Viewpoint is a unique alternative addiction treatment program

medication and addiction treatment program

Viewpoint Dual Recovery Center’s holistic, comprehensive treatment program acknowledges that addiction and co-occurring disorders require attention to the mind, body, and soul. We provide our patients with the latest evidence-based, client-focused treatment for addiction and mental disorders. Viewpoint is a unique alternative addiction treatment program. We are an Intensive Outpatient…

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What makes Viewpoint Dual Recovery Center different from other Treatment Centers?

substance abuse treatment

The goal of dual diagnosis interventions is to manage both illnesses so that the client can pursue meaningful life goals. Viewpoint Dual Recovery Center simultaneously addresses chemical dependency, substance abuse, and the “associated” conditions or illnesses. Although treatment centers and programs traditionally have focused on drug addiction within the framework…

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Blog Series Part 2: Effects of Substance Abuse

Effects of Substance Abuse

Imaging studies have revealed neurochemical and functional changes in the brains of drug-addicted subjects that provide new insights into the mechanisms underlying addiction (Volkow, 2003).  Most studies of drug addiction have concentrated on the brain dopamine system, since this is considered to be the neurotransmitter system through which most drugs exert their reinforcing effects (Koob, 1988). A reinforcer is defined as an event that increases the probability of a subsequent response, and drugs are considered to be much stronger reinforcers than natural reinforcers, like food or sex (Wightman, 2002). The brain’s dopamine system also regulates motivation and drive for everyday activities (Wise, 2002).

Neurochemical studies have shown that large and fast increases in dopamine are associated with the reinforcing effects of the drug and also has shown that after chronic drug abuse and during withdrawal, brain dopamine function is markedly decreased (Volkow, 2003). These decreases are associated with dysfunction of the prefrontal regions of the brain, including the orbitofrontal cortex (Volkow, 2003). The changes in brain dopamine function are likely to result in decreased sensitivity to natural reinforcers since dopamine also mediates the reinforcing effects of natural reinforcers and on the disruption of frontal cortical functions, such as inhibitory control (Hyman, 2001).

Functional imaging studies have also shown that during drug intoxication, or during craving, these frontal regions become activated as part of a complex pattern that includes the nucleus accumbens, the orbitofrontal cortex, the amygdala and hippocampus, and the prefrontal cortex and cingulated gyrus (Nestler, 2001). The nucleus accumbens is the brain circuitry involved in reward, the orbitofrontal cortex is the brain circuitry involved in motivation, the amygdala and hippocampus are involved with memory, and prefrontal cortex and cingulated gyrus are involved with cognitive control (Nestler, 2001).

Thus, in drug addiction, the value of the drug and drug-related stimuli is enhanced at the expense of other reinforcers (Volkow, 2003). During exposure to the drug or drug-related cues, the memory of the expected reward results in overactivation of the reward and motivation circuits while decreasing the activity in the cognitive control circuit (Hyman, 2001). When cues or stimuli occur that are associated with drug seeking, increased activation of projections from the prefrontal cortex occurs, which, in turn, increases the release of glutamate in the core of the nucleus accumbens (Thanos, 2001). This increase in glutamate causes an increase in drug seeking and intake (Thanos, 2001). Such cues or stimuli might include anything previously associated the drug use, a stressor, or even a single dose of the drug.

The release of dopamine in the prefrontal cortex and the amygdale is necessary for the amygdale to recognize cue-associations with drug use which are the motivationally relevant events, and for the prefrontal cortex to exert its effect on the nucleus accumbens which mediates behavior (Volkow, 2002). However, drug use does not allow the prefrontal cortex to restrict the compulsion to seek out stimuli that have cue associations with drug use (Volkow, 2002). This whole process may be the reason for the addiction or loss of control, with the addict continuing to use the drug even though there is no longer pleasure in using it (Volkow, 2002).

The changes that occur after chronic drug use are more permanent than changes that occur during acute drug use and may be a reason why relapse occurs in addicts (Simkin, 2006). Since adolescents may not be able to differentiate between motivationally relevant and irrelevant events, when addiction occurs, the prefrontal cortex may increase the tendency to seek out risky behaviors whether they are relevant or not (Simkin, 2006). Alternatively, addiction may turn the otherwise less sensitive amygdale found in adolescents into a more sensitive adult-like amygdala that seeks out only drug associated relevant events (Simkin, 2006).

Although patients may use substances to self-medicate their manic symptoms, it has been shown that the use of multiple substances may actually exacerbate the neurobiologic effects (Khantzian, 1997). In one study, patients (aged 18-65 years) presented with active marijuana and alcohol use in the manic phase, the marijuana did not decrease the level of the manic state (Salloum, 2005). It was determined that although the sensation of feeling calmer with marijuana may have been experienced by bipolar substance abusers who were manic and using alcohol, the mania symptoms were actually worse in those who presented with bipolar disorder and marijuana and alcohol use than in those  with bipolar disorder and alcohol use alone (Salloum, 2005).

