The Dilemma of a Dual Diagnosis


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This project is a requirement of the GOA Abnormal Psychology Course. Using the process of design thinking, a challenge in the world of mental health was identified, interviews and research were undertaken, and a solution prototype was developed. Below you will find information about the identified area of concern and my proposed solution. Please feel free to provide feedback on this prototype, using questions such as “How might we…”, “What if….?”, “I wonder….”, “I like…”, and “I wish.” Keep the comments positive, please. For more information on the process of Design Thinking, click here.



STOP! Before you proceed with my presentation, please take this short survey:


In a postmodern world, we are plagued by matters ranging from war, to political division, to serious illness. Two notions that scourge our contemporary society are, undoubtedly, substance abuse and the pervading, “Westernized” notion of mental illness. Alone, these two epidemics are consequential issues; together, the deadliness doubles. When patients suffering from substance abuse enter most conventional rehabilitation services, they are often informed that they are suffering from a mental illness as well. This condition, known as a “co-occurring disorder” or “dual diagnosis,” is one that permeates the world of mental health and deserves our full attention.

The graph to the right depicts the opioid overdose death rate, opioid treatment admissions rate, and opioid sales rate over the past twenty years. Each of the three criteria measured have increased steadily during this period of time (besides a recent stagnancy in overdose death rate). The epidemic has placed a harsh burden upon the government, as well as impacting smaller communities and family units.

The diagram above uses the concept of projectile motion to compare life expectancies from individuals who suffer from a range of ailments. The life expectancies of those who suffer from a drug abuse problem are shown in orange, and the ones involving alcohol are represented with yellow. From the same source, I found that the average lifespan for someone who suffers a drug overdose is 38.7 years, whereas the average lifespan for the “standard American” is 78.7 years. This drastic “loss of life”, as well as the data above, represents an enormous dilemma in our community. Coupled with common mental illnesses such as depression and anxiety, dual diagnosis should be recognized as a topical issue and one that deserves more attention in the psychiatric field.




Dual diagnoses occur when the patient experiences mental health and substance abuse disorders simultaneously. Oftentimes, substances are used as a form of self-medication (whether that be alcohol, prescribed drugs, or illegal drugs) or as a coping mechanism for distress.


According to the National Alliance on Mental Illness, symptoms of dual diagnosis include…

  • Withdrawal from friends and family
  • Sudden changes in behavior
  • Using substances under dangerous conditions
  • Engaging in risky behaviors
  • Loss of control over use of substances
  • Developing a high tolerance and withdrawal symptoms
  • Feeling like they need a drug to be able to function

However, these symptoms can manifest themselves in very different ways, depending on which mental illness the individual suffers from.

Approximately 22.8% of individuals with a mental illness are dependent on drugs and alcohol. Paired together, the two conditions produce a variety of impediments in one’s community and the workforce.

Before the 2000s, alcohol was the most common self-medication tactic for those suffering from mental illnesses. However, in the past two decades, prescription painkillers have become the prevalent source of addiction for patients.

Finally, dual diagnosis patients aren’t getting the treatment that they need. According to a SAMHSA study, “too often, those living with a Dual Diagnosis receive treatment for only one of their ailments. It is estimated that of the adults living with co-occurring disorders, 34% receive mental health treatment, 2% enroll in drug rehab, and 12% get the help they need for both disorders.”



One of the most controversial elements of a dual diagnosis is, in fact, that many patients who are diagnosed with this condition do not suffer from mental illness at all. The symptoms of withdrawal from drugs and alcohol can simulate those of a mental illness.

During withdrawal, the patient might experience the following symptoms:

  1. Physical sickness
  2. Guilt for one’s behavior
  3. Poor sleep patterns (insomnia or hypersomnia)
  4. Poor nutrition/eating habits
  5. Feelings of hopelessness
  6. Loss of interest in activities or life itself
  7. Restlessness

Each of the symptoms listed above are also manifested in the DSM-5, which outlines the standard for various mental illnesses including eating disorders, schizophrenia, anxiety, and depression. While the conditions aren’t identical, the proximity of symptoms often leads to a misdiagnosis – especially when patients are diagnosed while they are still experiencing withdrawal.

One way to solve this incorrect diagnosis is by studying patients before and after a rigorous withdrawal process. This determines which symptoms are actually a part of one’s true character. For instance, a rehabilitation center called Narconon Ojai in southern California begins treatment with a series of nutritional supplements and a deep detoxification process, “cleansing” the patients before they may be diagnosed with a mental health issue. The drug-free program focuses on alleviating any short-term symptoms of substance abuse as a critical first step.



