As the founder and director of UCLA Health’s Dual Diagnosis Program, Jason Eric Schiffman, MD, has both professional and personal connections to the work. He is by training a psychiatrist and an addiction medicine specialist. But his approach to treatment is also informed by his own recovery from addiction, an experience that provided him with a patient-centered perspective.
“I fundamentally view addiction as a solution that has become its own problem,” Dr. Schiffman said. “Addiction begins as an effort to anesthetize chronic emotional pain. So, to the degree that treatment is successful in eliminating the addictive behavior, it is also removing what has often been the individual’s only coping mechanism for this underlying pain. "
“For this reason,” he said, “effective treatment of addiction must also involve recovery from the source of the emotional pain that the addictive substance or behavior was serving to anesthetize.”
The Dual Diagnosis Program at the Stewart & Lynda Resnick Neuropsychiatric Hospital (RNPH), which Dr. Schiffman started in 2012 after finishing his residency, is an eight-week intensive outpatient program, or IOP, for people with addictions who also struggle with psychiatric conditions such as anxiety, depression, bipolar disorder or ADHD.
It is one of relatively few programs in the country structured to treat addictive disorders and often underlying mental health conditions at the same time.
The program, which operates under RNPH’s license, features daily group meetings, weekly individual therapy sessions and medication management. An IOP that operates under the hospital’s license can provide multiple services each day.
Patients are referred from a variety of sources: emergency rooms, inpatient psychiatry wards, primary care doctors and outside clinicians. Some patients seek out the program on their own.
During the pandemic, the program switched to online sessions from in-person sessions. For students and working people participating in the program, the change to telehealth has reduced the stress of commuting to UCLA’s Westwood neighborhood.
Dr. Schiffman said the program’s data about outcomes have shown “no detriment in efficacy of the program” during the time it has been conducted remotely, but the medical team is considering a return to in-person sessions.
Linking treatments
In a recent paper for the California Psychologist, Dr. Schiffman explained his reasoning for linking treatment of co-occurring mental health and substance use disorders and eschewing the more fragmented approach often typical of addiction treatment. He writes that because there was no systematic treatment for addiction until the founding of Alcoholics Anonymous in 1935 and few clinical or pharmacologic options until many years later, most addiction treatment in America has taken place outside of the standard health care system leaving individuals with addiction to piece together the needed elements of recovery on their own.
“… Until 1935 there was essentially no treatment for substance use disorders, and from 1935 until relatively recently the only treatment for substance use disorders was community-based, non-clinically administered interventions such as Alcoholics Anonymous and its derivatives,” Dr. Schiffman wrote. “The legacy of this history is that substance use disorder treatment to this day remains largely isolated from the rest of mental health care treatment and is itself typically divided into non-clinical, community-based approaches and clinician-administered psychotherapeutic and pharmacologic interventions.
“Unfortunately, this fragmented treatment landscape frequently results in substance use disorders going underrecognized by mental health care providers, and individuals with substance use disorders receiving disjointed treatment that doesn’t adequately address the complex interaction with co-occurring mental health conditions which are often the underlying cause of the substance use disorder.”
Dr. Schiffman says most individuals with addictive disorders are best served by a combination of medications, psychotherapy and community-based treatments. The goal of UCLA Health's Dual Diagnosis Program is to integrate these elements of care and provide education about addiction and its treatment so that patients can become effective stewards of their own recovery.
Therapy and education
According to Dr. Schiffman, one of the most important aspects of the program is educating patients about the numerous treatment options available to them and the importance of finding the best combination of treatments.
“I think addiction is a final common pathway with as many different origins as there are people with addictive disorders,” he says. “What unifies all individuals with addiction is that they discovered a way to use a rewarding substance or behavior to manage persistent dysphoric feelings and then subsequently lost the ability to control their use of that substance or behavior. In the program, we help patients address both the addictive process and the underlying dysphoric feelings the substance or behavior was being used to manage.”
That is just one of many messages he imparts to participants in his weekly lectures, which are followed by an hour of group therapy.
“Those lectures are the beating heart of the program,” said Eric Rosoff, MD, a staff psychiatrist with the Dual Diagnosis Program. “He does those on Thursdays for an hour, covering eight to 10 topics. He covers a lot of psychoeducation about addiction.”
Psychoeducation combines elements of cognitive behavioral therapy, group therapy and education to provide patients with knowledge about their illnesses so that they can work with mental health professionals to achieve the best possible outcomes.
Dr. Schiffman also lectures about the neurobiology of addiction and the role developmental trauma often plays in the origin of addictive disorders. Educating patients about both the neurobiological and developmental causes of addictive disorders helps them understand what led to their addiction, he said. They can then use that knowledge to create a road map for their recovery.
“The anxiety and depression that typically underlie addictive disorders are very often the consequence of adverse developmental experiences,” Dr. Schiffman said. “Identifying and healing these developmental injuries through ongoing recovery and psychotherapeutic work accomplish in a true and lasting way what the addictive drugs or behaviors were doing in an ineffective way — providing relief from pain.”
Dr. Schiffman cited a large Adverse Childhood Experiences Study which looked at whether there was a correlation between exposure to adverse experiences in childhood and the development of health problems later in life.
“What the study found was that individuals who had experienced four or more categories of adverse experiences in childhood, compared to those who had experienced none, had 4- to-12-fold increased risks for substance use disorders, depression and suicide attempt,” he said. “What studies like this show us is the large effect developmental issues can have on our mental health as adults and the importance of an integrated approach to addiction treatment that addresses both the current problem and its underlying cause.”
Commitment to sobriety
The Dual Diagnosis Program, Dr. Rosoff said, works best for people who are self-aware and ready to jump in and tackle the hard work to become sober while treating a mental illness. Before being admitted, each person is assessed.
“You have to be able to acknowledge that you have an addiction and to commit to sobriety,” he said. “We help patients establish sobriety, and we help prepare patients for longer-term treatment to address the root cause of their addiction. Such treatment includes ongoing psychiatric care, participation in community-based resources and weekly psychotherapy.”
James E. Rosser, LCSW, is a licensed clinical social worker and certified mindfulness teacher-professional level who is director of the RNPH’s Hospital Outpatient Programs, including the Dual Diagnosis Program. He came to social work after a decade in banking. During that time, he volunteered for an organization that provided emotional support for people with terminal illnesses and decided to pursue such work fulltime.
“Mindfulness is a part of the treatment of both substance abuse and mental health,” he said. “Mindfulness focuses on the ability to be present in the moment without judgment or needing anything to change.
“When you’re locked in the middle of a craving, it’s easy to forget and think it will last forever. In mindfulness, you realize that cravings come and go.”
Rosser said he is proud of the Dual Diagnosis Program because it delivers a well-balanced service that treats mental illness as seriously as substance abuse.
“We’ve found that the balance provides a better chance for patients to experience both sobriety and recovery that is sustainable over a long term,” he said.
Addiction treatment and research at UCLA
The Dual Diagnosis Program is one of multiple addiction-focused programs at UCLA Health.
“We are really fortunate at UCLA to have a broad range of addiction treatment, research and training programs across multiple departments, including Psychiatry, Family Medicine and Internal Medicine,” Dr. Schiffman said.
“Addiction is a multifaceted disease, and each of these departments makes an important contribution to the constellation of addiction treatment and research taking place here.”
Martha Groves is the author of this article.
