

developed. They included dextroamphetamine (Dexedrine,) and methamphetamine, marketed as

Desoxyn and Methedrine.

       Amphetamines became so popular, that even during WWII they were given to soldiers as

“pep-pills” and about this time in America, college students and truck drivers were using them to

stay awake for long periods of time, and housewives used them to curb their appetite and lose
                                                                                  Dual Diagnosis        8

weight. Bayer (2000) finds that athletes also took them to enhance performance, and doctors

began to prescribe it not only for weight loss, but in combination with other drugs to “cure”

depression. It is also reported that by the 1960‟s race horses were being given amphetamines to

enhance performance. At this time, soldiers stationed in Korea and Japan began mixing it with

heroin to make „speed balls‟ (Bayer).

       In the early 1960‟s the food and drug administration took measures to decrease the

amount of amphetamines in circulation with their “speed kills” campaign (Bayer, 2000) Despite

this, by 1965 there was a black market for amphetamines and abuse was common.

Amphetamines could be taken in pill form or intravenously in huge doses, and this problem was

made worse due to the fact that Methedrine was used in treatment programs as a cure for heroin

addiction (Bayer).

       Amphetamines are also used in the production of methamphetamines like ice and ecstasy.

Dr. Michael Abrams of Broadlawn Medical Center in Des Moines, Iowa, describes

methamphetamine as “the most malignant addictive drug known to mankind” (Bayer, 2000). It is

reported that the abuse of these drugs can affect a user‟s brain for up to six months following

binge use. Users of these drugs often exhibit paranoid psychosis that includes delusions and

hallucinations that can result in extreme agitation and violence, resulting in harm to others.

       Mentioned earlier was ephedrine, this drug is classified often as herbal ecstasy as it is

derived from a plant and mimics some signs of ecstasy intoxication (Bayer, 2000). Although this

is not an illegal drug it still is a dangerous substance that can cause high blood pressure, strokes,

heart attacks, and seizures. More and more reports are being made to describe the bad reactions

users experience with herbal ecstasy causing the government to consider restrictions on its sale

(Bayer). As of March, 1997 ephedrine products have been banned or restricted in at least 20
                                                                                 Dual Diagnosis     9

states, yet the potential for abuse and misuse remains. In New York regulations ban the sale of

products promoted as alternative psychoactives, which allows those marketed as weight-loss or

body-building supplements to still be sold (Weintraub, 1997). It is also hard to control

amphetamine abuse because the ingredients used to make many of these stimulants are also not

illegal. There are regulations to try and control large purchases of these ingredients, yet

methamphetamine use and abuse remains prevalent (Bayer).


        According to an encyclopedia entry (Infoplease, 2008), marijuana has been used to

achieve euphoria since ancient times; it was described in a Chinese medical report and is

considered to date from 2737 B.C. Marijuana was originally used as an all purpose medicine,

but there is no record of the Chinese using it a pleasure producing drug, (Hawley, 1992). Its use

spread from China to India and then to North Africa and reached Europe at least as early as A.D.

500. A major crop in colonial North America, marijuana (hemp) was grown as a source of fiber.

It was extensively cultivated during World War II, when Asian sources of hemp were cut off.

Marijuana was listed in the United States Pharmacopeia from 1850 until 1942 and was

prescribed for various conditions including labor pains, nausea, and rheumatism. Its use as an

intoxicant was also commonplace from the 1850s to the 1930s (Infoplease). Marijuana was not

widely used recreationally in the united states until just recently. It was always thought to be

connected mostly to the poor, musicians and youth at that time; but over the last four decades it

is reported that over 25 million of the population use marijuana (Hawley).

            A campaign conducted in the 1930s by the U.S. Federal Bureau of Narcotics (now the

Bureau of Narcotics and Dangerous Drugs) sought to portray marijuana as a powerful, addicting

substance that would lead users into narcotics addiction (Infoplease, 2008). It is still considered a
                                                                              Dual Diagnosis      10

“gateway” drug by some authorities. In the 1950s it was an accessory of the beat generation; in

the 1960s it was used by college students and “hippies” and became a symbol of rebellion

against authority. According to Infoplease, The Controlled Substances Act of 1970 classified

marijuana along with heroin and LSD as a Schedule I drug, i.e., having the relatively highest

abuse potential and no accepted medical use.

       Marijuana has been used since ancient times. Its use and users however have changed

significantly. As more research is done more proof emerges that marijuana use has dangerous

effects to the brain, heart, lungs and sexual potency (Hawley, 1992).