To realize the true gravity of dual diagnosis, one must practice empathy for the sufferers of this condition. In order for us to truly empathize with people to whom we might not be connected, it is imperative that we examine the narrative of dual diagnosis from a first-person point of view.


Watch this TedxCanmore Video by Margo Talbot to understand one perspective of how mental illness and drug abuse collide:

Climbing out of addiction and depression: Margo Talbot at TEDxCanmore

“But these coping mechanisms come at a price… because practiced over a lifetime they become our personality traits.” – Margo Talbot

In the Ted Talk, Margo Talbot offers the suggestion that problems like mental illness and substance abuse are symptoms of early emotional distress, but often do not cause the distress themselves. Talbot discusses her use of street drugs as a coping mechanism, until she was able to “trade in addiction for passion.”

Talbot’s analysis of her own emotional distress paints a compelling picture of the co-occurring condition and its impact on everyday life. At several points in the video, she criticizes individuals that she interacted with during childhood, as they lacked the capacity to understand her condition: “Nobody knew because nobody connected the dots that rocking [back and forth] is a symptom of an emotionally distressed person.” This deficiency in Talbot’s early life may have increased her potential to self-medicate using substances, leading to a bigger problem down the road.



In an article posted by Sovereign Health Treatment Centers, a mental health professional and former dual-diagnosis patient herself discusses her personal journey to overcoming her condition. Casey (a pseudonym) noted that her situation began with a young girl suffering from an anxiety disorder. Alcohol was the impetus for her condition — she began to turn to the substance because it “helped Casey put up a brave exterior, projecting her as an outspoken and party girl.”


A few years later, however, she had become hooked on harder drugs as well as prescription painkillers, which were first used to calm her nerves. Entering into a rehab facility, Casey was soon diagnosed with Obsessive-Compulsive Disorder. However, this discovery was used to her advantage and became inspiration to overcome her condition. Seven years later, Casey reunited with her family and entered the workforce as a mental health professional herself.


Casey’s story serves as inspiration for others suffering from co-occurring disorders. Because the symptoms of her two disorders were very similar, Casey was forced to combat the two simultaneously. At the brink of succumbing to the “abyss of addiction,” treatment facilities equipped to deal with dual diagnosis provided her with the opportunity to succeed.



Dual diagnosis treatment focuses on the five following criteria:

  1. 1.  Detoxification
  2. 2. Inpatient rehabilitation
  3. 3. Supportive housing (“Sober Houses”)
  4. 4. Psychotherapy and support group therapy
  5. 5. Medications


Narconon Ojai demonstrates an example of the detoxification process in their “cleansing” of patients when they first enter the treatment center. During this process, individuals are monitored for a week or more, relieving the alcohol from their systems and going through withdrawal in an inpatient facility.

Inpatient Rehabilitation:

Compared to outpatient services, inpatient rehab is useful because patients are able to receive mental health services and care on a consistent basis. In inpatient programs, patients go to individual and group therapy sessions, receive medical care, and are able to connect with others suffering from a similar condition.

Supportive Housing:

After attending rehab services, many recovering addicts look to “sober homes” as a method to avoid relapse and to hold oneself accountable during the recovery process. These facilities may be considered a “stepping stone” from dependence to independence, as they balance responsibility and connectivity.

Therapy Services:

Common forms of therapy used to treat dual diagnosis patients include CBT (cognitive behavioral therapy) and traditional group therapy. The former of these treatments focuses on the inner behaviors of the addict, whereas the latter connects him or her with the community. A popular support system for addicts in particular is Alcoholics/Narcotics Anonymous, which presents the group with a twelve-step plan for recovery. Some of these groups include the mental health element as well, which can be essential for dual diagnosis patients.


Lastly, prescription medicines are beneficial for treating mental illness. They can be used to wean an addict off from a certain substance, or lessen the pain from which someone suffers during withdrawal. However, it is imperative that these substances be regulated and administered to best promote recovery. Improper use of prescription medicine could worsen the afflicted person’s issue.

Across the board, there is evidence that suggests the following:

Dual Diagnosis is best treated when each disorder is treated in parallel.

In other words, those afflicted with this condition are best suited when their disorders are treated in a facility that can accommodate both of their ailments. This treatment method, called “integrated treatment,” is most effective and cannot be found at many standard rehabilitation centers.