Use of multiple substances may be a sign of a more progressive addiction, which would likely decrease the ability to inhibit compulsive behavior and the level of mania (Salloum, 2005). Furthermore, the type of treatment used may have greater effect on those who are actively using marijuana during their presentation with mania and alcohol (Salloum, 2005). Those who were treated with lithium and psychosocial therapy in this study, as opposed to those treated with one of those therapies alone, had the highest percentage of heavy drinking days (Salloum, 2005). The individuals who used alcohol and marijuana were younger than the other study participants; because alcohol and marijuana are the most frequent substances of abuse in adolescents with bipolar disorder, early onset of bipolar disorder and multiple substance abuse disorders may have a greater neurobiologic effect on the immature brain if the disorders go undetected and untreated (Geller, 1999).

If substance abuse occurs before the development of bipolar disorder, there may be a more rapid onset of mania because there is less ability to control or inhibit symptoms of mania or mood associated with sub-cortical structures because of the effect of addiction on the orbitofrontal cortex (Chang, 2004; Goldstein & Volkow, 2002). If the bipolar disorder occurs before the substance abuse , the effect on the orbitofrontal cortex may strengthen the compulsion to use drugs (Larson, 2005). In addition, the addiction process changes the way the orbitofrontal cortex normally performs by forming different connections; thus, the orbitofrontal cortex may not function as it normally would have before the addiction (Larson, 2005).

The reorganization of these connections may prevent the orbitofrontal cortex from ever fully developing (Simkin, 2006). If normal functioning or maturation of the orbitofrontal cortex does not occur in adolescence, this may lead to less control of symptoms of mania in adulthood (Simkin, 2006). This could explain why early onset of mania has a higher risk for a worse prognosis. Alternatively, if all adolescents must rely more on the less efficient dorsolateral prefrontal cortex for inhibitory control during adolescence, the adolescent with bipolar disorder, who has a less mature dorsolateral prefrontal cortex, may have more difficulty throughout this period of time (Simkin, 2006). Decreases in N-acetylaspartate levels in the dorsolateral prefrontal cortex which is used primarily during adolescence for inhibition, were found in euthymic bipolar patients and manic bipolar patients as compared to healthy adolescent subjects (Simkin, 2006). It is believed that earlier detection and treatment of bipolar disorder and substance abuse disorder, whether presented separately or together, would increase the likelihood that the orbitofrontal cortex would be able to fully mature (Simkin, 2006).


Early detection and treatment of bipolar disorder and substance abuse disorder seems extremely important to normal brain development in adolescents. If the developmental processes  discussed in this paper are accurate, not treating adolescents with bipolar disorder and substance abuse disorder may prevent normal development of the brain and decrease the ability of the adolescent to function at his or her fullest potential upon reaching adulthood as well as avoid permanent neurological damage (Winters, 2008). Similarly, not treating these disorders early may decrease the responsiveness of mature brain to medication interventions (Simkin, 2006). Since neurobiology is still in the early stages, more research is necessary to pinpoint and understand the underlying causes of bipolar disorder and substance abuse disorder in the developing brain (Volkow, 2002). More research is also needed in the area of finding treatments that would allow normal development of the brain to occur despite the onset of psychiatric disorders.

Blog Series Part 1: The Effects of Bipolar Disorder and Substance Abuse Disorder on the Developing Brain

Human Growth and Development


There is a strong association between bipolar disorder and substance abuse disorder.  This phenomenon has been explained in several ways. First, bipolar disorder may be causing substance abuse disorders. Next, substance abuse disorders may be causing bipolar disorder. Finally, both disorders may share common origins. However, the most recent literature states that none of these explanations is completely accurate (Brown, 2005).


Since both of these disorders predominantly have their onset in adolescence, it is important to look at the effects that bipolar disorder and substance abuse disorder have on brain development (Simkin, 2006). It is thought that either or both of these disorders disrupt the normal development of the brain to the extent that the brain never reaches full maturity (Simkin, 2006). As such, the question becomes whether or not the immature brain is more vulnerable to a much worse course of these disorders then if the brain had fully matured (Dahl, 2004). This paper will look at the development of the brain and whether neurobiology of the brain can play a role in predicting risk for future bipolar and substance abuse disorders.


Substance abuse disorders are exceptionally common in bipolar patients (Strakowski & DelBello, 2000). In the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area (ECA) study, substance abuse occurred in over 60% of type I bipolar patients (Regier, 1990). Correspondingly, rates of bipolar disorder are elevated five to eight times in patients with substance abuse disorders (Kessler, 1997; Regier, 1990). Substance abuse in bipolar disorder is clinically important because it is typically associated with poor treatment response and poor clinical outcome (Goodwin & Jamison, 1990; Strakowski, 1998; Tohen, Waternaux, & Tsuang, 1990).


