From Stigma to Recognition in Dual Diagnosis Care: A Multilevel Conceptual Framework.

People experiencing co-occurring mental health problems and substance use disorders face some of the most fundamental challenges in contemporary mental health and addiction services. Despite longstanding policy commitments to integrated care, dual diagnosis care remains characterized by persistent fragmentation. Existing multilevel perspectives have advanced understanding of how stigma contributes to exclusion across healthcare systems, yet provide less guidance for explaining how continuity of care is established and sustained across interconnected institutional, organizational, and relational contexts. Drawing on a conceptual synthesis of empirical and theoretical literature, this article develops a multilevel framework integrating recognition theory, stigma theory, and ecological systems theory. The framework conceptualizes dual diagnosis care as shaped by interacting stigma- and recognition-related processes operating across macro (institutional), meso (organizational), and micro (relational) levels. Fragmentation and continuity are understood as emergent outcomes of the degree of alignment or misalignment between these processes across levels of care. Recognition is conceptualized not merely as a feature of interpersonal encounters, but as a coordinating principle through which institutional commitments, organizational arrangements, and relational practices may become aligned to support continuity, participation, legitimacy, collaboration, and trust. By extending existing multilevel perspectives beyond explanations of exclusion alone, the framework provides an analytical lens for understanding why fragmentation may persist despite policy commitments to integrated care and how continuity may emerge when recognition-supporting conditions are aligned across systems of care.