Dual Diagnosis: A Comprehensive Guide to Understanding, Diagnosing, and Managing Co-occurring Disorders

Dual Diagnosis: Unravelling the Complexity of Co-occurring Disorders

Dual diagnosis, also known as co-occurring disorders, describes the presentation of both a mental health disorder and a substance use disorder at the same time. This presents special challenges in diagnosis and treatment and requires an integrated approach to deal with the complicated relationship between the two. Understanding the relationship between mental health and substance use is key to intervention and long term management. The Institute of Behavioural Medicine acknowledges the complicated biological, psychological and social factors involved in dual diagnosis.

Understanding the Interplay: Mental Health and Substance Use Disorders

The overlap between the presentation of mental health disorders with substance use disorders is likely not a coincidence, and we now know that several factors play into this complex relationship. Indeed, many people with mental health disorders seem to turn to substances as a way to self-medicate for symptoms like anxiety, depression or psychosis. Conversely, substance use is known to exacerbate mental health conditions creating a vicious cycle of dependence, mental health decline, and increased substance use.

Co-occurring risk factors like genetic predisposition, adverse childhood experiences and trauma can also increase vulnerability to both mental health and substance use disorders. Trauma plays a big role in susceptibility as people may use substances to cope with the emotional pain and distress of traumatic experiences. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has specific criteria for diagnosing mental health and substance use disorders, nevertheless, diagnosis of mental health conditions requires a thorough clinical assessment.

Prevalence and Identification of Dual Diagnosis

Research has demonstrated a high prevalence of dual diagnosis Indeed, according to the 2022 National Survey on Drug Use and Health (NSDUH), over 21.5 million adults and nearly one million adolescents (ages 12-17) in the USA were found to have a co-occuring Mental Health Issues and Substance Use Disorder, with fewer than half receiving some form of treatment.

Dual Diagnosis can be difficult to identify as symptoms of one disorder can mask or mimic the other. For example, symptoms of depression can be attributed to substance use alone, or anxiety symptoms can appear similar to withdrawal. A full assessment that includes a detailed history of mental health symptoms, substance use patterns and any co-occurring medical conditions is key to accurate diagnosis. Screening tools like the Addiction Severity Index (ASI) and the Mini-International Neuropsychiatric Interview (MINI) can help identify potential co-occurring disorders.

The Neurobiological Basis of Co-occurring Disorders

The neurobiology of Dual Diagnosis is complex and involves several different brain regions and neurotransmitters. Both mental health and substance use disorders affect the circuits in the brain that handle reward, motivation and impulse control.

Substance use can alter dopaminergic signalling pathways, mental health disorders can disrupt the balance of serotonin and alter noradrenergic signalling Research suggests Dual Diagnosis involves dysfunction in fronto-limbic neural pathways and circuitries that regulate reward, impulse control and emotional processing. This includes impairments in the prefrontal cortex , which affects decision making, and increases susceptibility to cravings and relapse. Understanding the neurobiological mechanisms that underlie Dual Diagnosis will be essential for the development of targeted interventions that tackle both shared and disparate neural pathways that contribute to mental health and substance use disorders. .

Diagnostic Criteria and Assessment Methods for Dual Diagnosis

Accurate diagnosis is essential for effectively treating Dual Diagnosis. Clinicians must assess whether an individual meets the criteria for both a mental health disorder and a substance use disorder, as well as the severity of each. The DSM-5 provides specific diagnostic criteria for mental health and substance use disorders including criteria for severity, duration and functional impairment.

A comprehensive clinical assessment for Dual Diagnosis usually involves clinical interviews that allows the clinician to gather information about the individual’s history, symptoms and functional impairments, self-report questionnaires such as the Beck Depression Inventory (BDI) and Addiction Sensitivity Index (ASI), structured diagnostic interviews including the Mini-International Neuropsychiatric Interview (MINI) as well as the collection of collateral information from family members or other healthcare providers that can provide valuable insight into the individual’s behavior and functioning from others

Evidence-Based Therapeutic Approaches for Dual Diagnosis

For Dual Diagnosis treatment you need an integrated approach that treats both the mental health and substance use disorders at the same time. Integrated treatment models combine psychological, pharmacological and social interventions to promote recovery and overall functioning. Several evidence based therapeutic approaches have been shown to be effective for Dual Diagnosis.

Cognitive Behavioural Therapy (CBT) helps individuals identify and change maladaptive thoughts and behaviours that contribute to mental health and substance use problems. Motivational Interviewing (MI) is a client centred approach that helps individuals explore their ambivalence about change and increase their motivation to engage in treatment. Integrated Group Therapy (IGT) provides a space for individuals with Dual Diagnosis to share their experience, learn coping skills and develop social support.

Integrated Treatment Models: Combining Therapies for Optimal Outcomes

Integrated treatment models are considered the gold standard, designed to give a person with a Dual Diagnosis comprehensive and coordinated care between mental health and addiction specialists. These models involve a team of professionals including psychiatrists, psychologists, social workers and addiction counsellors who work together to develop and implement individualised treatment plans. Integrated treatment models may include individual therapy, group therapy, medication management and case management services.

The key principles of integrated treatment are whole person focus, collaboration in treatment planning and ongoing support and monitoring. Integrated treatment models aim to address the underlying causes of the mental health disorder and the substance use disorder as well as the social, vocational and educational challenges.

Navigating the Challenges in Dual Diagnosis Treatment

Dual Diagnosis is tricky. People with co-occurring disorders are harder to engage in treatment because of denial, ambivalence and impaired cognitive functioning. They are more likely to relapse because of the interplay between mental health and substance use symptoms.