Bipolar disorder is a debilitating psychiatric illness that is uniquely characterized by switching between psychopathologically contrasting phases of mania and depression (Olley, 2005). These phases often have intervening periods of euthymia which are periods of remission (Olley, 2005). However, these periods of apparent clinical recovery (euthymia) are marked by subtle social, occupational, and cognitive impairments (Olley, 2005).


It has been shown that patients with either manic or euthymic bipolar disorder (aged 17 to 45 years), and healthy control subjects, performed virtually the same on tests which measure the spatial working memory involving the dorsolateral prefrontal cortex (Larson, 2005). However, patients with only euthymic bipolar disorder performed poorly on tests which measure inhibitory control involving the orbitofrontal cortex, which is the part of the brain that influences inhibition (Larson, 2005). This finding suggests that patients with bipolar disorder may have a deficit in the orbitofrontal cortex (Larson, 2005).


Inhibitory control may be involved in inhibiting manic symptoms, such as hypersexuality (Simkin, 2008). Inhibitory control also plays a part in substance abuse disorder (Simkin, 2006). Since bipolar disorder and substance abuse disorder may have their onset during adolescence, it is important to explore whether the orbitofrontal cortex deficit occurs as a result of these disorders preventing the brain from normal maturation or whether these disorders cause damage to the orbitofrontal cortex regardless of when they occur (Larson, 2005).


Adolescent Brain Development

In order to understand how brain development may be disrupted by the emergence of bipolar disorder or substance abuse disorder during adolescence, it is necessary to understand the normal development of the brain during this period. While a significant amount of research has emerged on the development of the adolescent brain, some of the findings can be summarized in terms of three important events: (1) pruning neurons; (2) the role of hormones; and (3) maturation of the prefrontal cortex (Chambers, 2003).


Advanced technology in brain imaging has provided windows to the developing brain. Evidence is accumulating that the brain is not fully formed at the end of childhood as earlier thought (Giedd, 2004). The juvenile brain is still maturing in the teenage years and reasoning and judgment are developing well into the early to mid-20s (Giedd, 2004).



During childhood, the brain grows an excessive number of connections between brain cells (Winters, 2008). At about 11 or 12, an adolescent begins to lose or “prune back” a substantial fraction of these connections (Winters, 2008). During pruning, adolescents lose 20% to 40% of their total connections, or neurons (Simkin, 2008). This loss is actually healthy in the long run and is a vital part of growing up because the pruning clears out unneeded wiring to make way for more efficient and faster information-processing as we become adults (Winters, 2008).  It also promotes building the long chains of nerve cells that are required for the more demanding problem-solving in adulthood (Winters, 2008).


However, one of the neurons involved during this pruning period is associated with serotonin (Simkins, 2006). When serotonin neurons are lost, impulsivity increases and may very well be the reason that adolescents are less able to carry on cognitive processes (Simkin, 2006). In a study of adolescent decision-making, it was shown that adolescents, as compared to adults, took significantly longer to decide whether or not a presented scenario was a “good idea” (Baird, 2005). Adults are usually able to quickly elicit mental images of possible outcomes that impact their decision-making processes (Baird, 2005). Adolescents may act impulsively without carefully considering their decision and are far less likely to use mental images when making that choice (Baird, 2005).


This does not mean that adolescents cannot make a rational decision or appreciate the difference between right and wrong (Winters, 2008). The adolescent brain is quite capable of demonstrating mental ability, but the adolescent with less than optimal brain-based mechanisms has the propensity to act impulsively when confronted with stressful or emotional decisions and to ignore the negative consequences of such behavior (Winters, 2008).



Second, when hormones are added to the equation, it is thought that they influence the primary motivational circuitry, which increases sensitivity to pleasurable experiences (Bjork, 2004). The seeking out of pleasurable experiences, many of which may be risky, may be caused not only by an increased sensitivity to these experiences but also by the inability to distinguish which events are motivationally relevant or irrelevant (Bjork, 2004).


The amygdala is the part of the brain that effects memory and establishes learned associations between motivationally relevant events (Kalivas & Volkow, 2005). This inability to anticipate what events are motivationally relevant or irrelevant may be why adolescents seek out risky behaviors more than adults (Kalivas & Volkow, 2005). In a study comparing adolescents to young adults, it was shown that there were no differences in brain activity while performing a task for monetary gain (Bjork, 2004). However, the adolescents had less recruitment of the right amygdala than adults while anticipating response for such gain (Bjork, 2004).


