Addiction and Dual Diagnosis

The co-occurrence of substance use disorders (SUDs) and mental health disorders can create complex treatment challenges. The National Institute of Mental Health (NIH) asserts that it is typically better to treat both disorders at the same time rather than separately, as some symptoms may be the same for both. 

Heavyn Jones, MEd, NCC, and Shakiema Raphael, MA, NCC, LMHC, LPC, QS, help us understand the dynamics of co-occurring SUDs and mental health disorders and offer their advice to best serve clients with these diagnoses.

Jones and Raphael agree that certain mental health disorders co-occur more frequently with certain addictions.

“Individuals with depression commonly abuse alcohol as a means to numb emotional pain, while clients with anxiety tend to seek short-term relief from chronic worry or panic through marijuana or benzodiazepine misuse,” says Jones. “Post-traumatic stress disorder (PTSD) is often associated with opioid use, especially in individuals with a history of trauma.”

Raphael experiences similar correlations among her clients but sees attention deficit hyperactivity disorder (ADHD) just as often.

“Individuals with ADHD may turn to alcohol and/or other drugs to self-medicate, which in turn makes their symptoms worse,” adds Raphael.

While these patterns are common, Jones and Raphael acknowledge that every situation is unique. Counselors should not assume that a client with a dual diagnosis who presents with depression is abusing alcohol, or vice versa.
 
Regardless of the actual means, Jones and Raphael each utilize the same first approach when working with clients struggling with addiction and dual diagnosis.

“Start by asking them about their willingness to change,” suggests Raphael. “With addictions, individuals have to want to stop this form of coping all together. Their substance use is masking underlying issues, and many clients tell me they fear being unable to handle their personal truth. Therefore, I strive to meet them where they are and communicate realistic expectations of what the process will look like.”

Raphael also advises against forcing clients into a rigid treatment path, as relying solely on a one-size-fits-all approach can alienate clients and hinder progress. She encourages them to explore what a sober life could look like on their own terms and empowers them to make their own choices around recovery from the beginning.

Jones pays special attention to the language she uses, avoiding confrontational and shaming tactics, while taking a comprehensive and integrated first approach.

“Gather biopsychosocial information from the client to understand their substance use patterns and mental health concerns and address their addictions and mental health challenges simultaneously. The controversial, ‘which came first, the chicken or the egg?’ is very relevant to addictions and dual diagnoses. It is an unfortunate cycle that cannot be stopped until both issues are given attention,” says Jones.

Jones and Raphael recommend training in Motivational Interviewing (MI) and Dialectical Behavior Therapy (DBT) to assist counselors in serving these clients. MI can allow clients to explore and resolve ambivalence about change, while DBT can assist with emotional regulation and impulsive behaviors, which are common in both addiction and mental health disorders. 

“Completing these trainings prepares counselors to assist their clients in recognizing their capacity for growth and resilience, even in the face of deep-seated hopelessness,” says Raphael. 

Eye Movement Desensitization and Reprocessing (EMDR) training, according to Jones, is also beneficial, as it may help clients prevent relapses. Education in trauma-informed care is valuable as well, as all of Jones’s clients in this population have experienced trauma either before, during, or even after addiction.

With addiction in particular, Jones cautions that clients may have experienced multiple prior failed attempts at treatment, or treatment could have been court-ordered or pressured by another external source. She recommends being patient, flexible, and compassionate, as these clients may be understandably hesitant about change.

“Clients with dual diagnoses often present with layers of trauma, mistrust, and unmet needs. Progress may be slow and nonlinear, but recovery is possible with consistent support,” says Jones.

While Raphael acknowledges that this work can be emotionally taxing, she believes clients struggling with addiction are “some of the best people in the world.”

“These clients are simply hurting and never had the support to teach them how to cope,” says Raphael. “Treat these clients like any other human being, not someone who is choosing to be an addict. Give them grace and liken them to a child hurting inside of an adult or adolescent body.”

While the intricacies of working with these clients can be complex, Jones and Raphael offer similar advice to their fellow counselors.

“Prioritize self-care, and remember that small victories, even a client simply showing up to a session or reducing their substance use slightly, are meaningful steps on their path to healing,” says Jones.
 

Heavyn Jones, MEd, NCC, is a mental health counselor dedicated to helping individuals manage the complexities of co-occurring disorders and heal from trauma. Jones obtained a master’s degree in mental health counseling from Lincoln Memorial University and currently practices at Mind Body Knox in Knoxville, Tennessee. Before transitioning to a private practice setting, she worked in a residential program for pregnant and mothering women with co-occurring disorders, an experience that deeply shaped her understanding of trauma-informed care.

Shakiema Raphael, MA, NCC, LMHC, LPC, QS, is a licensed counselor with over a decade of experience specializing in addiction treatment. Originally from St. Lucia, Raphael is licensed to practice in both Florida and Georgia and has been operating her own private practice for the past 5 years. She has a strong passion for trauma-focused therapy, recognizing its profound impact on individuals’ lives, and her mission is to help individuals realize their inner strength and capacity for meaningful change, regardless of their past experiences.

**Opinions and thoughts expressed in NBCC Visions Newsletter articles belong to the interviewees and do not necessarily reflect the opinions or practices of NBCC and Affiliates.