Another problem is the fragmentation of services. People with Dual Diagnosis are seen by different providers who don’t communicate or coordinate their care. That leads to inconsistent treatment and bad outcomes. Overcoming these challenges requires a collaborative and integrated approach with clear communication and coordination between all providers involved in their care.

Long-Term Management and Relapse Prevention Strategies

Recovery from Dual Diagnosis is a long term process that requires ongoing support and monitoring. Relapse is common but doesn’t mean failure, rather it provides an opportunity to learn from experiences and adjust treatment plans. Relapse prevention strategies are a key part of long term management.

These may include developing coping skills to manage stress and cravings, identifying triggers and high risk situations and building a strong support network. Regular follow up appointments with your healthcare provider are also important to monitor symptoms, adjust medication and provide ongoing support. With the right treatment and support people with Dual Diagnosis can achieve real recovery and live fulfilling lives.

Highlands Recovery recognises the complexity of dual diagnosis and uses behavioural medicine principles to address the biological, psychological and social aspects. By providing a structured environment and evidence based therapies Highlands Recovery aims to support individuals in achieving long term recovery from co-occurring disorders. Our approach is individualised to each client’s needs to promote self directed health and long term wellbeing.

Reviewed by: Dr. Emma Bardsley

Dr Emma Bardsley is a neuroscientist with a PhD from Oxford and a post doctorate from Auckland University, along with an undergraduate degree in Pharmacology from King’s College London. She has lectured extensively on neuroscience, physiology, and pharmacological interventions, bridging foundational research and its clinical applications. With a strong record of publications in high-impact journals and extensive experience in scientific writing, editing, and peer review, she excels at translating complex research into practical insights. Based in New Zealand and collaborating internationally, Emma is dedicated to advancing understanding and treatment in the fields of trauma, addiction, and recovery.

References

Drake, R.E. and Wallach, M.A., 2000. Dual diagnosis: 15 years of progress. Psychiatric services, 51(9), pp.1126-1129. https://doi.org/10.1176/appi.ps.51.9.1126

Kessler, R. C. (2004). The epidemiology of dual diagnosis. Biological psychiatry, 56(10), 730-737.https://doi.org/10.1016/j.biopsych.2004.06.034

Mueser, K.T., Drake, R.E. and Wallach, M.A., 1998. Dual diagnosis: a review of etiological theories. Addictive behaviors, 23(6), pp.717-734. https://doi.org/10.1016/S0306-4603(98)00073-2

Tiet, Q.Q. and Mausbach, B., 2007. Treatments for patients with dual diagnosis: a review. Alcoholism: Clinical and Experimental Research, 31(4), pp.513-536. https://doi.org/10.1111/j.1530-0277.2007.00336.x

Substance Abuse and Mental Health Services Administration (SAMHSA). 2022 National Survey on Drug Use and Health: Main Highlights https://www.samhsa.gov/data/sites/default/files/reports/rpt42731/2022-nsduh-main-highlights.pdf

[00:00:00] Jordan Harbinger: Welcome to the show. I’m Jordan Harbinger. On the Jordan Harbinger Show. We decode the stories, secrets, and skills of the world’s most fascinating people and turn their wisdom into practical advice that you can use to impact your own life and those around you. Our mission is to help you become a better informed, more critical thinker through long form conversations with a variety of amazing folks.

From spies to CEOs, athletes, authors, thinkers, performers, even the occasional organized crime figure, cold case, homicide, investigator, hacker or astronaut. And if you’re new to the show or you want to tell your friends about the show and hey, I appreciate it when you do that, I suggest our episode starter packs.

These are collections of our favorite episodes on persuasion and negotiations, psychology and geopolitics, disinformation, cyber warfare, crime, and cults, and more. That’ll help new listeners get a taste of everything we do here on the show. Just visit Jordan harbinger.com/start or search for us in your Spotify app To get started today on the show, Resh Joseph, a leading psychotherapist specializing in treating trauma and something called Sudden Wealth syndrome.

Yes. You heard that correctly in high net worth individuals providing luxury rehab again. Yes. You heard that correctly, providing luxury rehab again. Yes. You heard that right? Honestly, I’d never heard of this. I was initially pretty skeptical, but here we are and I’m curious what y’all think. Once you give this one listen as well.

This episode is brought to you ad free and is sponsored by Highlands Recovery. ssh. Joseph is the leading psychotherapist in residence.

Tell us a little bit about what you do. It’s safe to say I have questions ’cause I’ve never heard of a lot of this stuff.

[00:01:29] Resh Joseph: Well, I’m a therapist by training. I’m the clinical director here at a residential facility for former PTSD addictions and other disorders of. Extreme stress. I’m a therapist by training and my principal job here is to work with people who have trauma and all of the, the disorders associated with trauma.

I’m from Singapore and I moved here to Australia to take up this job to construct a clinical program to help people with former and stress related disorders of which addiction and alcoholism is a principle. Feature.

[00:02:08] Jordan Harbinger: So people are gonna say, wait, Jordan said he hadn’t heard of this. Surely you’ve heard of alcoholism and PTSD.

Yes, I have. But I know you also treat symptoms associated with something called Sudden Wealth Syndrome and I, I’ve never heard of that. So can you break that down for us a little bit? ’cause that’s, that’s completely new to me.

[00:02:27] Resh Joseph: Okay, so sudden wealth syndrome, um, as such as it is, is not really a clinical diagnosis, right?