Hormones encourage novelty seeking and promote social competitiveness (Winters, 2008). The massive hormonal production of adolescence may promote drug use to the extent that it represents a novel experience to the adolescent who is also seeking social approval from peers during the experience (Winters, 2008).


Maturation of the prefrontal cortex

Third, brain maturation tends to occur from the back of the brain to the front (Winters, 2008). So the front region of the brain, known as the prefrontal cortex does not become fully mature until around the early to mid-20s (Casey, 1997; Tamm, 2002). This means, of course, that the prefrontal cortex is immature in adolescents. The prefrontal cortex is the part of the brain that enables a person to think clearly, to make good decisions and to control impulses (Winters, 2008). As a result, adolescents will not have proper connections to other parts of the brain that would allow inhibition to occur quickly, especially in emotionally charged situations (Casey, 1997; Tamm, 2002). There is a growing sentiment among experts that when adolescents are feeling intense emotion or intense peer pressure, conditions are optimal for the still-maturing circuitry in the front part of the brain to be overwhelmed, resulting in inexplicable behavior and poor judgment (Winters, 2008).


Another separate process that occurs during adolescence is myelination (Simkin, 2006). This is the change or maturation of certain nerve cells whereby a layer of myelin forms around the axons which allows the nerve impulses to travel faster (Luna & Sweeney, 2004). This can influence the speed with which one processes and the speed with which one inhibits responses (Luna & Sweeney, 2004). The changes in the brain during adolescence occur in order to move from a brain that requires much more energy to process information to a more efficient adult brain (Luna & Sweeney, 2004). These processes can explain why experimentation is more likely to occur in adolescence (Luna & Sweeney, 2004). If adolescents do not have significant interests such as athletics or academics, they may be more likely to engage in risky behaviors if they are having to seek out other pleasurable experiences (Hops, 1999). In fact, academic and social failure by age 7 through 9 can predict substance abuse by age 14 through 15 (Hops, 1999). This suggests that prevention efforts for alcohol and other drugs may be more effective if directed at earlier antecedent behaviors rather than those that are concurrent with substance use (Hops, 1999).


If the adolescent does not succumb to substance abuse, or other psychiatric disorders that may influence normal development, the brain will continue to undergo these changes (Simkin, 2006). In particular, the prefrontal cortex and the corresponding inhibitory response will mature (Simkin, 2006). Therefore, one can assume that if the brain is allowed to develop normally, the mature prefrontal cortex can help to control or inhibit the disease state more effectively if bipolar emerges after adolescence than it could if the disorder emerges earlier (Simkin, 2006).


In a study of adolescents treated for bipolar disorder, scientists found that they had significantly lower levels of a chemical called N-acetylaspartate, which measures the density of neurons in the brain, in the dorsolateral prefrontal cortex (Chang, 2003). N-acetylaspartate acts as a “brake control” during adolescence and reduced levels of this chemical may mean reduced effectiveness of bipolar disorder patients to inhibit mania (Chang, 2003). This and other studies also found that there was no significant difference in N-acetylaspartate levels in patients with early onset bipolar disorder and in healthy control subjects (Chang, 2003; Gallelli, 2005). Therefore, these studies indicate that the longer the bipolar disorder progresses, the greater the effect on the dorsolateral prefrontal cortex (Chang, 2003; Gallelli, 2005).


Stay tuned for the conclusion – Part 2: Effects of Substance Abuse.

Borderline Personality Disorder

http://www.viewborderline personality disordrline-personality-disorder/
Current research indicates that personality disorders affect about 12% of the general population and constitute a significant mental health issue (Zanarini, 2005a). Recent studies have found that personality disorders (PDs) are more powerful predictors of quality of life than any one of the following: (1) socio-demographic variables; (2) Axis I disorders; and/or (3) somatic health (Zanarini, 2005a). It is also well known that patients with personality disorders make extensive use of mental health facilities and have more extensive histories of inpatient and outpatient treatment when compared to patients presenting only with Axis I disorders such as major depression (Zanarini, 2005a). All of the above highlight the importance of considering personality disorders in treatment planning and management of patients with dual diagnosis (Zanarini, 2005a).


Although it is generally recognized that personality disorders have a poorer response to treatment across all treatment modalities, there are a number of emerging findings that suggest more optimistic outcomes to treatment and management (Zanarini, 2005a). Most notably, emerging patterns indicate that personality disorders are not as stable as initially thought and studies indicate that they tend to go into remission at a quicker pace than expected (Zanarini, et al., 2007). It also appears that certain aspects of personality disorder are more amenable to treatment (Zanarini, et al., 2007). Further, there is now more evidence to suggest that borderline personality disorder (BPD) responds relatively well to treatment (Zanarini, et al., 2007).


Although borderline patients are very difficult to work with and pose many dilemmas for the treatment process, evidence suggests that they have a reasonably good prognosis when compared to other PDs and anxiety disorders (Zanarini, et al., 2005).

