Let’s discuss the term “Dual Diagnosis”. The term itself is relatively innocuous, with no obvious added stigma. But what does it really mean? Traditionally, it refers to someone with both a substance use disorder (SUD) and another psychological disorder. I have a few concerns with the term.
Dual diagnosis is nearly always used in reference to substance use and something else, creating a false distinction between a SUD and all other psychological disorders. I believe this separation contributes to the continued discounting of substance use as a serious mental health concern. No one uses dual diagnosis to refer to someone struggling with anxiety and depression, or an eating and panic disorder.
A work-group in our State is attempting to apply the Sequential Intercept Model to find gaps in our State’s jail diversion and reentry programs. The model as described in the article starts “with the ideal that people with mental disorders should not penetrate the criminal justice system at a greater frequency” than those without. I’ve heard that in Oklahoma around 30% of the inmate population has been diagnosed with a Serious Mental Illness (SMI). Of course those numbers don’t include SUD’s. Apparently we don’t consider those serious.
What if we counted those with severe SUD among the seriously mentally ill? The number of those incarcerated would certainly jump up to well over 50, 60, maybe even 70%. Perhaps then we could see the injustice of incarcerating people primarily for displaying symptoms of a psychiatric disorder. What if we had the same Crisis Intervention Teams (CIT) working to help those identified with a SUD?
In addition, the phrase dual diagnosis can create the image of a homogeneous group of people. Anyone working in this field should understand the complex and varied needs of the population. Assuming the next person with a “dual diagnosis” is going to look anything at all like the last person you treated is naive at best!
The label is also often misapplied. There are many who have only experienced depression, anxiety, psychosis or other psychological problems during the course of their struggle with a SUD. Although the DSM warns against making a diagnosis in the absence of sobriety, I’ve seen many patients with multiple diagnoses who report limited or no periods of sobriety in their adult life. So when was the diagnosis made? Often during active substance use or perhaps in the middle of a withdrawal.
In short, those with Substance Use Disorders (SUD) deserve the same level of treatment and consideration as those struggling with any other Serious Mental Illness (SMI). Use of the term Dual Diagnosis continues the distinction between SUD’s and the multitude of other SMI’s that deserve treatment, not incarceration. The term dual diagnosis is likely overused and often misapplied to a complicated population with a variety of needs. Classifying these patients into a seemingly homogeneous group not only diminishes the complex nature of the problems they face, it potentially limits our ability to assess and treat their individual needs.
3 thoughts on “Words Matter: Dual Diagnosis”
In addition to practicing the assessment and treatment of “Co-Occurring Mental Health and Substance Use Disorders” I teach a graduate course with the same title. SAMHSA has some wonderful material available in their series “TIP 42 Substance Abuse Treatment for Persons with Co-Occurring Disorders.” Go to: for a wealth of materials
I tend to prefer co-occurring to dual diagnosis but still think it creates a false distinction. Don’t you think the language creates the impression that substance use is somehow separate from mental health disorders? Maybe I’m hoping for too much in thinking we can start to view substance use in the same way we do other mental health disorders.
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