So if you looked in the DSM five, you wouldn’t find it. So it’s not an actual clinical syndrome. It’s a term that has become very catchy. It’s a term that is used to refer to people who acquire a great deal of wealth suddenly, or come into a great deal of wealth suddenly, and for, and all of the. Issues that people have.

That may be associated with this acquiring of wealth. So people such as the Novo people who grow up the children, the very rich people, you know, so they don’t do anything to acquire that wealth. So what sudden wealth syndrome is such as it is, it looks at people who. Have acquired wealth very rapidly or through non-traditional means, and how the acquiring of that wealth can cause really quite serious problems for the, for those individuals.

[00:03:28] Jordan Harbinger: I had no idea. So we’re talking about maybe people who won the lottery or inherited a bunch of money suddenly, or, or, or like you said, grew up very wealthy. That can actually, cause I don’t know if my, if I’m using the right word, but that it sounds like that can actually cause trauma of some kind, or is, is that not the right word?

Well,

[00:03:48] Resh Joseph: the best way to think of this is if you’ve got someone who, you know, grew up in an ordinary family say, and they became an overnight sensation as a result of, say, a pop career or they became a movie star. Right. And we, and we see. Snippets of these stories in the media all the time. What happens when someone transitions from being an ordinary person to being an incredibly wealthy person is that certain things can happen where they just are not able to cope.

Now, that’s not a trauma in the strict definition of a word, but it’s certainly a stressor. It’s certainly a stress on the individual, and the interesting thing is that individuals adapt to stressor in all kinds of interesting ways, and that for some people, those adaptations become maladaptive. They stop working and they start doing harm.

And what this sudden wealth syndrome thing, as I understand it is, is there a way to try and understand the challenges that face the individual who goes from an ordinary situation? To an extraordinary one. Is there a way in which to understand how people react in these situations and what that tells us about how people adapt, if you like?

[00:05:09] Jordan Harbinger: Yeah, that does make some sense. And, and I’m wondering, given the name is Sudden Wealth Syndrome, of course it seems like the answer is yes, but I wonder what if it’s not only sudden wealth? What if you become. Famous and you’re not that wealthy. You just happen to be like a, a YouTube sensation or a TikTok sensation and sure, maybe you’re making like a few hundred grand off of this, but you, you know, you have expenses and you have your production co.

So you’re not necessarily loaded beyond all your wildest dreams, but maybe millions of people know who you are. Is that gonna be a similar kind of thing? ’cause it seems like that the changes you’re talking about or the adaptations you’re talking about. Aren’t necessarily pinned only to finances or are they, uh,

[00:05:50] Resh Joseph: well, that’s a very astute observations, uh, because first of all, where does one draw the line in terms of wealth?

For some, for some of us it may be 10 million. For others it may be a hundred. And for others it could be, as you say, you know, 500 grand. That could be the difference. And, uh, the other part of the question, as I understand it, is. Why do some people adapt in certain ways whilst others don’t? That’s another very, very interesting questions.

Are there things that perhaps happened earlier that would predispose certain people to mal adapt where others do not? That’s a fantastically interesting question. Yeah. The answer is yes.

[00:06:31] Jordan Harbinger: Can. Can we talk about what some of those early experiences might actually be like? Is it. I’m gonna go out on a limb here and say, if you grew up with a really strong, tight loving family, maybe you’re less likely to go off the rails.

If somebody who I dunno, was emancipated at 15 and then went off on their own and suddenly became a professional athlete or, or a pop star and just has no kind of grounding relationships around them, for example.

[00:06:56] Resh Joseph: Some of why certain people adapt whilst others mal adapt can definitely be found in the genetic material.

Some people are just predisposed, right? And, and I can certainly say a little bit about those particular genes, but it’s a very technical topic and I’m not sure how interesting. Yeah. Might it would be, might

[00:07:13] Jordan Harbinger: not make sense. Yeah. For the, for our audience here.

[00:07:15] Resh Joseph: Yeah. But suffice to say, there is certainly enough evidence to say that, that some of us are genetically predisposed and whilst others are not.

The second, of course, is the childhood environment. The childhood environment is fantastically important in how the brain is sculpted as the person grows up and the connections that are made, et cetera, et cetera, et cetera, inside the brain. And certainly if you grew up in an environment. For example, prized things like healthy boundaries, prized the importance of communication, prized the importance of trust and a autonomic nervous system.

You know, all of the things that we think of as as being critical to relationships. Then that becomes adapted to the person when they. Become an adult and face a challenge such as this. However, if you have someone who grew up, say, in a family where there were no boundaries, people could do and say as they please, if trust was not prized, if all of those healthy components of a, of a loving family are not there, then when they go into adulthood, those coping strategies are simply not there for them.

Then the chances of mal adapting are that much greater, I would say.

[00:08:27] Jordan Harbinger: Gotcha. Okay. By way of background, I’d love to hear about your history of treating prisoners and addicts and things like that. I’m curious how you got started with all this.

[00:08:36] Resh Joseph: Well, I started, as most of us do, you know, we don’t start at the top end of the.

Private sector, most of us start in the government sector. That’s just the trajectory most people take. Right? We work in hospitals, we work in nursing homes, we work in prisons where you, the phrase that I would use is you earn your chops. You know, you earn your stripes, you have to do the hours, as it were.

And so, yes. You know, like most of my colleagues, I started in the public sector, which in my case was prison service, where I worked in the chief of prison psychiatry, and I was. Basically the person who ran around and did, as I was told. Yeah, sure. How much therapy I actually did. I would unashamedly say zero because it’s in that situation there you have a specific job to do.