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Killing Them with Love

One of the most difficult things about working with addicts can be working with the families.  The families are scared to death that the next phone call will be the police, or God forbid, the morgue.  I know that I put my family through hell.  However, the best thing that loved ones can do for the addict in their life is to let them go with love when they relapse.  Trying to “save” the addict doesn’t work.  I always counsel families to support health and recovery, not sickness.

I recently worked with a family who keeps trying to “save” their child.  Unfortunately, the message that they send the addict is counterproductive as well as counter-intuitive.  The client was doing fairly well although struggling behaviorly, and we were trying to work with that client to become less entitled and more humble and willing, without much success.  The client got a job finally which was great.  Unfortunately, that client no longer felt that the rules applied to him/her and when we tried to enforce the rules, that client decided to leave treatment.

However, that client didn’t have a plan for living or many life skills and returned to addiction.  The client proceeded to also lose the job.  However, instead of cutting the client off, the family ran to the rescue.  This was the rescue plan…they took the client on a vacation, let the client go to inappropriate and dangerous venues and then kept the client in a hotel room instead of putting the client immediately back in a sober living environment as a requirement for getting back into the treatment facility.  The client didn’t like the sober living options and wanted to do it the client’s way.

Unfortunately again, the client had the family too terrified to say no or to make rational decisions.  Guess what, that client relapsed again and got his/her way…the client got to go back to another treatment center that wasn’t requiring behavioral change (yet), and now doesn’t have to work or take responsibility for life.

So what is the message here?  If I use drugs then I get vacations, hotels and go back to a cushy treatment environment.  But if I get sober then I actually have to take responsibility for my life and I have to work and pay my own way.  How’s that client going to learn about consequences and living life on life’s terms that way?  I know that the family meant well but rescuing that client will end up being that client’s demise.

Dual Diagnosis Article -Published in InRecovery Magazine

Dual Diagnosis

by Amy Novicoff-Fackrell

After approximately 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with co-morbid disorders. This article seeks to describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery, assertive outreach, motivational interventions, provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals, and cultural sensitivity and competence. While there have been some state implementation dual diagnosis services within the mental health system, funding has been markedly decreased and high-quality services are rare. This article also seeks to provide a current, comprehensive approach to implementing a dual diagnosis program that incorporates clarity of program mission with structural approaches designed to support dual diagnosis services, training and supervision of clients, and to disseminate accurate information to consumers and families to support understanding.


Although treatment centers and programs traditionally have focused on drug addiction within the framework of 12-Step philosophies and treated the associated conditions that perpetuate addiction as secondary, it is more effective to address chemical dependency, substance use, and the “associated conditions” equally and simultaneously. The goal of dual diagnosis interventions is recovery from two or more serious illnesses. “Recovery” means that the individual with a dual diagnosis learns to manage both illnesses so that he or she can pursue meaningful life goals.


A client-centered approach to working with people “where they are” rather than “where they should be,” as dictated by many treatment providers and therapists who specialize in dual disorders is more effective. Clients should be encouraged to set their own goals while staff continues to provide support and assistance as these goals change over time.


What is Dual Diagnosis?

“Dual diagnosis” is defined as having a severe mental illness associated with dependence on alcohol, or other substances. Epidemiologic studies have shown that between 25% and 50% of people with one mental disorder have at least one co-occurring mental disorder. There are two subgroups of patients: major substance abuse disorder coupled with another major psychiatric disorder; and abuse of alcohol and/or other drugs in ways that affect the course of treatment of the mental disorder.


Surveys have shown that one third of dual diagnosis psychiatric patients will abuse or depend on alcohol and that one third of individuals suffering from alcohol abuse will be additionally diagnosed with a psychiatric disorder. Sixty percent of individuals who abuse drugs other than alcohol will be dually diagnosed


For individuals who experience mania, the lifetime risk for developing alcoholism is six times greater than compared to the general population while major depression carries a risk of twice the average. Individuals who are dually diagnosed may have slower rate of recovery than individuals without major substance abuse. Currently, there are few comprehensive, integrated, recovery programs for these individuals, although research is continuing. A moderate lifestyle will help control the illness.


Mood Disorders

The term mood describes a pervasive and sustained emotional state that may affect all aspects of an individual’s life and perceptions. Mood disorders are pathologically elevated or depressed disturbances of mood, and include full or partial episodes of depression or anxiety. A mood episode (for example, major depression) is a cluster of symptoms that occur together for a discrete period of time. People are more likely to seek help when moderately depressed versus when they are experiencing an episode of mania.



Everyone has feelings of sadness and disappointment. Depression’s main symptom is that of intense, pervasive, persistent feelings of sadness, hopelessness, and frustration that cause considerable impairment in social and occupational functioning. Untreated, moderate to the more severe depression can lead to suicide attempts or psychotic thinking and behavior.

