The Dually Diagnosed: A Therapist's Guide to Helping the Substance Abusing, Psychologically Disturbed Patient

Dennis Ortman, who once provided counseling as a Catholic priest before receiving his doctorate in clinical psychology, describes in the preface of this well-written and tightly organized book his own conversion to providing integrated substance abuse treatment to his patients. As a psychodynamically oriented clinician in training in an outpatient setting, Ortman was treating a young woman referred to a university clinic after two years of unsuccessful therapy had exhausted her insurance benefits. In his dynamic formulation, he interpreted her chronic marijuana abuse, which was not part of her chief complaint, as a symptom of an underlying conflict. He expected it would abate in the working-through phase of her psychotherapy, a view shared by most of the psychiatric establishment of the day.

But Ortman began to have doubts, which became crystallized after several months by the patient's wounding revelation that she had come to several therapy sessions stoned. So, bucking the conventional wisdom, he chose to actively treat both of her problems together, which meant that he would have to learn about substance abuse treatment on his own. The dearth of literature on treating the less severely impaired dually diagnosed patient in outpatient settings forced him to embark on a personal investigation, which eventually resulted in this valuable book.

Many clinicians today, trained only in caring for patients with a single disorder, face the same dilemma. Some may minimize, look obliquely at, or ignore the severity of the substance abuse or the role it plays in the overall clinical picture. Some clinicians may opt to refer the case to another therapist. But in today's managed care environment it may no longer be economically wise or even possible to avoid entering this new territory. Dr. Ortman's practical and quite readable guide can help outpatient clinicians chart a viable course into the realm of integrated treatment with confidence.

The first of the book's three sections introduces the reader to the broad landscape of basic concepts about dual diagnosis, some definitions and subtypes within this remarkably heterogeneous group of conditions, and the special clinical challenges they pose in the outpatient setting. He presents a variety of models of interaction between psychiatric and substance use disorders and their treatment implications and takes the firm position that both disorders should initially be treated together regardless of which one is viewed as primary. Ortman proposes a “paradigm shift,”urging mental health practitioners to incorporate some of the methods and techniques used successfully by their counterparts in the addictions treatment community. And he tells what they are.

The middle section contains 11 chapters, each dealing with “urgent clinical questions” that address the full range of issues and topics related to the vicissitudes of treatment. For each of them, Ortman suggests strategies and provides a “treatment principle” that encapsulates his position on the matter. Each chapter is replete with relevant conversations and interviews with other therapists, as well as clinical vignettes, to further illustrate the application of these principles.

In the third section, the author gives perfunctory but adequate attention to inpatient treatment. In a concise epilogue, and consistent with his effective pedagogy, he repeats the 16 treatment principles, to which one can quickly refer.

Outpatient counselors and therapists in both the mental health and the addiction treatment communities who are ready to make the leap into, or who are about to be pushed into, providing integrated treatment to dually diagnosed patients would do well to acquire this volume. It will soften the landing.

Mr. Radosta is dual diagnosis services coordinator for the Central Massachusetts Area of the Massachusetts Department of Mental Health in Worcester.