       Alcohol has been used since the time of Native Americans and slavery. What is striking

about the history of alcohol is that in colonial times it was consumed throughout the day by men,

women and children and integrated into nearly every ritual of social and political significance

(White, 1998). Alcohol was considered the „Good Creature of God” and although public

drunkenness had regulations, drinking itself was not considered a problem (White). According to

white, Benjamin Rush was very influential with his writings regarding alcohol and its abuse.

Rush was considered the father of psychology and wrote quite a bit about his concerns with

drunkenness and alcohol abuse. Rush‟s first writings date back to 1777 where he addressed the

drunkenness of continental soldiers. In 1782 he wrote an article urging farmers to stop supplying

liquor to their laborers. He continued to write articles that made him famous, concerning alcohol

and concerns of abuse. He continued his research and articles, which eventually led to awareness

and others‟ involvement which in turn resulted in the efforts towards the temperance movement.

This movement‟s goal was to push toward more social drinking, urging heavy whiskey drinkers,

for example to drink beer socially. Acknowledging that there was a problem and increased public
                                                                                 Dual Diagnosis   11

drunkenness, the movement also pushed for abstinence (White). Following this was the

formation of inebriate homes and asylums where people addicted to alcohol were sent to stay. It

wasn‟t until the 1900‟s that treatment for addictions emerged and in 1935 Alcoholics

Anonymous was born (White). Today there are many more options for treatment as well as

education and support for those who are addicted to alcohol.

Brain chemistry

       Over the past couple of decades, it has been found that alcohol and every major class of

drugs of abuse all interact with the ventral tegmentum part of the brain, which is connected to the

medial forebrain, (Henderson, 2000). According to a 1950‟s study, the ventral tegmentum

produces the intensely pleasurable reaction to electrical stimulation (Henderson). The tegmentum

is located in the lower central portion of the brain; this is the part that regulates automatic

functions such as breathing and appetite. Henderson reports that this part of the brain is

connected to the relay centers in the brain that include the thalamus and hypothalamus, as well as

higher parts of the brain such as the cortex, where most learning and reasoning takes place. The

primary purpose of the ventral tegmentum seems to be to produce a pleasurable sensation when

it is stimulated and to make sure that the higher parts of the brain remember what this stimulation

was so that it will be repeated (Henderson).

       Brain cells communicate messages via chemicals in the brain that are called

neurotransmitters (Henderson, 2000). Normally, once a neurotransmitter has attached to a

neuron‟s receptor site and caused a change in the cell, it is pumped back into the neuron that

released it. When someone has a mental illness, they may be prescribed medication that will

either affect the rate of reuptake of the neurotransmitter or by inhibiting its destruction by

enzymes within the synapse (Henderson). On the other hand, mood altering drugs; which can be
                                                                                Dual Diagnosis      12

addictive, often override this system by tricking the nerve cell into thinking it is being stimulated

by a natural neurotransmitter (Henderson). In discussing addictive substances, Henderson states

that drugs not only affect the ventral tegmentum but also alter mood. Mood-altering drugs

change brain chemicals and brain cells in a way that affects one‟s mood regardless of the

circumstances (Henderson). Medications that are prescribed for depression or anxiety work

within brain cells to prompt them to function properly. According to Henderson, these

medications permit people to functional optimally, so that a person is better to deal with their

reality; but not true for mood-altering drugs. Henderson states that no matter what the condition

of your brain at the time its use is started, it will be changed. Mood-altering drugs tend to

override normal systems in the brain to produce an artificial mood state (Henderson). When

these drugs leave your system there is rebound effect. Henderson states that the brain resists this

unnatural override, and will not get back to normal for some time. The brain fights the effects of

depressants by becoming over active and to fight the effects of stimulants it becomes sluggish

and depressed (Henderson). An example of this is brought to light by Bayer (2000). A stimulant

causes the neurotransmitter to build up in the gap, or synapse between neurons. As a result, the

chemical keeps affecting neurons long after it should have stopped. Amphetamines also cause

both dopamine and norepinephrine to build in the brain so while dopamine produces feelings of

pleasure for a short time, norepinephrine increases heart rate, blood pressure and pulse rate


       Basically this information shows the struggle that dual diagnoses patient must have,

especially those with persistent mental illness. If a client doesn‟t take medicine as prescribed,

neurotransmitters may not be working properly. The use and abuse of drugs affects and changes

their brain. On the other hand if a person did take medications as prescribed but also used or
                                                                                    Dual Diagnosis        13

abused drugs their brain would be changed too. When the drugs leave the system, or attempt to

another change may also occur. So it is easy to see how many different factors could lead to a

person becoming symptomatic and how these different symptoms may be confusing for the

therapist and client as it is unsure if the symptoms stem from the mental illness, the addiction or


Treatment options

          As a person neglects his or her mental illness, that illness may recur. This recurrence

may, in turn, lead a person to feel the need to "self-medicate" through drug use (Mogil, 2001).