Some typical symptoms of depression are: poor appetite and weight loss or marked increase in appetite and associated weight gain; sleep disturbance; loss of energy, excessive fatigue or tiredness; slow speech and movements; change in activity level; loss of interest or pleasure in usual activities; decreased sex drive; diminished ability to think or concentrate; indecisiveness; withdrawal and isolation from family; decreased memory function and lack of concentration; disorganization; highly critical of self; low self-esteem feelings of worthlessness or excessive guilt which may reach delusional proportions; recurrent thoughts of death or self harm contemplating or attempting suicide; heightened or changed perceptions


Mood Disorders Due to a Medical Condition

Mood disorder due to a general medical condition can be described as having (1) manic features, (2) depressive features, or (3) mixed features in which symptoms of both mania and depression are present and neither predominates (DSM-IV-TR, 2000).


Medical conditions that can either precipitate or mimic mood disorders include the following:

  • Malnutrition
  • Anemia
  • Hyper- and hypothyroidism
  • Dementia
  • Brain disease
  • Lupus
  • Post-cardiac condition
  • Stroke, especially among elderly people.

Medications, including medications that treat hypertension and hypotension, can cause conditions that may be confused with psychiatric or alcohol or drug (“AOD”) disorders. Both prescribed and over-the-counter (OTC) medications can precipitate depression.


Diet pills and other OTC medications can lead to mania. Patients treated with neuroleptic (antipsychotic) drugs may have a marked constriction of affect that can be misinterpreted as a symptom of depression.


The anxiety disorders are the most common group of psychiatric disorders (DSM-IV-TR, 2000). The term anxiety refers to the sensations of nervousness, tension, apprehension, and fear that emanate from the anticipation of danger, which may be internal or external. Anxiety disorders describe different clusters of signs and symptoms of anxiety, panic, and phobias.


Post-traumatic stress disorder (PTSD) begins with an individual experiencing a psychologically traumatic stressor such as witnessing death, being threatened with death or injury, or being sexually abused. At the time of the stressor event, the individual experiences intense fear, helplessness, or horror (Retrieved 3/12/2010 from PTSD entails a persistent re-experiencing of the trauma in the form of recurrent and intrusive images and thoughts, or recurrent dreams, or experiencing episodes during which the trauma is relived (perhaps with hallucinations) (Retrieved 3/12/2010 from People with PTSD experience persistent symptoms of increased arousal such as insomnia, irritability, hypervigilance, and exaggerated startle response. They persistently avoid stimuli related to the trauma such as activities, feelings, and thoughts associated with the traumatic event (Retrieved 3/12/2010 from


Interest in the role of sexual abuse and incest in PTSD and other psychiatric and AOD disorders has increased. Clinicians note that long-term responses to childhood and adult sexual abuse often include symptoms associated with PTSD and other psychiatric problems, including an increased risk for AOD disorders (Retrieved 3/12/2010 from Many such problems are addressed in treatment efforts popular in adult children of alcoholic (ACOA) programs, some of which are controversial and unsubstantiated by research or long-term observation (Retrieved 3/12/2010 from Such treatment approaches may exacerbate AOD use and psychiatric disorders and should be cautiously undertaken. Amnesic periods have to be carefully evaluated both as blackout phenomena and as possible dissociated states (Retrieved 3/12/2010 from Such differentiation can be extremely complicated. While a clinician’s immediate response may be to identify these patients as being intoxicated, they may be experiencing independent psychiatric phenomena (Retrieved 3/12/2010 from



Prevalence rates for anxiety disorders in the general population can be estimated from the Epidemiological Catchment Area (“ECA”) studies. According to the ECA studies, anxiety disorders affect more than 7 percent of adults in the general population, the lifetime prevalence rate of anxiety disorders is 14.6 percent. Women, individuals under age 45, those who are separated or divorced, and those in low socioeconomic groups all have a higher rate of anxiety disorders than individuals in other groups.


These same ECA studies indicate that in the general population:

  • The 1-month prevalence rate for any anxiety disorder is 7.3 percent (4.7 percent for males and 9.7 percent for females), and the 6-month rate is 8.9 percent.
  • The 1-month prevalence rate for phobia is about 6.2 percent (3.8 percent for males and 8.4 percent for females).
  • The 1-month prevalence rate for panic disorder is about 0.5 percent (0.3 percent for males and 0.7 percent for females).
  • The 1-month prevalence rate for obsessive-compulsive disorder is 1.3 percent (1.1 percent for males and 1.5 percent for females).
  • Lifetime prevalence of post-traumatic stress syndrome in the general population is estimated to be less than 1 percent. The prevalence among individuals who have experienced a psychologically traumatic stressor and then developed psychiatric symptoms is poorly understood.

