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Can The Freedom Model Help With
Dual-Diagnosis?

If you've been involved in the addiction treatment system for any amount of time, you've surely heard that "dual-diagnosis treatment of co-occurring disorders" is necessary for overcoming addiction. When traditional 12-Step based treatment doesn't work (or when you specifically seek out an alternative or non-12-step treatment), the substance user is then quickly diagnosed with additional mental health issues (such as major depressive disorder or generalized anxiety disorder, among others), and then dual diagnosis treatment is naturally the next recommendation. This type of treatment will take place in a residential facility filled with addiction counselors, therapists, and psychiatrists; or it may take place in outpatient treatment, on an intensive schedule of appointments with various specialists. The Freedom Model can help people who've been told they need dual diagnosis treatment, by using a unique approach that clarifies and untangles the issues, isolating each issue to make them more manageable. This article lays the groundwork for you to decide whether our approach to the issue of dual diagnosis is right for you.

First, there are a lot of terms out there like comorbidity, co-occurring disorders, underlying causes, self-medication, and dual diagnosis, that all refer to the same basic issues and theory, which is: sometimes people fit the diagnoses for both a substance use disorder and another mental disorder (such as depression or anxiety), and it is thought that those other mental disorders cause or exacerbate the addiction. In this framework, heavy substance use is often portrayed as a symptom of these other mental disorders. It is then suggested that if the other disorders are not successfully treated, it will be impossible to end the addiction. This also suggests that any reoccurrence of the co-occurring disorders (an episode of depression or increase of anxiety) will cause the dual-diagnosis patient to relapse into heavy substance use.

In The Freedom Model System, we question the wisdom of the dual diagnosis treatment approach, while still acknowledging the reality that it is common for people struggling with substance use problems to also struggle with severe depression, anxiety, and other mental health issues. However, these added diagnoses, treatments, and medications that come along with the dual diagnosis treatment approach can confuse an already difficult problem and create a new set of challenges.

For most people with these struggles it is difficult, if not impossible, to know which problem came first, depression and anxiety, or heavy substance use. Dual diagnosis treatment often overcomplicates these issues by linking them into a causal relationship, stating that depression/anxiety causes substance use, which then causes depression/anxiety, which then causes more substance use, and so on.

Simply put, when a person with a substance use problem comes to believe the dual diagnosis treatment model, they get caught in a circular trap with no escape:

If each problem truly causes the other as the purveyors of dual diagnosis treatment assert, then the only way out of the cycle is through a nearly impossible balancing act in which both problems are simultaneously and successfully treated. Any flare-up of one issue will then knock everything off balance, cyclically exacerbating both issues and trapping the dual diagnosis patient back in the vicious cycle. This is why we question the wisdom of the dual diagnosis treatment approach. As the oldest existing non-12-step residential program, people often come to us at The Freedom Model Retreats after dual diagnosis treatment has rendered them utterly hopeless and confused. We're painfully aware of its unintended consequences.

Certainly, feeling out of control of your substance use can lead to feeling depressed and anxious. And feeling depressed and anxious can seem like a good reason to use substances, (because of the cultural myth that alcohol and other drugs are an effective means of self-medication). The way The Freedom Model addresses these issues is to completely disconnect them; show the causal link to be erroneous and help people to address each issue individually. We also help our guests see through the illusion that alcohol and other drugs are effective self-medication, with a thorough set of lessons on drug effects.

How Does The Freedom Model Directly Address Dual Diagnosis?

Chapters 4-6, 8-9, and 17-18 of The Freedom Model for Addictions all discuss reasons for substance use versus the alleged causes of substance use, as well as the learned connection between mental health and substance use. The Freedom Model breaks down your choice to use substances and shows a much wider array of reasons for it than just stress, anxiety and/or depression. In many cases, once analyzed fully, people come to realize they use substances for a variety of reasons, in various circumstances and in every mood imaginable. One day you may choose to drink due to feeling depressed and the next day you may choose to drink to celebrate. While many people come to associate their problem substance use with all kinds of negative "causes", in reality depression or anxiety may be just one reason among many.

