An introduction to dual diagnosis for the new therapist

By Marie Hartwell-Walker, Ed.D.
August 26th, 2019

When I was newly licensed and newly in private practice, a patient told me at intake he had to have therapy before he could be granted visits with his young daughter. He seemed heartsick that he couldn’t see her. He said he wanted to be a good dad. He wanted to pay for her braces. They always had good times together.

Concerned about what I was getting into, I asked him why he had been referred. He reluctantly admitted that he had been addicted to crack cocaine but also claimed that he was in recovery and his daughter was more important to him than crack. He just wanted relief from the anxiety that made him want to get high.

Foolishly, I took him at his word. (I told you I was a newbie). I should not have been surprised when, several weeks later, he came in abashed and ashamed. “What happened?” I asked. “I tried,” he said. “I really did but you can’t understand how wonderful that first drag is. When I think about it, I just have to get some more.”

He was mortified. He genuinely wanted to see his daughter. He was in tears when he told me the money he’d saved for her braces had literally gone up in smoke.

Being new and untrained in substance abuse, I had no idea what to do next. At least I was smart enough to refer him to a local substance abuse program. But the experience made me realize I needed more training to responsibly treat clients who are in recovery and to recognize when it’s best to immediately refer to a specialty program.

Maybe you share my experience. Perhaps, like me, your degree program and early experience didn’t include a comprehensive unit and supervision on substance abuse. If so, do consider getting the in-service development you need. I’ve been very glad I did. Why? Because dual diagnosis (mental illness and addiction) may be more common than you realize.

Patterns Identified Between Co-Occurring Mental Health and Substance Abuse

According to a report by the National Institute of Mental Health (NIMH), in 2014, 20.2 million adults in the U.S. had a substance use disorder. Of those, 7.9 million had both a substance use disorder and another mental illness.

In a recent study, researchers at the American Addiction Centers examined statistics based on SAMHSA (the Substance Abuse and Mental Health Administration) reports to identify patterns between co-occurring mental health and substance abuse. Among patterns reported in the study are:

People diagnosed with depression had the highest rates of substance abuse overall, followed closely by bipolar disorder, and schizophrenia and psychotic disorders.

For those with anxiety disorders, opioids were the most commonly abused substance. For ADD/ADHD, marijuana was the most common substance to be abused.

According to reports published in the Journal of the American Medical Association:

Roughly 50 percent of individuals with severe mental disorders are affected by substance abuse.

Thirty seven percent of alcohol abusers and 53 percent of drug abusers also have at least one serious mental illness.

Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or drugs.

Either issue may come first. Sometimes, people turn to alcohol or drugs to “self-medicate” to relieve their anxiety or depression, for example. They then become medically or psychologically dependent on it.

Sometimes, continual substance abuse results in depression and/or anxiety. Drug-induced psychosis can result from taking too much of a certain drug, after mixing substances, during withdrawal from a drug, or if the patient has underlying and perhaps, undiagnosed, mental illness.

To complicate matters, a client might have both mental illness and substance-induced mental disorders. The two diagnoses can also be in a continuous recursive loop: When a mental health problem goes untreated, the substance abuse problem usually gets worse. When alcohol or drug abuse gets worse, symptoms of mental illness usually do too.

In the not distant past, people with mental illness were screened out of addictions rehabilitation programs. Most in-patient programs now recognize and treat both. That’s the good news. But not every patient can afford the time or the money to participate in a 30 day or more in-patient program.

When such individuals recognize they need help or when they finally accept the pressure from family or friends to do something, they start with a local out-patient clinic or private practice.

Unfortunately, many clinicians who have not worked in an integrated facility are as unprepared as I once was for co-occurring mental illness and substance abuse. As in the medical field, treatment of mental illness is becoming specialized. Many graduate programs and licenses now separate substance abuse treatment from treatment of mental illness or emphasize one at the expense of the other.

For treatment of people with dual diagnosis to be successful, treatment planning should address the substance use or addiction and the mental illness simultaneously and from the start. The potential for relapse of both disorders needs to be addressed early and often.

Strategies for Competency

If you haven’t had adequate training in the treatment of substance use and abuse, consider the following strategies for developing or enhancing your competency for working with the dually diagnosed:

Educate yourself. Your graduate program is only a foundation, not as a complete training for private practice. If your degree did not include training in a behavioral therapy, consider adding those skills to your repertoire through in-service programs. CBT (Cognitive Behavioral Therapy), ACT (Assertive Community Treatment), DBT (Dialectical Behavior therapy), and CM (Contingency Management) have been shown to be promising for treating co-occurring mental illness and substance abuse.

Read. There are many fine books about dual diagnosis assessment and treatment.

Become familiar with assessment tools to help you identify addictions and mental illness and to measure progress. You can find a number of assessment tools at PsychCentral at . Another resource is the website for SAMHSA-CIHS (Substance Abuse Mental Health Services Assn and Center for Integrated Health Solutions) at

Include substance abuse inquiry at intake. Sometimes, people with a serious addiction are unaware of how much it is impacting their life so present only their anxiety or mood disorder when they come in for treatment.

In addition, people who are abusing drugs and alcohol often minimize, deny, or hide the amount and impact of substances they are using. When asked, though, many clients will acknowledge their use of alcohol or drugs.

Consider specializing: Treating dual diagnosis has become a field in its own right. If you find that your practice is drawing many individuals with dual diagnosis and you are interested in the population, consider post graduate work in co-occurring disorders counseling.

Marie Hartwell-Walker, Ed.D. is an author, licensed psychologist, and a marriage and family therapist who has been in practice for more than 35 years. She is a regular contributor to Psych Central and one of the therapists who answer questions at Ask the Therapist.

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