Dual diagnosis is an incredibly influential force in modern society, and for this reason it deserves our full attention. During an interview with Dr. Marla Wald of Duke University, I discussed recent trends in opioid use and abuse relating to the world of mental health. According to Dr. Wald, the number of individuals addicted to drugs like Fentanyl and other opioids has decreased while the deathrate continues to rise. Wald’s guess for this phenomenon was that the drugs are becoming more potent and uncontrollable. What does this mean for addicts? Most of them can’t even make it to the hospital to receive proper treatment.


According to the infographic in the section entitled “Treatment”, individuals afflicted with a co-occurring disorder are placed at a severe disadvantage in society. They are more likely to be jailed or end up homeless, and are less likely to obtain an adequate job. Only 7.4% of those afflicted receive proper care; therefore, it is our job to spread awareness about this deficit and strive to raise this statistic.


My home state, North Carolina, has been heavily impacted by the opioid crisis and thus is at a high risk for developing a large dual-diagnosed population. In a 2016 healthcare report, four North Carolina cities made the list of the “25 Top Cities for Opioid Abuse.” Heading the list was Wilmington, which is located a mere two hours from me. My proximity to this crisis has motivated me to inspire change in my community. On a large scale, I hope to foster institutional change, but this cannot occur without proper awareness of dual diagnosis itself.




As already mentioned, my overall goals regarding dual diagnosis are to lessen the stigma surrounding sufferers of this disorder, investigate the best treatment methods, and someday create institutional change to better the treatment of these individuals. However, this project’s aim is to raise awareness about dual diagnosis itself, a necessary stepping stone for my other goals. Besides this presentation, I plan to educate those in my school and community about the disorder using resources like flyers and the narratives I have posted above. Hopefully, someone else like me will become invested in this topic and I will be able to stimulate greater change.




Now, it’s your turn! Take this information, spread it to your community, and help me inspire change not only in my hometown but across the entire world of mental health. The first step to catalyzing change is by spreading the word. Therefore, to help dual diagnosis patients receive proper care for their condition, we must learn about the issue at hand and place ourselves in the narrative. This process, helping us practice empathy, can foster institutional and social change. Please leave comments below if you have any questions, feedback, or resources that I could use to further my research of this essential issue. Asking questions like “What if…?” and “How might we…?” are key for promoting the best results! Remember,

Change begins with YOU!

Made with Padlet



Birkenshaw, Sue. “The Dual Diagnosis Dilemma.” November 2016. Narconon Ojai. 10 April 2018. <>.

“Dual Diagnosis.” August 2017. National Alliance on Mental Illness. 7 April 2018. ,>.

Gagne, Cheryl “Recovery: A Common Vision for the Fields of Mental Health and Addictions.” Boston: Psychiatric Rehabilitation Journal, 2007. 6 April 2018. <>.

“How I survived – A first person account of dealing with addiction and co-occurring mental condition.” February 2018. Sovereign Health. 15 April 2018. <>.

“Important Statistics.” Foundation Recovery Network. 10 April 2018. <>.

Knopf, Taylor. “Four North Carolina Cities Make Top 25 List for Opioid Abuse.” July 2017. North Carolina Health News. 1 April 2018. <>.

Kolodny, Andrew. “The Opioid Epidemic in 6 Charts.” October 2017. The Conversation Online. 12 April 2018. <>.

“Life trajectories cut short by drug and alcohol-related deaths.” American Addiction Centers. 14 April 2018. <>.

Talbot, Margo. “Climbing out of addiction and depression.” TED. Nov. 2013. Lecture.

“10 Things You Should Know about Treatment.” Foundation Recovery Network. 11 April 2018. <>.



Comparative life trajectories diagram. “Life trajectories cut short by drug and alcohol-related deaths,”, American Addiction Centers, 15 April 2018, <>.

Image of blue Help logo. Fundación Help, 15 April 2018, <>.

Image of crowd forming the shape of a strong man. How to Bring Positive Social Change, The Thinking Muslim, 11 December 2016, 15 April 2018, <>.

Image of cut-out paper figures holding hands. NAMI Adult Support Group, National Alliance for Mental Illness of Greater Wheeling, WV, 15 April 2018, <>.

Image of orange prescription medicine bottles. How to Get Free Prescription Meds, The Oz Show, 15 April 2018, </>.

Image of pills and alcohol. Geriatric Substance Abuse Recovery Program, The New Jewish Home, 15 April 2018, <>.