Over time, the lack of progress toward recovery on both fronts may trigger feelings of failure and

alienation. In addition, people with serious persistent mental illness and addiction often lack the

ego strength and coping skills necessary to put a recovery program into action (Henderson,

2000). Mogil reports that perhaps the greatest tragedy is the damage that occurs to the

individual‟s self-esteem.

          The American board of psychiatry and The American Society of Addiction Medicine


          It is critical to identify the coexistence of a major psychiatric disorder or personality

          disorder because if it is not appropriately treated, it often results in relapse to substance

          abuse. To complicate matters, individuals may present with various types of psychiatric

          symptoms as a result of their response and reaction to involvement with addiction

          treatment. (Mogil, 2001, Pg. 73)

          When a dual diagnosis is made correctly, treatment can be individualized more

effectively, and according to the Department of Health and Human Services‟ Center for
                                                                                 Dual Diagnosis    14

Substance Abuse Prevention, there are three effective approaches to treating dual disorders

(Mogil, 2001). With any treatment, the important things to remember are that to achieve the best

possible outcome, both disorders must be treated simultaneously because the cumulative effect

influences all aspects of the individual‟s life and greatly increases their risk for relapse.

Secondly the body must be cleansed of substances. This is known as detoxification, and should

be monitored in a hospital setting (Helpguide.com, 2008). A successful dual diagnoses program

is staffed by clinicians who have had training and experience in addiction treatment (Henderson,

2002). The first kind of treatment is Sequential treatment. This is where the person first goes to

one kind of therapy and then to the other, alternating procedures between mental health and

substance abuse. The second is Parallel treatment where a person participates in two different

kinds of treatment at the same time. Lastly there is integrated treatment which is generally the

most effective and involves the individual getting help for both disorders in one program.

Henderson brings up that an important principle in the management of a dually diagnosed

individual is that the treatment for both conditions must receive equal emphasis and attention.

Henderson also contends that ideal programming integrates mental health care with

interventions for the addiction; the patient should receive everything necessary to treat both the

condition and the addiction. Utilizing these three treatments can be in several different forms.

According to Helpguide, these include, inpatient treatment, which involves an assessment.

Usually an appointment is necessary and there are many centers available 24 hours a day. If

there is a serious problem a person can also go directly to an emergency room. Medical

detoxification (detox), this usually involves a 3-5 day stay for alcohol detox in a medically

supervised treatment center. The program includes counseling; medications, and group sessions.

Long-term residential programs involve a stay for a few months but it can last 12 months. These
                                                                              Dual Diagnosis       15

therapeutic communities are geared toward addicts and those with mental illnesses who have

more severe problems and more than one relapse. There is an emphasis on group affiliation and

counseling to prevent relapse. Dual diagnoses treatment centers are where services are tailored

to the individual and include different types of assistance that go beyond standard therapy or

medication: assertive outreach, job and housing assistance, family counseling, even money and

relationship management. A comprehensive program takes into account a number of life‟s

aspects including stress management and social networks. These programs view substance abuse

as intertwined with mental illness, and therefore provide solutions to both illnesses at the same

time. Outpatient/partial hospitalization involves a relapse prevention treatment program usually

meets 3-5 days a week, 4-6 hours/day and is for people who require medical monitoring on an

outpatient basis. Intensive outpatient programs (IOPs) meet 3 days a week, 2-4 hours/day.