Among patients with AOD problems, there is a significant likelihood of a coexisting anxiety disorder. One study noted that more than 60 percent of patients being treated for AOD disorders had a lifetime diagnosis of an anxiety disorder, and about 45 percent experienced an anxiety disorder within the past month (Grant, et al., 2004). Other studies have demonstrated that most anxiety disorders among patients in addiction treatment are AOD induced (Grant, et al., 2004).

Treating Dual Diagnosis

Those who have both a mental illness and an addiction to drugs or alcohol present a challenge for medical professionals. Treating these individuals is complicated by the overlapping symptoms of the addiction and the mental illness. Complete treatment takes time and great care due to the delicate nature of the individual and due to the fact that symptoms of one condition complicate or impede the symptoms and treatment of the other.


Because these individuals have a mental illness, getting them to comply with the rules and regulations of a typical drug rehab program can be difficult. It is difficult to get them to take their meds, attend counseling or other basic necessities associated with success in a rehab program.

The most successful approaches for dual diagnosis patients are the integrated programs that treat all aspects of the illnesses in a single location. Mental health professionals and addiction rehab counselors work together in these programs to provide well-rounded care that encompasses everything involved in the diagnosis.

The dual diagnosis treatment process may include:

Intake interviews from mental health professionals to assess the psychiatric issues the patient is experiencing. This stage will help identify which mental illness the individual is experiencing.

Psychiatric/clinical diagnosis and assessment of the mental illness. Medication may be prescribed at this point, as well as general psychiatric counseling to address the illness.

Integration of addiction rehab. Using the knowledge gained from the psychological evaluation, counselors will begin working with individuals to address their drug or alcohol addiction. This process may be move at a more deliberate pace than “stand alone” rehab because of the complications caused by the mental illness.

  • Treat for the mind, body and spirit. Programs that employ holistic treatments such as massage therapy, yoga, nutritional counseling and meditation help the individual find balance in their lives (often for the first time). Not all dual diagnosis rehab programs offer holistic care, but those that do enjoy high rates of success, and low relapse rates.
  • Coping skills. Individuals are taught new methods for coping with their mental illness and shown how to avoid the triggers that can cause relapse. In this final phase of the dual diagnosis rehab, the individual learns to master the tools needed to succeed in the outside world.
  • Relapse prevention. Aftercare programs provide a support structure and accountability for the individual. The period after leaving rehab can be difficult, and indeed, scary for the recovering addict with a mental illness.
  • There is much to do (take meds regularly, avoid triggers of addiction) and even more to rebuild (personal relationship, careers, etc.) but the aftercare program lets the individual know that they are not alone during this part of their journey and provides much needed structure.

Professional and Vocational Planning

Although some patients with dual disorders have severe and poorly remitting mood and AOD disorders, most patients improve, especially with careful psychiatric treatment. Since these disorders are generally well controlled, patients can experience very high levels of vocational, social, and creative functioning. As a result, vocational planning should be long term and accentuate patient strengths.

Interview with Amy Novicoff-Fackrel

“Be true to yourself and believe in yourself,
play on your strengths and go for it.”


Amy Novicoff-Fackrell, is a former lawyer, a recovering alcoholic, bipolar and the owner and executive director of Viewpoint Dual Recovery Center in Prescott, Arizona.  She practices what she preaches.   The biggest influence in her life was her own mother, who she described as a brilliant, informed, strong woman; words that clearly apply to Amy as well.

Amy’s program treats those caught in the difficult collision of mental illness and addiction.  A difficult job by any measure.  We recently interviewed her to find out what made this talented, successful young lawyer turn to such a challenging career path.  Her answers were thoughtful and revealing.


Amy, tell us about you . . .


I grew up in an amazing family with the world at my feet.  My parents are loving, caring, and supportive people.  I went to fantastic schools, took gymnastics, piano, ballet lessons and went to camp every summer.   We travelled; my family showed me the world.

My parents sent me to college at the University of Texas in Austin, Texas, and then to law school at Northwestern University in Chicago, Illinois.  I practiced law for the next 16-17 years, for a few years in Texas, and then in California for the balance of my law career.

After my first divorce, I remember making a conscious decision to get high every day.  My rationale was that since time healed all wounds, I would drink and use until my pain was gone.   I spent the next year and a half doing exactly that, until my family stepped in and I had my first treatment experience.   I was in treatment for eight months and managed to put together four and a half years of abstinence, though not necessarily sobriety.  I went back to practicing law; my ego came back; and I picked up a drink again.

I spent the next six years trying to make it back.  I knew I was miserable; I had even resigned myself to the fact that I would be an active alcoholic and drug addict.  I didn’t know how to get out of the dark, deep hole I was in.