It’s a very important one. Uh, and I was there to support, you know, the, the people doing very important work. You know, the psychiatrists, the prison. Psychological services, et cetera, et cetera. However, what I would say is that it was an extremely valuable experience for me in terms of learning, because I saw how men put in very, very stressful situations, reacted, take away the fact that these men were, you know, criminals or.

Uh, gang members or drug addicts, you know, take all of that stuff away and simply look at them humanistically as human beings, they were put in extraordinarily stressful situation, right? Things like incarceration, having your rights taken away, uh, solitary punishment, you know, bars and all that, that sort of thing.

It’s an extreme stressor. And just looking at how some men were able to adapt and become really quiet. Amazing individuals where others just couldn’t, they could not adapt. They maladapted or they didn’t adapt at all. They just collapsed. And I left that period of time asking myself, why was it that some people were able to cope, if I can use that word.

While others just completely collapsed. The great gift that the prison service gave me was that I started asking those questions, and as I transitioned from public sector and slowly and gingerly over to the private sector, those questions, the questions that started then still persist. Jordan, I still ask those questions.

Why is it, and I ask, I get asked it all the time, why is it that someone who is say, born into privilege. And this is part of what Sudden Wealth Syndrome is as well. Why is it that someone who is born into privilege and they have everything, appearances, tell us that they have everything that they need.

They don’t seem to cope with the challenges that life throws at them, whilst other people have every handicap. You can imagine that, and I know some of these people, I mean, I’ve done work with a Afghani women, you know, who have every disadvantage you can imagine. Yet these women are able to forge ahead in life and adapt to incredible circumstances.

The question, Jordan, is why is that? It’s a question that, that, that drives me defines women based,

[00:11:45] Jordan Harbinger: I’m sure. Yeah, I’m sure it’s, it’s, it’s fascinating. I mean, you cracked the code on that one. And, uh, you’ve changed humanity, right? Essentially. So, but what led you then to specialize in trauma and sudden well syndrome now, particularly among high net worth individuals?

’cause that is quite the departure in terms of clientele, right? To go from the incarcerated. And unfortunately, you know, this is a callous way to phrase it, but kind of like the bottom rung of society in many ways, right? The people that have been locked away forever in some cases, and now it’s, Hey, you know, let’s, let’s work with high net worth individuals.

I mean, it’s again, like quite the departure in terms of clientele. It’s an interesting shift.

[00:12:21] Resh Joseph: Wow, that’s a very broad question. Yeah, I mean, my own personal journey speaks to that as well. But if I had to articulate one question that I get asked more than any other question, that question would be why me?

And that question essentially says I come from a particular background. You know, very often the people I work with these days are very privileged. So what they mean is I come from. Uh, decent family, privileged background, went to a good school, good education opportunities presented to me, and yet things have gone so badly wrong for me because I’m sitting here, right?

This indeed this may be a very, very nice facility and you can see the oak paneling on the wall behind me sometimes. I think I’ve landed in, uh, in the Ho Hogwarts school for magic, uh, being in this. Beautiful place. But even so, the people who are here are all asking that question are all articulating that question.

I don’t understand why me. And there’s almost implicit in that question, a denial of permission. It’s almost as though they say to themselves, I’m not really allowed to have trauma. I’m not really even allowed to suffer because I had such a good life. I have this terrific house that I live in, and I have these wonderful people that help me, and I have these brilliant doctors that treat every illness I have, and I have a business that sends me on vacation twice a year.

So I’m not really allowed to suffer. Not really, I. That’s the point that is implicit in the question of why me? And it’s in trying to answer that question that this work is in service of why you, let me tell you why you, here’s why. And for many people answering that question is if therapy can be described as a structured exploration of personal suffering, then it’s really the ability to answer that question.

I know. Why me? I know why, and that is the door to whatever solution lies on the other side.

[00:14:29] Jordan Harbinger: But I’m curious, what are some of the most common challenges that your clients face? I mean, you mentioned addiction. I. Is it common for people to sort of lose their way with this stuff and then self-medicate? Is that what we’re looking at?

You mentioned also PTSD, but I’m trying to figure out how that happens. I guess if you come from a privileged life, it’s not, you know, you’re not in a war zone. Where does the PTSD come from? I, I’m, I obviously don’t fully understand PTSD in asking that question.

[00:14:54] Resh Joseph: Well, I have some earth shattering news for you if you’re ready for it.

I am ready. Rich people can suffer pain too.

[00:15:03] Jordan Harbinger: Yes. I, I’m sure, I’m sure bad things happen to, to people at in all levels. Yeah. But I wonder, you know, is it the wealth that causes it or is it they’re wealthy but then their family splits apart because everyone’s fighting over the money and that’s what causes the PTSD or you know, for example,

[00:15:19] Resh Joseph: very interesting question.

If we’re looking purely at it from a wealth angle, the wealth itself can very often become the locus of suffering. And what I mean by that is simply by its existence, it can cause relationships to fracture, it can cause division that where there perhaps. Wasn’t any. It can, uh, you know, cause a great deal of, um, suffering to the people who have to manage it.

It can cause relational dysfunction, social dysfunction, occupational dysfunction, even personal dysfunction, and all of these things can happen purely because the wealth is there. It has an effect from the people around them, and it’s the way that people negotiate those dysfunctionalities that decide whether they come end up in a place like this or not.