Insurance companies encourage attendance at IOPs. These relapse prevention treatment

programs are scheduled around your work or school schedule. Intensive case management is

where a case manager is assigned to the individual to provide frequent weekly contact and

phone calls to follow-up regarding their compliance with attending doctor‟s appointments,

medication management, and aftercare. Finally there is also counseling or talk therapy offers an

opportunity for emotional healing through exploration and education. Treatment is most

effective when it occurs once a week. People with severe mental illness and addiction make

steady progress in these programs, achieving recovery from the addiction and remission from

mental illness (Helpguide). It is also important to help find support groups for people with co-

occurring disorders that can serve to reinforce important issues such as opportunities to

socialize, having access to recreational activities, and developing peer relationships. Attendance

in groups that deal with education and awareness of dual diagnosis issues, medication
                                                                              Dual Diagnosis      16

management, life skills, and improvement in activities of daily living is also helpful



       Dual diagnosis is defined as any psychological disorder that co-occurs with substance

abuse, (Dual Recovery Anonymous World Services Inc, 2008). This paper discusses the

histories of the substances most commonly abused by those with a psychiatric illness. This is a

complicated disorder that can be hard to treat as patients with dual diagnosis disorders can be

extremely challenging. Lateness, rudeness and demanding behavior are common during

consultation, Kahn, A (2007, June 28). Substance abuse can also make it difficult to distinguish

between psychological symptoms and effect of substances. The Journal of Mental Health

(December, 2006) also states that it is common for people with co-occurring disorders to have

low motivation for change, making treatment difficult. Throughout this paper, different

substances and their histories are discussed as well as treatment options. There is treatment

options out there that have been proven to be effective, however for them to be successful there

needs to be an understanding of the interaction between psychosis and substance use

(Barrowclough et al, 2006).

                                        Personal Reaction

       In today‟s ever changing world, many people‟s needs can be overlooked or neglected

because resources are not in place or not enough is known to effectively help people; but as our

world changes, so come improvements in many things including new findings, new treatment

methods and available funding. As these things change and improve, I believe that already

established programs that treat mental illness can make the step upward to improve and include
                                                                               Dual Diagnosis       17

treatment programs for dual diagnoses that helps people address both issues and become

successful at understanding and compliantly treating their illness. As Mogil (2001) stated, the

idea of addressing both the mental illness and the addiction is crucial to finding appropriate


       As illustrated in this paper, drug and alcohol use and abuse has been around for decades

and many of people have experienced the struggled that is presented with it. These drugs and

methods used have also evolved over time creating struggles for those diagnosed with dual

diagnosis. The symptoms of each are so similar that they mask each other and contribute to

resistance in treatment, (Dual Recovery Anonymous World Services Inc, 2008). How easily

most abused drugs and alcohol are available also make it hard to monitor and control.

       I feel that it is very important for any community to understand dual diagnoses and the

importance of how easily attainable these abused drugs are. As someone who works day in and

day out with the mentally ill I can attest to the large amounts of people who have a mental

illness and also have a drug, alcohol or prescription addiction. I feel that there is an enormous

need to understand the individual components surrounding dual diagnoses. As I look around a

community like mine that strives to provide as many services as possible to people, I am

disappointed to see that there are not more programs or affordable programs at that that can

offer the intensive therapy needed to treat dual diagnoses. Many people are treated for one

disorder and not another. I can‟t help to ask myself what good this can do. It is difficult at times

to distinguish between symptoms from mental illness and those that result from drug or alcohol

abuse. I also see people who work with individuals with dual diagnoses and their tireless efforts

seem not to pay off. Psychiatrists in busy programs who are often spread too thin as it is, are

pressed to choose between treating only one of a person‟s disorders. Social workers and case
                                                                                 Dual Diagnosis    18

managers work hard to ensure a person can stabilize and be successful; yet deciding if someone

is symptomatic or are reacting to drug or alcohol abuse is also hard. These workers do the best

they can but years can go by with no significant improvement in a person‟s status. I believe

there would be much more visual change and success in these programs if people had the

opportunity to work on both diagnosis and it was affordable. There are programs that offer

treatment of both at once as well as individual ways to treat. I believe this would also affect

research and design of medications currently on the market.

          When you think about it, it is a terrible thing that as a society we have learned from

several avenues on how to self medicate when times are tough or we feel that there are no other

options. This learning does not exclude anyone, including the mentally ill. It begins a vicious

cycle that most likely ends in addiction and worsening the condition of someone‟s mental health


          As our world continues to change, it is important to remember that we as a society shall

too. I believe that stronger efforts need to be made to recognize problems like dual diagnosis and

efforts made to treat it. We can not continue to allow individuals to fall through the cracks by

overworking our therapists, social workers and case managers. We need to expand services and

work as a team to help these individuals become informed and educated about their disorder.

