Comorbidity occurs when people have two or more illnesses or disorders at the same time. Individuals who have co-occurring disorders (sometimes still referred to as dual diagnoses) have at least one substance use disorder and at least one comorbid non-substance-related mental health disorder, such as depression, a personality disorder, bipolar disorder, a trauma- and stressor-related disorder, an eating disorder, etc. These cases can often be more challenging for treatment providers despite their prevalence. 

In a residential treatment program, the client lives in and gets treatment in the same facility. Typically, residential treatment programs are not hospital units or inpatient psychiatric units. Those treatment programs are typically reserved for individuals with very acute issues who require 24-hour medical supervision or psychiatric care, whereas individuals in residential treatment facilities require intensive treatment but do not need the intensive level of monitoring around the clock that occurs in a more acute setting. 

Because residential treatment programs do offer a lower level of 24-hour monitoring and access to care, they are designed for individuals who need intensive treatment, may be coming out of an inpatient psychiatric or substance use disorder treatment unit, or have certain types of conditions/disabilities that result in it being very difficult for them to function without supervision.
 

Treatment for Co-Occurring Disorders

Individuals getting treatment with co-occurring disorders often require intensive treatment. These individuals need to have concurrent treatment for both (or all) of their mental health disorders, including their substance use issues and other psychological disorders, at the same time. Because these individuals need multiple interventions from different mental health specialists, individuals with co-occurring disorders are often treated by a multidisciplinary team of healthcare providers who specialize in different disorders.

According to the book Integrated Treatment for Dual Disorders: A Guide to Effective Practice, this is often referred to as an integrated treatment approach because the treatment for individuals with co-occurring disorders integrates specialists from different fields. The multidisciplinary team will most often consist of: 

  • Physicians, such as psychiatrists or addiction medicine physicians 
  • Other medical personnel, such as nurses and physician assistants who specialize in treating the specific disorders in question 
  • Psychologists who specialize in treating substance use disorders and psychologists who specialize in treating the particular mental health disorder that is co-occurring 
  • Social workers or counselors  
  • Other specialists who treat aspects of various disorders, such as speech therapists, occupational therapists, vocational rehabilitation specialists, etc. 
  • Case managers who organize treatment and make sure that the treatment runs smoothly 
  • Other professionals who address other specific issues 

The team will typically work together to assess the functioning of the individual, make the specific diagnoses in the person, and develop a treatment plan for the individual. Each individual specialist will address their area of expertise. The team will communicate through the use of progress notes and team meetings.
 

Residential Treatment

The American Society of Addiction Medicine categorizes treatment levels for substance use disorders according to their intensity.  These treatment levels can also apply to integrated treatment. 

  • Level 0.5: Early Intervention 
  • Level I: Outpatient Treatment 
  • Level II: Intensive Outpatient/Partial Hospitalization Treatment 
  • Level III: Residential/Inpatient Treatment 
  • Level IV: Medically Managed Intensive Inpatient Treatment 
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    Residential treatment (Level III) for the treatment of substance use disorders can occur in numerous different settings, including short-term residential abilities, long-term residential facilities, halfway houses, and even in institutions involved in the criminal justice system. There are no hard and fast rules to decide which type of individual should be placed in a residential treatment program. Most often, individuals entering residential treatment programs are in subacute crisis situations, such that their needs are too intense to be fully addressed in an outpatient treatment program, but the situation is not severe enough to warrant hospitalization. This can include individuals who are being transitioned to a lower level of care from inpatient treatment, individuals with cognitive or physical disabilities, or individuals with severe substance abuse issues or psychiatric issues that do not require 24-hour medical supervision but do require close monitoring and intense treatment.

    Additional circumstances may benefit from residential treatment.

    • If individuals were originally in outpatient treatment, but their symptoms were not successfully addressed and they continue to demonstrate significant occupational or social functioning issues, residential treatment may be appropriate.
    • Clients who have inadequate social support networks may benefit from residential care. Due to an unsafe or unsupportive home environment, these individuals may not be able to function in early recovery without close supervision.
    • There may be safety concerns for the individual, such that it is believed that outpatient treatment is not a proper course of action.
    • There are issues with the potential diagnoses for the individual. For instance, individuals with certain types of personality disorders may often be diagnosed with depression or an anxiety-related disorder. Personality disorders are far more severe, and depression and anxiety are often symptoms associated with these disorders. Because it is important to know the diagnosis before one begins treatment, having treatment professionals monitor and observe the individual around the clock can help to solve issues with ambiguous diagnoses and aid in developing a proper treatment plan.
    • Situations where the needed resources from treatment providers are not available except in a residential treatment program necessitate this level of care.