In the case of some people where the wealth has caused enough dysfunctionality in the close relationships where people no longer speak to siblings. Or children where the wealth is enough of an obstacle to prevent close family members from talking to each other, where the wealth by its mere existence can cause such a social fracture that the ordinary support upon whom the person relies and no longer accessible or available to them because everyone is now suspect, I heard, is in group just this morning.

Everybody just wants my money. If I’m thinking that it doesn’t make me a very good friend. It makes other people very suspect, and that’s just because the wealth happens to be there. The wealth is benign, but the effect it has on people is quite extraordinary. And then of course. And this refers to, I really don’t like this phrase, I’ve heard it so I’ll use it, but what are have become to be called nepo babies.

I dunno if you’ve heard this. Yeah,

[00:17:19] Jordan Harbinger: yeah, exactly. Yeah, I’ve heard of this.

[00:17:21] Resh Joseph: I, I dislike that very much, but I’ll use it because I think most people have heard of that. In other words, children who have grown up in very wealthy families who really can’t seem to get going. You know, people like me have variously called it.

Other things. Some people call it Nero baby. I prefer to call it failure to launch.

[00:17:39] Jordan Harbinger: I was gonna say failure to launch is another way to say it. That’s maybe, maybe not as horrible. Yeah. I don’t know. Yeah.

[00:17:44] Resh Joseph: Nipple Baby just has a horrible rate to it, doesn’t it?

[00:17:47] Jordan Harbinger: Right. Yeah. Yeah. It’s it, it sort of implies that if you did do something, it wasn’t because of anything you’ve accomplished in your own life, somebody put you somewhere, failure to launch means you haven’t done anything.

So I don’t know. They actually, no, no, no. I’m not sure which one is worse now that you mention it.

[00:18:02] Resh Joseph: Yeah, so I’d prefer to say sort of failure is a launch, and this comes under the area of, you know, occupational dysfunctionality. We as human beings are built to climb up a hill, to lift a load and carry it up the hill.

That really where we find meaning in life is in the struggle that we wake up every day that we’re. We enter the struggle for something meaningful, whether that’s this place or your job or it doesn’t matter, but it has to be meaningful to the person. If on the other hand, you wake up and you don’t have that, because through no fault of your own, every pressure in life, occupational pressure in life has been taken care of for you.

You don’t have to go out there and struggle. You can if you wish, but you don’t have to. Then it brings a certain challenge, an occupational challenge, because if you don’t have to work, would you really, and could you blame, say the son of a billionaire, if he was to possibly unconsciously feel, you know, what really is the point of me going out there and struggling hard and honestly and diligently to earn?

Decent wage, you know, 250,000 a year when my father spends that on his, you know, Gulf Stream every weekend for a perspective that I think that would be difficult for anyone. I’m not in that situation. I’ve never been in that situation. I very much doubt it unless I’m very rich. Hes looks upon me in a kindly way.

That’s very unlikely. Very unlikely. Unlikely to happen to me.

[00:19:38] Jordan Harbinger: You’re in a good position to make that happen. I’m just saying.

[00:19:42] Resh Joseph: I wasn’t suggesting anything, but Aris is out there, the application. No. Um, but um, yeah, I, I, I, I work with people who are now in that position and the struggle is real and I’m asked by these very nice young men and women, you know, rush.

What is the point of me going out there is struggling? It’s hard to, to do x when my father plays at the weekend and he spends more.

[00:20:09] Jordan Harbinger: Right? It, it would be very demotivating to, to go, okay, I’m gonna study hard. Get into a good college, study hard, get into a good law school, work really hard, go work on Wall Street.

In five years, I’ll be making Gulfstream gas fuel, you know, weekend money in a year. And then if I make partner and sacrifice most of my prime life getting there, I will make what my dad makes or what our family fortune generates an interest every couple of days or whatever, you know, or every week. And then I’ll have more money than I can spend in my entire life, or I do nothing.

And I have more money than I can spend in my entire life and 20 or 30 extra years to enjoy it.

[00:20:50] Resh Joseph: I’m reminded of a young man I worked with and he doesn’t mind me sharing this because he’s shared this very openly himself. So I know I’m liberty to say this, but we were speaking once and he was, you know, telling me about some enterprise that he’s a failure to launch kid.

Very, very nice young man, and he was telling me about some enterprise that he was on and he was building some. Innovat new media company. I don’t understand any of this stuff, but he was telling me about it. It seemed very good, and I said to him, well, the potential for that is extraordinary. You know, and I hope you go on and build this, and blah, blah, blah.

And he just looked at me very casually, and not in a, in an unpleasant or rude way. He says, well, the amount of money we, if I look at the turnover we had last year, I made more in interest whilst I was asleep on my trust fund whilst I was asleep last night. And that stayed with me because it really, for the first time, I think really showed, gave me a, a window into the challenges that these very nice young men and women face.

Where if you have that in your mind, I’m struggling every single day to go out there. And the annual revenue of the company I’ve built with, you know, help and guidance and recovery and all the rest of it. I’m now, I’m acutely aware of the fact that I made more in interest on my trust fund whilst I was asleep, right?

Someone like me, I am continuously talking about the importance of motivation and how to achieve it. People like me, you know, we are just. Continuously preoccupied this, how to get people motivated and how to keep them motivated, because as the research tells us, that’s one of the keys to any kind of successful change.

So, you know, a great deal of my time is spent thinking about that, but in that moment, I really had to ask myself, how does this young man stay motivated? And I honestly cannot tell you. Couldn’t tell you.

[00:22:43] Jordan Harbinger: Yikes. Yeah, that would be really demotivating. I mean, you, you just look at the best case scenario.