We then need to offer the effective treatments to these individuals so they to can become stable

and successful, in turn offering there support and knowledge for those who may follow.
                                                                            Dual Diagnosis       19


Barrowclough, C., Haddock, G., Fitsimmons, M., Johnson, R. (2006). Treatment development
      for psychosis and co-occuring substance misuse: a descriptive review.
      Journal of Mental Health, 15(6), 619-632

Bayer, L. Ph.D. (2000). Junior Drug Awareness: Amphetamines and Other Uppers. U.S.A:
       Chelsea House Publishers.

Dual Recovery Anonymous. (2008). Dual Diagnoses or Co-Occurring Disorders. Retrieved
      August 23, 2008 from www.draonline.org.

Hawley, R.A. (1992). Drugs and Society: Responding to an Epidemic. U.S.A.: Walker
      Publishing Company Inc.

Helpguide.com (2009). Information on Dual Diagnosis. Retrieved February 17, 2009 from

Henderson, E.C. Ph.D. (2000). Understanding Addiction: A Concise overview for all those
      affected by addiction—addicts, their family members, their employers. MS: University

Infoplease. (2009). History of Marijuana Use. In the online encyclopedia Infoplease. Retrieved
       December 12, 2008 from www.infoplease.com.

Kahn, A. (2007, June 28). Dual Diagnosis. Pulse Clinical, 36-37.

Mental Health America. (2009). Mental Health America: Dual Diagnosis. Retrieved January 19,
       2009 from www.mentalhealthamerica.net.

Mogil, C.R. (2001). Swallowing a Bitter Pill: How Prescription and Over-the-Counter Drug
       Abuse is Ruining Lives—My Story. NJ: New Horizon Press.

Weintraub, J. (1997). Adverse Effects of Botanical and Non-Botanical Ephedrine Products
       Retrieved January 29, 2008 from www.hsph.harvard.edu/Organizations/DDIL

White, W.L. (1998). Slaying the Dragon: The History of addiction treatment and Recovery in
       America. IL: Chestnut Health systems/Lighthouse Institute.
             Dual Diagnosis   20

Appendix A
                                                                 Dual Diagnosis   21

  Appendix A: The Twelve Steps of Dual Recovery Anonymous*
   1. We admitted we were powerless over our dual illness
       of chemical dependency and emotional or psychiatric
       illness - that our lives had become unmanageable.
   2. Came to believe that a Higher Power of our
       understanding could restore us to sanity.
   3. Made a decision to turn our will and our lives over to
       the care of our Higher Power, to help us to rebuild
       our lives in a positive and caring way.
   4. Made a searching and fearless personal inventory of
   5. Admitted to our Higher Power, to ourselves, and to
       another human being, the exact nature of our
       liabilities and our assets.
   6. Were entirely ready to have our Higher Power
       remove all our liabilities.
   7. Humbly asked our Higher Power to remove these
       liabilities and to help us to strengthen our assets for
   8. Made a list of all persons we had harmed and
       became willing to make amends to them all.
   9. Made direct amends to such people wherever
       possible, except when to do so would injure them or
   10. Continued to take personal inventory and when
       wrong promptly admitted it, while continuing to
       recognize our progress in dual recovery.
   11. Sought through prayer and meditation to improve
       our conscious contact with our Higher Power,
       praying only for knowledge of our Higher Power's
       will for us and the power to carry that out.
   12. Having had a spiritual awakening as a result of these
       Steps, we tried to carry this message to others who
       experience dual disorders and to practice these
       principles in all our affairs.

*From Dual Recovery Anonymous (draonline.org, 2008)

*Adapted from    The   Twelve    Steps   of   Alcoholics
             Dual Diagnosis   22

Appendix B
                                                         Dual Diagnosis   23

Appendix B: Additional Resources

National Clearinghouse on Alcohol and Drug
Phone:            800-729-6686

Dual Recovery Anonymous World Services Central
P.O. Box 8107
Prairie Village, KS 66208
Toll-Free Number:           (877) 883-2332
Website URL: http://draonline.org

Alcoholics Anonymous
P.O. Box 549
New York, NY 10163
Phone Number:        (212) 870-3400
Website URL: http://www.alcoholics-anonymous.org

Narcotics Anonymous World Service Office in Los
P.O. Box 9999
Van Nuys, CA 91409
Phone Number:          (818) 773-9999
Fax Number: (818) 700-0700
Website URL: www.na.org

Alanon and Alateen Family Group Headquarters Inc.
1600 Corporate Landing Parkway
Virginia Beach, VA 23454-5617
Phone Number:          (757) 563-1600
Fax Number: (757) 563-1655
Email address: wso@al-anon.org
Website URL www.al-anon.alateen.org
Dual Diagnosis   24

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