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Guide counselors on co-occurring issues

March 1, 2007
by Thomas G. Durham, PhD, LADC
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Clinical supervisors play a critical role of ensuring that addiction counselors are not only skilled at distinguishing between symptoms of a primary psychiatric illness and a primary substance use disorder, but also are able to determine whether these problems co-exist. Indeed, there is a growing awareness of the frequency with which psychiatric illnesses co-exist with substance use disorders. However, some counselors still lack an understanding of the interplay between substance use and mental illness.

Back in the 1970s, we often used to say that symptoms of what appeared to be a mental illness would disappear once the patient got sober. Although this was true for some, this stance seemed to serve more as a repudiation of the old stigmatizing notion that alcoholism and drug addiction were actually symptoms of a mental illness. However, our field may have overreacted to this by attempting to separate mental illness from substance use disorders, and as a result we ignored many of the symptoms that were in fact indicative of what we now consider a co-occurring disorder. Today, while we still find that the psychiatric symptoms presented by some patients at admission are drug-induced and hence disappear after a month or two of sobriety, these cases represent a relatively small number of those who appear to present with psychiatric symptoms.

There are various subgroups of those with co-occurring disorders. For an accurate diagnosis to be made, a counselor must be adept at knowing what signs to look for—and some of these may not be clearly evident until after the patient is clean for several weeks. This complicated process requires oversight and training by knowledgeable and experienced supervisors.

Understanding the subtypes

According to co-occurring disorders expert Kenneth Minkoff, individuals with co-occurring disorders account for a majority of patients seen in substance abuse treatment facilities.

1 Since most patients entering substance abuse treatment programs have symptoms of psychiatric illness at the time of admission, counselors must be adept at distinguishing among the characteristics of the three main subtypes of patients with co-occurring disorders: those who present with alcohol- or drug-related psychiatric symptoms (where the psychiatric symptom preceded the substance use); those who present with alcohol- or drug-induced psychiatric syndromes (where the substance use preceded the psychiatric symptoms); and those with comorbid alcohol/drug and psychiatric disorders (two primary diagnoses).


Thomas G. Durham, PhD, LADC

Counselors who are not prepared to distinguish substance abuse problems from psychiatric problems often treat patients with co-occurring disorders the same as they would those with a single diagnosis. Unfortunately, this lack of understanding often results in patients being bounced between psychiatric and chemical dependency services. During mental health treatment, it is common for patients with co-occurring disorders to be treated for their psychiatric disorder while the chemical dependency problem is ignored, and patients as a result may be prescribed potentially addictive drugs as part of their psychiatric care.

2 Conversely, patients treated solely for their substance use disorder often face an insurmountable task of remaining drug-free.

Unfortunately, many patients with co-occurring disorders tend to have trouble accepting the need for abstinence as a treatment goal—a complicating factor for treatment. These patients also appear to be at a higher risk for suicide compared to psychiatric patients with no substance use issues.2

New outlook

In some states, the single state authority for substance abuse treatment has either merged with or is working more closely with the state mental health authority. It is my hope that in the future, this will become more the norm than the exception. In the meantime, we must be more vigilant in the training and supervision of counselors in the nuances of co-occurring disorders. With the vast challenges inherent in diagnosing and treating patients with co-occurring disorders, supervisors must not only be knowledgeable about co-occurring disorders, they must continually bring to the forefront this knowledge and its application to the counselors they serve.

We have an ethical responsibility to see that all who deliver services are equipped to do an accurate job of diagnosing, treating, and referring each individual in order to individualize treatment—especially for people with co-occurring disorders.

Thomas G. Durham, PhD, LADC, is Executive Director of The Danya Institute in Silver Spring, Maryland, where he coordinates training programs including those delivered by the Central East Addiction Technology Transfer Center. His e-mail address is


  1. Minkoff K. Developing standards of care for individuals with co-occurring psychiatric and substance use disorders. Psychotherapy Theory Res Prac Train 2001; 52:597–99.
  2. Doweiko HE. Concepts of Chemical Dependency. Belmont, Calif.:Thomson Brooks-Cole; 2006.