A “Chicken or the Egg” Dilemma: Mental Illness and Addiction

I was very young when I knew I wanted to be a therapist. I became particularly interested in depression and how people deal with traumatic events. Never in a million years did I think I would be an addiction expert. After my graduate studies I took an internship at a substance abuse outpatient center. This was purely by chance and because they had a reputation for offering really good supervision. During my internship it quickly became clear to me that my graduate program in mental health had left me ill prepared to work with substance abuse issues. I kept screening for mental health symptoms because that’s what I knew and we tend to go where we feel comfortable.

Substance abuse counselors on the other hand are often under-trained in mental illness and tend to ignore or dismiss signs of it, thinking once the drugs are out of someone’s life they will get back to normal functioning. And when they don’t they blame the clients “for resisting happiness” or being “chronic complainers”.  We fail to recognize that sometimes, even after drugs and alcohol are long gone, people struggle with what could have been there all along: mental illness.

The coexistence of mental illness and substance abuse disorders is now known as dual diagnosis or co-occurring disorders. Best practice tells us to treat both simultaneously. Yet the separation still persists. I don’t know where the separation between mental health and substance abuse treatment came from. If I were to guess it would be payment sources. I also believe the counseling field has a tendency to take sides; “mental illness is more important, if you don’t treat it right, the client is at high risk for relapse” or “substance abuse is the key issue, if one stops using drugs, there will be no mental illness to treat”. Funny thing is, these statements are both true and could both be untrue for some people. In this “competition” no one really wins. Our clients are the ones who lose in the end if we fail to recognize the complexity of their suffering.

So here I was, an inexperienced intern thrown into the unknown. My clients often feel like I felt when faced with their issues. Confused, lost, and frightened, trying to make sense of what experts say is “wrong” with them. Most of our clients don’t care about diagnosis. They just want to know that they will get better. But they often get too caught up in a Chicken or the Egg dilemma. Because there it was, a parade of undiagnosed or untreated mental health issues, streaming down dressed up in drug withdrawal symptoms posing one unavoidable question: which came first? Did mental illness go untreated for so long that these people started to “medicate” it with alcohol and drugs? Was this the reason why people who had suffered from ADHD or bipolar as youth, had an affinity for stimulants such as meth or cocaine? Was this the reason kids who suffered from social phobia figured out drinking could make socializing possible? Was this the reason why people who were depressed or suffered from panic attacks (or PTSD) particularly liked opiates or benzodiazepines (which are often prescribed to treat anxiety but are highly addictive)? And on the other hand, had years of substance use and abuse, significantly and sometimes permanently, altered one’s brain chemistry to the point of “producing” depression, panic, OCD, etc, etc?

I’m fully aware that this is too simplistic of a view. After all, the correlation between mental illness and substance abuse still remains somewhat of a mystery. Further more, correlation does not mean casualty. I’m not interested in trying to figure this mystery out. I’m in the business of treating individuals in their complexity and this piece is a reminder to professionals and clients to not ignore something just because they don’t know about it or even worse “don’t believe” in it. We need to spread awareness and education for our clients so they can understand themselves better, gain insight into their issues, find hope in knowing what to expect and power in planning for success. We need professionals to ask the right questions and pay attention when client speak their truths. We need people who are willing to get educated in the unknown. We never stop learning. No matter how many degrees we have collected or years of experience we have in the field.

If you are struggling with addiction but wonder if mental illness was there all along and is waiting in silence to jeopardize your recovery, I want you to know, help is out there for you. Find a counselor or a doctor who understands both addiction and mental illness and is willing to create an individualized treatment plan that will maximize your chances of success.

You can also read here http://www.goodtherapy.org/blog/comorbid-mental-illness-addiction/


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