Bounced Between Systems: Patients Describe Life Inside a Coordinated Dual Diagnosis Treatment Model

For people living with both a mental illness and a substance use disorder, the healthcare system is supposed to be a safety net. Instead, many patients describe it as a pinball machine, ricocheting between municipal addiction services and regional psychiatric clinics that rarely talk to each other. That vivid self-description, quoted in the title of a new qualitative study published in BMC Psychiatry, sits at the heart of research from the Capital Region of Denmark examining how patients experience SPOR, a coordinated treatment model designed to knit together concurrent psychiatric and substance use treatment across administrative boundaries.

The study, conducted by Mie Pyrmer, Ditte Maria Sivertsen and Signe Wegmann Düring, researchers affiliated with the CAG Dual Diagnosis unit of Mental Health Services in the Capital Region of Denmark, the University of Copenhagen and the Department of Research at Central and Western Zealand Hospital, set out to answer a deceptively simple question: what is it actually like to be a patient inside a coordinated treatment model? Coordination schemes look impressive on organizational charts, but the researchers wanted to know whether the promised coherence reaches the people it is meant to serve.

Dual diagnosis, often abbreviated DD in the clinical literature, refers to the co-occurrence of a psychiatric disorder and a substance use disorder in the same person. The combination is clinically demanding for reasons that go beyond simple addition of two conditions. Substance use can mask or mimic psychiatric symptoms, psychiatric illness can drive relapse into drug or alcohol use, and each condition is typically treated by a different arm of the public system. In Denmark, substance use treatment is organized at the municipal level, while outpatient psychiatry belongs to the regions. A single patient may therefore have two treatment teams, two treatment plans, two sets of appointments and, in the worst case, two sets of goals that pull in opposite directions.

SPOR, whose Danish name Sammenhængende Psykiatri Og Rusmiddelbehandling translates as Concurrent Psychiatric and Substance use Treatment, was created in the Capital Region of Denmark precisely to close that gap. The model establishes structured collaboration between municipal substance use centres and regional outpatient psychiatry, including elements familiar from other integrated care frameworks such as network meetings across sectors and designated contact persons who follow the patient through the system. The researchers interviewed eight participants with dual diagnosis who were currently receiving cross-sectoral SPOR interventions, using semi-structured interviews to capture their experiences in their own words.

The central finding is sobering. Participants reported inadequate cross-sector communication, and that shortfall had a corrosive effect on their sense of care. Rather than experiencing the system as coordinated, patients felt they had to take responsibility for coherence themselves, relaying information between clinicians, reminding one service what another had decided, and effectively acting as their own case managers. For people already struggling to balance substance use, psychiatric symptoms and the demands of everyday life, this added burden is more than an administrative nuisance. It places the heaviest organizational work on the shoulders of the least stable participants in the network.

The pinball metaphor captures the mechanics of the problem. When information does not travel between sectors, the patient does. Each referral, each handover and each change of plan sends the person bouncing from one service to another, with momentum supplied by the system rather than by any deliberate clinical strategy. The researchers found that this dynamic undermined trust and made patients feel unsafe and uncared for at precisely the moments when continuity mattered most. In effect, the coordination model existed on paper, but the lived experience of coordination depended on whether communication happened in practice.

Network meetings, a core component of the SPOR model, received a more nuanced verdict. Participants considered these meetings, in which professionals from both the municipal and regional sides convene around a shared patient, to be important in principle. When they functioned well, they offered a visible demonstration that the two halves of the treatment system were aligned. In practice, however, the study found that network meetings were not conducted stringently. They were often postponed, inconsistently held or otherwise not delivered as designed, and as a result they frequently failed to feel helpful to the patients they were intended to serve. The lesson is a familiar one in implementation science: an intervention is only as good as its fidelity. A coordination mechanism that exists intermittently may be worse than none at all, because it teaches patients not to expect follow-through.

Against these systemic failures, one element of the model emerged as decisively positive: the contact person. Participants reported that the individual clinician assigned to follow them had a considerable influence on whether they felt safe and cared for during treatment. It was considered particularly helpful when the contact person was mindful of the participants’ ongoing struggle to balance substance use, psychiatric symptoms and the rest of their lives. In other words, what patients valued most was not primarily a structural feature of SPOR but a relational one, a trusting therapeutic alliance with a professional who understood the whole person rather than a single diagnosis. This finding echoes a large body of research on the therapeutic relationship, which consistently identifies alliance quality as one of the strongest predictors of engagement and outcomes across mental health and addiction treatment.

The authors conclude that good collaborative practices, including effective cross-sector communication, properly conducted network meetings and continuous feedback, alongside a trusting therapeutic alliance with the contact person, are considered meaningful by patients with dual diagnosis. They note that this aligns with existing research emphasizing how difficult it is to achieve continuous collaboration between hospital-based and municipality-based services. The structural divide their study documents is not unique to Denmark; health systems internationally struggle with the seam between addiction services, which are often locally administered and socially oriented, and psychiatric services, which are typically regionally or centrally administered and medically oriented. Patients with concurrent disorders fall exactly into that seam, and the new study suggests that the seam is felt most sharply by the patients themselves.

The methodological approach deserves attention as well. Semi-structured interviews with eight participants cannot quantify how common these experiences are, but qualitative designs of this kind are well suited to revealing how a policy model is actually lived. The study was carried out according to the ethical principles of the Declaration of Helsinki, approved by the Capital Region Data Protection Agency, and conducted with verbal and written informed consent from all participants. The researchers recruited through clinicians and a peer employee at Psychiatric Centre Amager, and they acknowledge the participants who, in their words, had the courage to be vulnerable and share personal experiences. The study received no external funding and the authors declare no competing interests. Published open access in BMC Psychiatry on 23 September 2026, the paper offers health planners a clear, patient-centred checklist for integrated care: communicate across sectors as a default, hold network meetings reliably rather than occasionally, close the feedback loop, and above all invest in contact persons who can see the whole person. When those elements hold together, patients stop feeling like pinballs and start feeling like people in treatment.

Subject of Research: Patient experiences with coordinated cross-sectoral treatment for dual diagnosis in Denmark

Article Title: ‘I feel like a pinball’: patient experiences with a coordinated treatment model in dual diagnosis

Article References: Pyrmer, M., Sivertsen, D. M., & Düring, S. W. (2026). ‘I feel like a pinball’: patient experiences with a coordinated treatment model in dual diagnosis. BMC Psychiatry. https://doi.org/10.1186/s12888-026-08658-x

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08658-x

Keywords: dual diagnosis, substance use disorder, mental health, cross-sectoral collaboration, coordinated treatment, patient experiences, qualitative research, therapeutic alliance, Denmark, psychiatry, network meetings, contact person