As they work through The Freedom Model, many people begin to realize that they used because they were seeking some level of happiness or relief, and they believed getting drunk or high to be the best way to achieve it. Additionally those who learn The Freedom Model gain a sense of control over their thoughts, behaviors, circumstances and life. With this new feeling of self-empowerment people naturally begin to feel less depressed and less anxious. After all, depression and anxiety are often caused, and definitely exacerbated, by feeling powerless and out of control. By gaining a perspective on your substance use and feeling empowered to make a change, this improves an individual's overall mood and personal motivation.

Even those who've struggled with anxiety and depression for many years have been able to greatly improve their quality of life or completely solve these issues by learning The Freedom Model. For those guests at our retreats who feel they need additional help to solve their mental health issues, they can see a psychiatrist or therapist who is familiar with The Freedom Model who can give them empowering strategies to solve their mental health issues. Many mental health professionals, especially those who employ solution-based therapies, have endorsed The Freedom Model and are happy to work with our guests.

Untangling Causation and Correlation with the Facts

The treatment industry confidently claims that co-occurring mental illnesses cause addiction, because there are real correlations between these problems. However, this claim of causation hasn't been satisfactorily demonstrated in the research, and may even go in the opposite direction. Even the director of the National Institute on Drug Abuse (NIDA) attests to the ambiguity of this connection, stating:

"It is… not surprising that population surveys show a high rate of co-occurrence, or comorbidity, between drug addiction and other mental illnesses. While we cannot always prove a connection or causality, we do know that certain mental disorders are established risk factors for subsequent drug abuse—and vice versa.
It is often difficult to disentangle the overlapping symptoms of drug addiction and other mental illnesses, making diagnosis and treatment complex." [1] (Volkow, 2010)

The language used here is much more careful than the broad sweeping claims issued by treatment centers. In short, they are saying that while these two sets of problems often happen together, we simply cannot say that one causes the other. It would be like saying that electronic gaming causes obesity or vice-versa. It could be that gamers gain weight because they're inactive, or that people who are inactive find gaming to be a convenient hobby that fits with their preferred level of activity. Nevertheless, the two may often occur together, because they fit together conveniently. Gaming may be a "risk factor" for obesity, and vice-versa.

The logical error of the dual-diagnosis proponents is a classic one, where correlation is considered proof of causation. Epidemiological studies have repeatedly shown that people with addictions are twice as likely than the general population to have other mental illnesses. For example, NIDA reports that about 20% of the general population has mood disorders such as depression or bipolar, whereas about 40% of addicts have these same disorders. From this fact, the treatment industry concludes that depression causes addiction. However, you could also conclude the reverse - that addiction causes depression. In the absence of other evidence, we have no way of knowing if either proposition is true - both may be simultaneously false as well. But any interpretation that says one causes the other will help treatment providers to justify providing and billing for more services. This wouldn't necessarily be bad if it worked. But as we discussed above, it can make both problems harder to solve.

There is more evidence to consider. The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that in 2015, 43.4 million adults (or 17.9% of the adult population) have any mental illness (AMI). This fits with other reports that about 20% of the population has mental illnesses. They also report that there are 20.8 million people with Substance Use Disorder (SUD), 8.1 million of whom also have AMI (that is, 8.1M have "co-occurring disorders" and thus need dual diagnosis treatment).[2](Hedden et al., 2015)

When you look at that 8.1 million as a portion of the 20.8 million people with SUD, they make up 38.9% of all addicts (in line with the common claim that 40% of addicts have co-occurring disorders). So, 17.9% of all adults have AMI, and 38.9% of addicts have AMI - repeating the point that addicts are twice as likely to have other mental disorders. This seemingly bolsters the claim that mental illnesses cause addiction.