Image of prescription Rx medicine. Why Isn’t Prescription Rx Medication Being Regulated?, Addiction Recovery Radio, 15 April 2018, </>.

Image of two brains with puzzle pieces. Benefits of Dual Diagnosis Treatment, Foundations Recovery Network, 15 April 2018, <>.

Infographic describing integrated treatment and dual diagnosis statistics., Foundations Recovery Network, 15 April 2018, <>.

“Opioids on the rise.” The Opioid Epidemic in 6 Charts, The Conversation, 4 October 2017, 15 April 2018, <>.

Orange stop hand logo. “Living with a dual diagnosis: 5 Strategies for a successful recovery.”, Mountainside Treatment Center, 9 April 2016, 15 April 2018, <>.

Venn diagram describing dual diagnosis. Dual Diagnosis in Addiction Treatment Centers, Inspirations for Youth and Families, 15 April 2018, <>.

Screenshot from Margo Talbot’s Ted Talk. “Climbing out of addiction and depression,” TED, Nov. 2013, 15 April 2018, <>.


Share this project
  1. April 26, 2018 by Summer

    Rory, it has been so interesting to see your project grow as you made progress with it. It is clear how much work you put into this, and I appreciate how you explained your personal connection with the topic. I think this is a great start to making a big difference in the North Carolina community. Great job!

    • April 29, 2018 by Rory Smith

      Hi Summer! Thank you so much for your help with my presentation and advice during the peer-editing process. It has been so fun working with you!

  2. April 26, 2018 by Mila Tewell

    Rory, thank you for this well researched and thoughtful presentation on a critical issue in our world today. What a fine beginning to achieving your goal of raising awareness locally, regionally and indeed globally. Well done!

    • April 29, 2018 by Rory Smith

      Mila, thank you for your kind words! I am glad that you enjoyed the presentation, and I hope that it provided a comprehensive overview of the issue for which I hope to raise awareness!

  3. April 26, 2018 by Ella.Durbin

    Wow, your presentation looks so put together and has a pleasing aesthetic. Your information is formatted well and is easy to read which keeps your audience engaged with the information. How can I change how I interpret someone with a co-occurring condition? In Seattle, we have a large homeless problem as well as a heroin issue. A vast amount of homeless people have a mental health disorder like schizophrenia as well as drug problem which makes it very hard to get off the streets and into homes. I hear people talk very negatively about these people, how can I educate and inform people of mental illnesses that may be occurring? Overall great job!

    • April 29, 2018 by Rory Smith

      Ella, thank you so much! Your presentation also is beautifully formatted and has a very pleasing, polished look. I think the most important thing when assessing someone with a co-ocurring condition is by keeping an open mind and understanding the complexity of their condition. With any mentally ill person, it’s important to be sensitive to their condition – someone with a co-occurring condition might not even know themselves how to overcome their ailment, which condition triggered another, etc. To help the population in your community, I would stress the importance of reducing stigma because these individuals didn’t choose to be in their situation. Mental illnesses AND substance addiction are heavily influenced by genetics, and nobody should be blamed for that.

  4. April 26, 2018 by Julia.Cohon

    Rory, your presentation looks great! I was wondering what aspect you found most interesting? I am also really curious about how students can help with this issue? How can we most effectively make a change?

    • April 29, 2018 by Rory Smith

      Thank you, Julia! I think the most interesting aspect of dual diagnoses is the uniqueness of each patient’s condition, and how it can be manifested in very different ways and orders of occurring. Of course, this aspect places a large emotional strain on both patients and those caring for them, because the diversity in patients’ stories makes it harder to treat the condition in a uniform way. When thinking about this project, I had a hard time trying to figure out how students can help, as this disorder mainly manifests itself among older demographics. However, I think it is important that teenagers learn about this condition early because many students begin to use substances in high school, and it’s important to recognize the factors that contribute to addiction and how mental health plays a role as well. Besides spreading the word, I think that the best thing to do is by shifting our mindset to being more open to others’ mental health conditions so that we can reduce stigma. If more awareness is raised from the younger generations such as ours, then we will be able to implement programs for better treatment and care. Thanks for checking out my page!

  5. April 27, 2018 by Eden Sokoloff

    Your presentation was amazing Rory! I can tell you’re so passionate about the topic and really understand what you’re talking about. I’m excited to see how you decide to further your research because effectively making a change on this issue seems so difficult. You outlined some fresh and powerful ideas, and I’d love to see more from you! Love it girl!