I had struggled with depression and ADHD over the years and was given various medications to deal with those diagnoses.  However, it wasn’t until I was finally accurately diagnosed with bipolar disorder and found a psychiatrist that helped me find the right medication that I got one more chance.  I grabbed on to it for dear life.

More importantly, I finally surrendered and started taking direction, which included being medication compliant on a daily basis.  I got a sponsor and worked the steps again and again.

I went back to school and got my Master’s degree in counseling and psychology.  I knew if I went back to practicing law, I would have a hard time having any peace and serenity in my life and would have trouble staying sober.


Looking back at where you were when you started your recovery journey, where did you think it was going to lead you?


I could not have imagined the path that I would eventually take.  I thought that I would go to treatment, get fixed.  Then I’d go back to practicing law and life would be perfect.  Talk about delusional!  It has been a bumpy road but I wouldn’t trade it for anything.  I have worked hard to get where I am and I can’t wait to see what the rest of the journey brings.


What’s the hardest thing for you about being a recovering person?


The hardest thing for me to reconcile was all of the horrible decisions I made, the accompanying horrible behaviors and, most importantly, how I hurt the people I love.  The great thing is that I don’t ever have to go back to that way of life.

Recovery is awesome and it has shown me how to have a better life.  The most difficult thing for me is getting out of my own way.


Why do you do what you do?  What motivates you?


I am just a person trying to get better and am no different than any other recovering person.   I am trying to give back because people were there for me.  I believe that recovery from a dual illness is possible.

After receiving treatment at some of the finest chemical dependency facilities in this world, there was no place for me to go to learn how to live with my co-occurring disorders.  I am bipolar and an alcoholic.  Remove the substance addiction and I was still bipolar; my life was still compromised.  Thank God, people were there for me.  I wanted to take what they taught me and help others learn how to live a healthy and productive life in spite of the issues that come with a dual diagnosis.

I decided – with a lot of guidance and support – to create a place, Viewpoint, where people battling a dual diagnosis could come to heal.  I have never looked back.  I have been able to share my experience, strength and hope with others and hopefully have been able to give back that which was given to me.


Working in the addiction field and managing a treatment program, what have been some of the expected and unexpected hurdles?


It is frustrating to see someone who is not ready and still maintain good boundaries in the therapeutic relationship.  It’s hard because I want my clients to succeed and receive all of the benefits and gifts of recovery.

Funding is a critical issue in dual diagnosis treatment.  Funding for long-term mental health programs has been severely cut over the past 20 years.  This type of treatment is expensive.  Insurance coverage, usually costly, typically only partially covers mental health and addiction treatment.  Most people cannot afford the treatment they need.


What has been hard for you?


Seeing all of the death and destruction, knowing there is a better way.   All I can do is be of service to others and not play God.  There is nothing easy about this job, but I have walked in my clients’ shoes and have a deep understanding of their illnesses, and what they are going through.


Do you have advice to offer people who are aspiring to do what you do?


Be true to yourself and believe in yourself, play on your strengths and go for it.  Surround yourself with good people and ask for their help.   Remember that you are perfectly imperfect and that mistakes are okay, that’s how we learn.

Life is full of difficulties and problems.  It’s how you handle those experiences that make the difference between lemons and lemonade.

The Forest AND the Trees

…what comes to us alone may be garbled by our own rationalization and wishful thinking. The benefit of talking to another person is that we can get his direct comment and counsel on our situation…

—Twelve and Twelve p.60

The Viewpoint Edge

What makes Viewpoint Dual Recovery Center different from other Treatment Centers?

The goal of dual diagnosis interventions is to manage both illnesses so that the client can pursue meaningful life goals. Viewpoint Dual Recovery Center simultaneously addresses chemical dependency, substance abuse, and the “associated” conditions or illnesses.

Although treatment centers and programs traditionally have focused on drug addiction within the framework of 12-Step philosophies and treated the associated conditions that perpetuate addiction as secondary, Viewpoint Dual Recovery Center addresses chemical dependency, substance use, and the “associated conditions” equally and simultaneously. The goal of dual diagnosis interventions is recovery from two or more serious illnesses. At Viewpoint Dual Recovery Center, “recovery” means that the individual with a dual diagnosis learns to manage both illnesses so that he or she can pursue meaningful life goals.

Viewpoint Dual Recovery Center’s holistic, comprehensive treatment program acknowledges that addiction and co-occurring disorders require attention to the mind, body, and soul. We provide our patients with the latest evidence-based, client-focused treatment for addiction and mental disorders.

Viewpoint is a unique alternative addiction treatment program. We are an Intensive Outpatient Program coupled with a structured Sober Transitional Living environment, designed to help men and women reintegrate back into life through recovery living. We customize our approach with the client to create a progressively responsible plan integrating recovery behaviors, skills, and lifestyle changes to address addiction and co-occurring illnesses.