You’d have to rewire your reward system to not prioritize the money, but to prioritize whatever bringing a, a result in your community with the thing you’re putting out there to help people or. To, I don’t even know. You’d have to just sort of reprogram what the reward is, right? Because it can’t be financial.

Because unless you are printing money, you’re printing money sleeping like that guy and you know, his trust fund’s printing money, so he, he’s gotta find some other reward. But that’s hard to do, right? If you grow up your whole life measuring things with finance like we all do, you have to suddenly figure out a way to do a different thing.

That’s gotta be challenging.

[00:23:30] Resh Joseph: Well, you’ve just hit the $50 million cash prize. They’re already, maybe I should say 50 billion given the data of our conversation. That’s right. That’s right. You’ve hit a bit of, a bit of a jackpot there when you say that. Would it not mean that we would have to help rewire.

The reward system. I think you’re exactly right. I think part of the problem comes from a misunderstanding of what reward actually is because we have a tendency to associate reward with either feelings of euphoria, the hedonic response pleasure. You know, if I eat, it’s pleasurable. I eat. That’s really a mis, a mistaken interpretation of what brain reward is.

The first clue that that’s a mistake comes from research that I first saw about 10 years ago, eight years ago, that very clearly show that the chemical associated with reward dopamine. We all know that dopamine is released in the brain, that they showed in the brains of addicts that very often the dopamine hit would come before.

The consumption, it was anticipatory. So even the anticipation of the reward or anticipation of, as they call it, the stimulus, that the anticipation of the stimulus is what produced the reward, not the stimulus itself. So it wasn’t the cocaine or the heroin or the alcohol or the drug or the gambling. It wasn’t that.

In the case of addicts, it was the anticipation of the reward. That gave the dopamine spike in the brain and that really set off the research on my part. Investigations on my part, and I’ll cut the story short. I’ve broken reward here in rewiring people. I’ve broken it into what I call the four ms. That brain reward actually is a combination of these four things.

It’s a combination of memory. Motivation, movement and meaning. Anything that is rewarding to us as human beings, I say, has to have some hook in the memory. In other words, it has the ability to really activate. So if you smell a food you like and you start salivating, and it’s rewarding for you to eat that it hooks into your memory in some way.

I say that it has to have the ability to really motivate you to go out there and get it. You don’t simply sit on your couch, it makes you want to go out there and pursue it. It has to have that. It has to have the ability to move. And by the way, movement in the brain is initiated also by dopamine, just in the different circuits, but most importantly.

For something to be rewarding, it has to be meaningful to the individual. You and I may not know what that meaning is, but it must be meaningful to that person. If we took someone like an alcoholic or an addict, the meaning of the drug use, very often, not always, but very often, that is meaningful to that person because it represents relief from pain.

If I’m in a person in terrible emotional pain or terrible physical pain, if I’ve found something that can give me relief from that can make me feel at peace, well that will become particularly meaningful to me. And so the challenge for someone like me in a place like this is how do we rewire the brain in such a way that the person finds something?

That can activate the memory, can activate the motivation, can activate the movement, and is deeply meaningful to that person. If we can fulfill those four ms, I submit that whatever that person doing, even if they can’t explain it to me, their therapies, it matters. Not like the young man who is out there building his wonderful media company.

He can’t explain to me. What it is that hooks into his memory. Can’t tell me why it motivates him, why it gets him moving every morning in the way that it does, or why it’s so meaningful to him. But he doesn’t, he needs to know it. And that’s all that really matters. And so I think part of what is ultimately, uh, a panacea or solve for certain wealth syndrome, such as it may be called, is that people can rewire their brains to.

The plants, the four s with four different ones, then they have the beginnings of a solution.

[00:28:02] Jordan Harbinger: That must be kind of a complex process. ’cause I’m imagining these guys, guys and gals coming in and saying everything is meaningless. There’s no point in anything. Right. I, I mean, not, maybe not everybody, but certainly some of them.

And it’s like, where do you even begin with somebody who doesn’t know what would bring them pleasure, which is maybe one of the reasons why they’re using drugs, for example, right? They’re not interested in cooking, they don’t care about building a company because there’s no point and they can’t do it.

You know? Where do, where do you sort of like start the introspection that’s required to find that meaning?

[00:28:35] Resh Joseph: I mean, I’ve worked in places like this for a number of years now, so I’ve had the opportunity to see what doesn’t work as well as what I think does. Here’s what doesn’t work look like. What doesn’t work is people in a facility like this where they’re very well looked after, they have chefs and Mac pursuers and chauffeurs and et cetera, et cetera, but all they do is they sit around all day, they do nothing.

They drink coffee, they smoke cigarettes. They are bored and listless and in my book Unrewarded, it’s just the boredom and the restlessness and the listlessness and the irritability that one associates with being chronically under rewarded, which is what people mean when they say, God doing this is so meaningless.

That is a sure ticket to going back to the thing that was rewarding in the first place because. Well, that’s what you know. That’s what you’ll do. And therefore what I think works is whatever a place like this does, has to address that. It has to provide people with those four s and I look at it from.

Three perspectives, a biological, a psychological, and a social. This relates to George Engel’s 1977 paper on the biopsychosocial model. So what angle and what we all pretty much say these days is if you want to be, well, then you have to have a biological component, a psychological component, and a social component.

The biological component in a place like this is about enhancing dopamine functioning. And there are certain things that we now know definitely enhance dopamine functioning. The people who’ve written very brilliantly on this are actually the people who lead the field are Americans. So I’m thinking of, uh, professor Anna Leke at Stanford who wrote a brilliant book on this.