    • April 29, 2018 by Rory Smith

      Hi Eden! Thanks for checking out my page and supporting my work! I hope that the presentation was compelling and inspired you to raise awareness for this very real issue. Thanks again for reading and commenting!

  6. April 27, 2018 by Wilson Mueller

    Really enjoyed exploring the idea of a double diagnosis, thank you for enlightening me in this area. I previously was not familiar, but now I am aware of a completely new spectrum of mental illness. Great job Rory!

    • April 29, 2018 by Rory Smith

      Hi Wilson! Thanks for checking out my page, I hope you learned something!

  7. April 27, 2018 by Sophie Staeger

    Wow! This is really well done and contains some impressive insight. What actions do you suggest therapists/psychologists take in treating dual-diagnosis effectively?

    • April 29, 2018 by Rory Smith

      Sophie, thank you so much! In my opinion, the most important thing that therapists/psychologists can do to treat dual diagnostic patients is taking a genuine interest and care in their condition. With dual diagnosis, patients’ stories and situations can be very diverse and hard to grasp, because they are so complex with causes and different factors contributing to their affliction. When doctors truly attempt to understand and empathize with their patients, they are more capable of providing the most comprehensive treatment plan that will have the highest success rate.

  8. April 27, 2018 by Isabella Towning

    YES RORY! I loved your topic and I learned a lot! Very proud!

    • April 29, 2018 by Rory Smith

      Thank you Isabella! Hope you enjoyed!

  9. April 27, 2018 by maggie

    oops my insta is @maggiesfitz follow me

  10. April 27, 2018 by Lucinda Thompson

    Really nice job! I think you clearly articulated the problem as well as a path that we should embark on to start solving it. I found this super interesting as I was aware of this problem, but not the details of it. I’d be interested in hearing if you have any more ideas as to what we can do in the future besides raising awareness.

    • April 29, 2018 by Rory Smith

      Lucinda, thank you so much for your kind words! My overall goal is to formulate a better treatment plan for dual diagnostic patients, because, as stated in my presentation’s statistics, most patients with the condition do not receive suitable care for both of their afflictions. However, it’s hard to even begin coming up with a single plan due to the diversity of narratives within this disorder. Besides raising awareness, you can try to reduce stigma in your community for those with both mental illness and SUD, as this negative outlook puts dual diagnostics at a great disadvantage in every community.

  11. April 28, 2018 by Saanya Kapasi

    This presentation had detailed information, infographics, and analysis that identifies the problem, what is currently being done to solve it, and what we can do to help. You had a great balance of statistics, treatment methods, and personal experiences; this truly emphasized the importance of empathy! A question for further exploration would be is if dual-diagnosis is something that affects teenagers, as mental illnesses tend to arise during this time as well as the introduction to substances. Does this issue tend to arise during early adulthood, as patients have easier access to substances but harder access to care with insurance policies? Overall, incredible job!

    • April 29, 2018 by Rory Smith

      Hi Saanya! Thank you so much for your heartfelt comment. I am glad that you noticed my emphasis on empathy, because that’s an essential aspect of assessing a dual diagnostic. To answer your question, about 38% of dual diagnosis patients are between the ages of 18-25, and the majority of the rest are aged 25-50. This disorder can impact anyone, regardless of demographic, but yes – it tends to influence young adult males the most. I’d assume that this is for the very reasons you stated, regarding teenage onset of mental illness as well as access to substances and trouble with insurance policies. A very thought-provoking question, thanks again!

  12. April 28, 2018 by Sydney.Medford

    This is a really interesting and important topic. You did a really good job of explaining the problem, social impact, and solution.

    • April 29, 2018 by Rory Smith

      Sydney, Thank you so much! I hope that you learned a lot from my presentation, and that it inspired you to foster change in your community as well.

  13. May 03, 2018 by Sofia

    Hi Rory,

    I think that this is a really interesting and complex topic. This seems to be misunderstood in many places because of how intertwined the dual diagnosis. I love how many sources you used and that everything is so well cited. I learned a bunch from this presentation!

    • May 06, 2018 by Rory Smith

      Hi Sofia,
      Thank you so much for the kind words! I’m glad that you learned a lot from my presentation!

  14. May 03, 2018 by Natalie

    Awesome job! This presentation was super informative and intelligent, with such a creative topic. I loved how you used a diverse group of colorful pictures to make the presentation easy on the eyes. Overall, I learned a lot and was really interested the whole time.

    • May 06, 2018 by Rory Smith

      Thank you so much for your support!

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