However, when you look at that 8.1M as a portion of the 43.4M people with AMI, the picture changes drastically (from here on out, we will round the percentages to make the logic easier to understand). These dually diagnosed addicts make up only 18.6% percent of people with AMI, which means that 80% of people with AMI do not have SUD. So although 40% of people with SUD have AMI, only approximately 20% of people with AMI have SUD. If we had to guess the direction of causation between AMI and SUD based on this bigger picture of the evidence, we'd come to the opposite conclusion of the treatment industry: that SUD causes AMI. People with SUD are twice as likely to have AMI (40%) than people with AMI are to have SUD (20%).

However, this is where we will agree with NIDA: none of this really proves a connection or causality between AMI and SUD. We just wanted to show you the other side of the argument. We wanted you to know that the treatment industry's confident claim that co-occurring disorders cause addiction is unwarranted given the evidence.

Now here are some more pertinent facts:

  • Over 90% of people get over their addictions even though only 20% will ever get addiction treatment. A smaller percentage will receive dual diagnosis treatment specifically. [3] (Slate, 2018)
  • Epidemiological surveys show that people get over their addictions at higher rates and more rapidly than they get over other mental disorders (the currently recovered rate for addiction is twice as high as the rate for other mental disorders). [4] (Heyman, 2009)
  • Almost 60% of people with addictions do not have co-occurring disorders. [2]
  • People with co-occurring disorders are just as likely to get over their addictions as people with addiction only.[5] (Lopez-Quintero et al., 2011)

These bullet points are important to know. They are empowering. In dual diagnosis treatment, people are taught that their addictions cannot be overcome as long as they experience mood disorders, anxiety disorders, and the like. This claim is discouraging, robs people of the motivation to deal with their addictions, and is false. The fact that other mental illnesses last longer than addictions proves the point: people regularly get over their addictions despite continuing to have other mental health issues.

None of this should be taken as an argument against getting help for other mental illnesses/disorders. We encourage our guests to seek any such help they believe to be proper, but we have seen the destruction that tying these problems together causes. Substance use is a volitional behavior, driven by each individual's thoughts and beliefs. When you believe that your substance use choices are dependent upon perfect emotional health, you're making the problem harder to solve. By teaching people with SUD to make future substance use conditional on full resolution of every other emotional/mental health problem, treatment and mental health professionals are setting people up for a failure, and a lifetime of treatment. The Freedom Model removes dependence on treatment, and shows the individual how to approach the prospect of future substance use as a choice over which they wield full control, no matter what other life problems they are facing.

The keys to solving these problems are to gain personal empowerment through knowledge and to separate substance use from other mental health issues and address each issue individually. The Freedom Model for Addictions empowers the individual to make this separation and move on from their addictions.

For more information about The Freedom Model System offered at The Freedom Model Retreats, call 888-424-2626 and talk to one of our caring consultants today. The call is completely confidential.

References:

  • [1] Volkow, N. D. (2010). Comorbidity: Addiction and other mental illnesses (NIDA Research Report Series No. 10–5771). National Institute on Drug Abuse; National Institutes of Health. Retrieved from https://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf
  • [2] Hedden, S. L., Kennet, J., Lipari, R., Medley, G., Tice, P., Copello, E. A. P., &Kroutil, L. A. (2015). Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health, 74.
  • [3] Slate, S. (n.d.). Over 90% of addicts will recover even though less than 25% will get treatment. Retrieved May 4, 2018, from https://www.thecleanslate.org/over-90-percent-of-addicts-will-recover-even-though-less-than-25-will-get-treatment/
  • [4] See table 4.2 in: Heyman, G. M. (2009). Addiction: A Disorder of Choice (1st ed.). Harvard University Press.
  • [5] Lopez-Quintero, C., Hasin, D. S., de los Cobos, J. P., Pines, A., Wang, S., Grant, B. F., & Blanco, C. (2011). Probability and predictors of remission from lifetime nicotine, alcohol, cannabis, or cocaine dependence: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Addiction (Abingdon, England), 106(3), 657–669. https://doi.org/10.1111/j.1360-0443.2010.03194.x

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