And others who, from the Stanford group as well, will become very well known in their own way, but doing all of the biological stuff through diet, through exercise, through cold plunging, through, you know, all of those things to try to enhance dopamine functioning. As much as possible, or as Anna Leke says, try and rid oneself of the gremlins.

She talks about the seesaw and the gremlins on one side, you know, so it’s a great analogy. You should read the book. That would be one part of it. The second part of it is the psychological, where we basically work with people to examine the environment and how they’ve constructed it. Behavioral psychology, cognitive psychology, somatic psychology, all of those components.

Number two. And number three, of course is the social component because we are social animals whether we like it or not. And if you put people in socially cohesive groups, that will in itself become rewarding. I’m sure you’ve noticed this of yourself. If you are in a group of people where you feel there’s a real group cohesiveness where you feel understood and you feel aligned with people, it just motivates you to do stuff.

You know, I remember as a young boy going in a football match and standing on the stands of a team I’d never heard of. By the end of that match, I was cheering for the team. I didn’t know who the hell they were, but I was cheering for them because everybody around me was having such a great time. But that’s how I would describe a place like this.

A place like this, if it’s going to work, has to have all three. You’ve gotta have the good biology. You’ve gotta have the good psychology and you’ve gotta have the good sociology. And if we get those three things right, then what you don’t get are people sitting around, bored out of their skulls, smoking cigarettes, drinking coffee, moaning about the world and its dog.

And generally listeners bored and unhappy. That’s in theory. I mean, I’m making it sound very, very easy, but Sure, sure. It’s a challenge.

[00:32:37] Jordan Harbinger: Yeah. I mean, of course it is. And I know generally something like 40 to 60% of, let’s say addicts for example, they relapse after rehab. And Highlands, your facility I know has a bunch of aftercare that extends.

Is it one or two years after the resident leaves the facility? And I assume that’s sort of mandatory to make sure that you accomplish the mission at hand.

[00:32:58] Resh Joseph: The length of the aftercare is a client, depending on their clinical need, depending on their journey, depending on, yeah. So if I had my way right and there’s no reason to suspect that I will because I’m a bit of a bully and I.

Tend to get my way and the people here, very nice said they let me get away with stuff, but no, not really. But when I get my way, eventually that aftercare will never end because one of the things that we’re doing where we’re harnessing new technology, although this is not new, is we’re building an an app for our alumni, and that app will basically form the basis of a Highlands alumni around the world that the client here will have access.

In, they will never, they can choose not to use it, but if they choose to be a part of the aftercare community, they can do so for two years, three years, five years, for as, as long as I’m in charge for as long as they wish. So in that way, the goal is to have aftercare that is perpetual, that never actually ends.

[00:34:03] Jordan Harbinger: Yeah. That act, I mean, that makes a ton of sense to me. I think a lot of people are wondering how much it costs to go to a facility like Highlands, for example. I. That deals with the ultra wealthy, I assume it’s quite pricey because it’s gotta be nice in order to accommodate what those people are used to.

Right? They don’t wanna be miserable, they’re already doing something challenging. They wanna be in, you know, safe and familiar and it surroundings that are up to their standards. I, I’m, or, or am I putting words in, in your mouth here? ’cause it seems like that would be important.

[00:34:34] Resh Joseph: Well, you are correct to say that we are not cheap, but interestingly enough, we are also, we would not be considered expensive.

So if I’m looking at a comparative chart, which is. Really what this is us in comparison to say, competitors in Australia and competitors globally. There are definitely people out there who are doing it cheaper and, and certainly you could have a less, you could get rid of the oak paneling and that would be, you know, a cheaper of doing this.

So certainly there are places doing this, uh, more cheaply than us, but there are also a lot of places who are doing this much, much more expensively. Very interestingly, and we are kind of in the middle. I see somewhere.

[00:35:15] Jordan Harbinger: Can I ask what the price range is?

[00:35:18] Resh Joseph: Obviously the rooms and the facilities are priced differently depending on which part of the facility you are in, but the top, absolute top price for the.

Most luxurious facility that we have here. That would be the price. Yeah. $25,000 a week, and I think that’s 25,000 Australian dollars, which makes it a hundred thousand a month, which makes it, I think about 65,000 us.

[00:35:42] Jordan Harbinger: Okay. I’m gonna do a little currency calculation here. Uh uh, on the weekly amount. So 25,000.

Yeah, so it’s about 16, 17,000 US dollars per week. Yeah. 66,000 US dollars. A month. I mean, that’s, you know, that’s the average annual salary in the United States. So that ends up being, it ends up being quite pricey. But for the people that are attending your facility, of course it’s, you know, it’s not, it’s not as significant investment as it would be for, for others.

So what does that include? Because that’s, people are gonna go, what do I get for that? I, I’m also curious.

[00:36:18] Resh Joseph: So what they get when they come here is, I mean, there is the obvious part of it, which is the facility itself, you know. All of the stuff that they get access to, you know, the Great Shep and all that stuff.

But I think what people are really paying for when they come to a place like this is they are paying for access to top class professionals at a top tier clinical program. Something that’s bespoke, that’s been handcrafted, that’s been written from scratch, that’s not. Secondhand or bought from another institution, or cut, cook, uh, cookie cutter in any way or downloaded or bought off the internet.

You know, they’re paying for something that has been constructed specifically by me for this place. And I think the real value of this place is in the quality of the professionals that work here, the therapeutic star. As well as some of the associated staff. Everyone here is an expert in their field, handpicked by myself and the CEO, and I’d like to think that we’ve as assembled an incredible team.

