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A Counselor’s Perspective: Dual Diagnosis

A Counselor’s Perspective: Dual Diagnosis

We’ve all either performed or reviewed client initial screenings, biopsychosocial assessments, and doctor’s coordination of care notes. And we see it too—clients show up for substance use disorder (SUD) treatment and frequently report mental health disorders (both real and imagined!) and often symptoms are observable in the milieu. Sure, coming down from drugs can make anyone anxious and depressed, the two disorders seemingly most often reported, and of course there’s the drive to combat these disorders with substances. In early treatment it looks sort of like the chicken or the egg scenario. Hopefully we’re mindful and certainly we ought to be connecting our clients to services to treat both the mental health as well as chemical dependency issues they present with.


At my facility every client is connected with a psychiatrist in the very early stages of treatment, regardless of whether they admit through the residential or outpatient sides of the facility. Not only do we believe this is good case management and appropriate care, we see the client experiencing a marked improvement in both engagement and retention in the event a mental health component is diagnosed and managed effectively.


Now, you may be thinking this is all pretty elementary stuff, and on the surface I’d agree with you with two caveats. The first is this: if it is all so elementary, why isn’t every single facility, without exception, connecting every client to mental health services for evaluation and treatment? Of the facilities I’ve worked for, my current one is the only facility that makes this effort with every client we see. This leads to the second caveat: why is it that for such a pervasive condition, 92.3 percent of dually-diagnosed adults are not getting treatment for both disorders (SAMHSA, 2012)? 


I thought I knew a little something about the subject, however when I was asked to write this article and began to do some background research, I was shocked at what I found. As a solutions-based field it’s important for us to take a look at the problem. However, it’s even more important to make a decision to do something about it. Let’s take a look at the problem first.


According to SAMHSA, and using 2010 numbers, 20.3 million adults had a SUD and of those 9.2 million (just over 45 percent) also had a mental health disorder (2012). Think about that for a minute. In 2010 there were just over nine million adults in our country walking around with concurrent disorders and the accompanying potentially dire consequences.


Now, it would be nice to think that each of these folks will encounter services at some point. Unfortunately that’s far from true; significant barriers to help still remain. Only 7.7 percent of dually-diagnosed clients received treatment for both their SUD and mental health disorders and 55.6 percent received no treatment whatsoever (SAMHSA, 2012). Finally, 33.6 percent of dually-diagnosed adults only receive mental health treatment, which means 89.2 percent of dually-diagnosed adults don’t receive the chemical dependency treatment they vitally need. And we get asked why relapse is so common?  


So what’s the solution? I say the solution is well rooted in our responsibility to our clients. If you’re reading this, you’re probably essential to that solution. Remember, just less than half the people in treatment facilities have both a SUD and mental health disorder. If a corresponding number of clients are not receiving focused mental health care in addition to the chemical dependency services the facilities provide, failure is looming large. Unfortunately for our clients, failure is potentially fatal.


Whatever role I play for my facility, in my heart I am a drug and alcohol counselor. I know how difficult case management is, I am all too familiar with client resistance, and managing time effectively is something I think we all struggle with. I get that it’s harder to coordinate care with referral sources, and I understand that managing two aspects of the same case—along with all the other collateral damage the client has created for themselves—is a tremendous drain on resources. Still, we need to look at why we got into this field in the first place.
As chemical dependency professionals we have pledged ourselves to work diligently to create and support change in our clients; change that is consistent with living a happy, healthy, and productive life. Why on earth would we do half a job in the process? Wouldn’t that be wasting our time in addition to doing the client a huge disservice? We signed up for “this,” and by “this” I mean all of it. It’s our responsibility to turn over every stone, to pull out every stop, and to exhaust every resource in the course of serving our clients.


If you’re not sure how to go about doing this, please seek supervision in your facility. If your supervisor is not sure, please reach out further. CCAPP would be a great resource, and SAMHSA is another. Additionally, take it upon yourself to reach out to mental health professionals in your area. They will be happy to help and your clients will benefit greatly for your efforts.




Substance Abuse and Mental Health Services Administration (SAMHSA). (2012). Results from the 2010 national survey on drug use and health: Mental health findings. Retrieved from http://archive.samhsa.gov/data/NSDUH/2k10MH_Findings/2k10MHResults.htm