For some individuals with co-occurring diagnoses, a lower level of care such as outpatient treatment may be more appropriate than residential treatment, whereas for others, residential treatment may be a more appropriate starting point than outpatient treatment.

Individuals with severe issues may need inpatient treatment (Level IV). There are some other advantages to placing individuals with co-occurring diagnoses in residential treatment facilities if the facility meets the needs of the individual.

Advantages of Using Residential Treatment for Co-Occurring Diagnoses

There are several general advantages to using residential treatment facilities to address issues with individuals who have co-occurring diagnoses. These advantages are only present if the facility has the resources to address the specific types of substance use disorder and co-occurring psychological/psychiatric diagnosis that the individual presents with. According to the principles of treating co-occurring disorders described in the book Treating Co-Occurring Disorders: A Handbook for Mental Health and Substance Abuse Professionals, these advantages are:

  • Residential treatment programs typically have readymade teams of different mental health specialists, such as psychiatrists, addiction medicine physicians, therapists, and other treatment providers. These individuals can work together as soon as the client is admitted to the program to perform a thorough assessment, develop a treatment plan, and implement the plan.
  • For diagnostic issues that may be ambiguous, the residential treatment facility has the advantage of having the treatment team continually observe the individual on a daily basis, and this allows for better clarification.
  • In some residential treatment programs, the withdrawal management (medical detox) program can be implemented without transitioning the client to inpatient care. The integrated treatment plan and program can be initiated while the individual is undergoing withdrawal management, and this can help give them a jumpstart on their treatment.
  • Abstinence from drugs or alcohol is far easier to maintain in a residential treatment facility compared to an outpatient program. This can be extremely important in getting individuals in the early stage of recovery to commit to abstinence, develop self-confidence regarding their ability to remain abstinence, and form positive habits and behaviors to foster drug-free living.
  • Individuals with co-occurring disorders are typically under significant distress and often suffer severe functional impairment in their lives. Having them live in the treatment facility can reduce some of the stress and help them begin to get their lives in order before they return to independent living.
  • Because individuals with co-occurring diagnoses often have numerous crises events, having them in close proximity to treatment providers around the clock can help address any crises situations immediately.
  • Treatment providers are in close contact with each other daily in residential treatment facilities. This facilitates communication, better addresses client needs, and helps to monitor and document client progress. Even though individuals should be assessed initially before entering the program, the assessment process is ongoing. Because the team is present at the facility on a daily basis, this process is facilitated.
  • Individuals with co-occurring disorders who are being treated in residential treatment programs are in close personal contact with others with similar issues. This helps them learn to benefit from the experiences of others and also gives them the feeling that they are not alone in their struggles. This can be very important in recovery from a dual diagnosis.
  • Residential treatment facilities should have access to urgent or emergency care facilities if the need arises. Individuals who have an accident or emergency can be immediately transitioned to one of these facilities, whereas in an outpatient program, this may take a longer amount of time.
  • Because of the attitude that is present in these facilities, there is a higher level of commitment for many individuals regarding their approach to recovery and to the treatment of their psychological issues. Just being in a facility, away from the outside world, helps to strengthen one’s commitment to change.

Thus treatment process, while it is always important to remember that treatment should be personalized for the individual needs of each client, residential treatment facilities offer specific advantages in the early stages of treatment of those with co-occurring disorders. They help these individuals transition to more independent living with significant progress regarding their treatment goals already under their belt. This fosters a more successful prognosis in the long-term.  

It should be understood that the residential treatment portion of an individual’s overall treatment program is only one step in their recovery from a substance use disorder and any other co-occurring diagnosis. Once they are discharged from the residential treatment facility these individuals should be transitioned to some form of aftercare program, most often some type of outpatient aftercare program in order to ensure long-term success. Individuals who do not transition to a structured aftercare program run the risk of relapsing. An individual who relapses back into their old substance abuse habits will most likely begin to experience other issues that led to their co-occurring diagnosis, such as depression, anxiety, etc., or they are more likely to no longer engage in treatment for their co-occurring psychological disorder. While residential treatment can be an extremely crucial component of overall recovery, it is only one step in the process of recovery from co-occurring disorders.