I think that a lot of the price has to do with, I. Those professionals and the fact that they don’t come cheap.

[00:37:32] Jordan Harbinger: Sure. No, that makes complete sense. I know there’s also for the program six days a week. Correct. So it’s, it’s also quite intense. It’s not exactly, you know, punching out on Thursday. There’s a lot going on and you’ve gotta include food and I, I assume people are, do people work out when they’re there?

That seems like a thing you would do, uh, when you’re trying to get back on the rails.

[00:37:51] Resh Joseph: Well, I, you know, if we’re going to say biological health is a critical part of their recovery. Then yes, working out is part of the program that they pay for. They spend 14 hours a week in various different kinds of therapy.

So therapeutically, there’s a, there’s 14 hours a week, just slightly less than that in terms of physical sessions. So yoga and I. PT and all of the physical dopamine building activity that we talked about and an equal amount of time set aside for the social health aspect, the community components that bring the community together, which is so important.

I wanted 15, 15, 15. I’ve got 14, 12, and 11, which is pretty close, but. What was said to me, which I happen to think is a good point, is it has to be balanced against enough rest and recovery because the program as it is, keeps people engaged between 7:00 AM and 7:00 PM every single day, Monday to Friday, and then Saturday mornings they’re engaged in group and PT and stuff, and then in the afternoons it’s family.

They really only have one day a week off. And that it was important for people to have a day where they could just breathe and think. And reflect and work on the exercises in the manual, that that’s also a pretty important part of it.

[00:39:17] Jordan Harbinger: Sure. How do you kind of ensure that the luxury part doesn’t overshadow the therapeutic part?

Does that, is that ever a problem? I, I can imagine. Sometimes people come in, in their, you know, they’re the boss of their own realm. And they come in, and this is a very similar standard and a very similar type of thing that there used to in terms, in terms of the environment, right? It’s a high standard. It seems like maybe there’s a potentially slight danger of that getting in the way of like, okay, but we now we have to buckle down and talk about your real stuff here.

[00:39:45] Resh Joseph: Yeah. What we try to do is we try to anticipate the needs of a person from that socioeconomic group coming, right? The people who work here. All of our experience of working in that particular sector, you know, for. For some time, for some for some years. So the ability to anticipate those needs before they arise, the ability to recognize people from that particular sector will probably require A, B, C, D, and E.

And to have that on hand or the ability to provide that, and that frees the clinical team. Okay? What we don’t want, what I have seen happen is where that hasn’t been done well. And then. A lot of therapeutic time is spent dealing with the natural resentments that arise when people don’t get what they feel they’re paying for.

You know, to be fair, I would be as well, you know, if I’m paying for a certain level of syllabus and I don’t feel I’m getting that, I would be unhappy and resentful and annoyed, and then that. Hijacks the therapeutic process. Whereas if that is seen to and taken care of in anticipation, then what you get is that doesn’t bleed over into the therapeutic space.

But I tell you what, it is an absolute job, a whole team of people to just ensure that that is taken care of.

[00:41:05] Jordan Harbinger: That makes a lot of sense. Yeah, you’re right. You want it to be sort of frictionless, right? You want it to be, I’m getting what I need and so that it’s not a distraction. You want them to be comfortable enough that this is not going to be an issue.

Well, thanks so much, Russ. This, this stuff is fascinating. I really had no idea this existed. I’m curious how this is gonna land with the listeners. Usually when we do episodes like this, some folks get personal in the inbox. I pretty much guarantee someone listening to this episode. Is dealing with this kind of stuff right now.

So thank you very much for speaking with me today. Really super interesting, uh, an insight into something I’d never heard of before.

[00:41:39] Resh Joseph: Well, it’s a real pleasure talking to you Jordan, and thank you so much for having us on your, you know, podcast and it’s been a real joy talking to you as well. I.

[00:41:49] Jordan Harbinger: Imagine facing a rare, incurable disease and finding out that AI could repurpose an FDA approved drug as a potential cure.

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I was terrified. I was like, had my last rights read to me. Course, you know, no one thought that it was even possible that I could survive. You’re dying from this horrible disease, chemotherapy just gave you a little bit of a window, but it’s probably gonna come back. So, you know, what’s your game plan to prevent this thing from killing you?

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[00:43:28] Jordan Harbinger: Tune into episode 1005 of the Jordan Harbinger Show to explore how existing medications are bringing new hope to those confronting elusive illnesses. Thanks again to Rush for coming on the show today. Highlands Recovery is a luxury rehabilitation center in Sydney, Australia that offers holistic and personalized treatment approaches for high net worth individuals suffering from trauma, addiction, and related mental health issues.

Again, something I think most of us never knew existed. All things Rush Joseph will be in the show notes@jordanharbinger.com. Thanks to Highlands Recovery for bringing this episode to us sponsored and ad free. I’m at Jordan Harbinger on both Twitter and Instagram. You can also connect with me on LinkedIn.

This show is created an association with Podcast one. My team is Jen Harbinger, Jace Sanderson, Robert Fogarty, Ian Baird and Gabriel Mizrahi. Remember, we rise by lifting others. The fee for the show is you share it with friends. When you find something useful or interesting, the greatest compliment you can give us is to share the show with those you care about.

So if you know somebody. Who might need a little, uh, attention in this department or is suffering from anything that Highland’s Recovery might be able to treat. I highly recommend that you share this episode with him. In the meantime, I hope you apply what you hear on the show so you can live what you learn, and we’ll see you next time.