Co-Occuring Disorders in Addiction Counseling

Instructor: Jennie Lannette

Jennie is a therapist and licensed clinical social worker with a master's degree in social work.

When someone has both a substance abuse problem and another type of mental illness, it's called a co-occurring disorder. Treating both of the illnesses together is shown to be most effective for long term results. This lesson will describe co-occurring disorders, ways to screen for common mental illness that can occur, and some of the most common treatment options.

What Does Co-occurring Mean?

Have you ever had the misfortune to have two illnesses at the same time? Maybe you had bronchitis and then came down with the flu. Or maybe you have a family member with both diabetes and high blood pressure. You can see where one illness may complicate or worsen the other. That's similar to what happens with co-occurring disorders. Co-occurring disorders happen when someone has both a substance abuse diagnosis and another mental health issue like depression. This may also be referred to as a dual diagnosis.

These diagnoses can have tricky relationships with each other. For example, someone may develop a substance abuse disorder first, such as an addiction to opioids (like pain pills or heroin). Because of the mental and physical effects on the body and brain over time, plus all of the life complications of an addiction, that person may then start to develop depression and anxiety disorders as well.

Likewise, someone may have post-traumatic stress disorder that was never diagnosed or treated properly, and then start depending on alcohol to control the symptoms. This is understandable, and may even be effective in the short-term. But over time this almost always makes things worse since it then leaves the person with yet another struggle to deal with.

People who have a mental illness are also more vulnerable to developing a substance abuse problem. Sometimes this is referred to as self-medicating. Among the most common disorders to occur in substance abuse treatment are major depressive disorder, general anxiety disorder, and post-traumatic stress disorder.

The most common signs of depression are decreased interest in daily activities, a change in sleep and eating patterns, self-isolation, and thoughts of shame and self-blame. A short standard screening test called the PHQ-9 (or patient health questionnaire-9) can be used as a beginning screen for depression.

Major signs of general anxiety include nervousness, worrying about different things, and a feeling of doom -- like something horrible could happen at any moment. Another scale called the GAD-7 (or General Anxiety Disorder-7) can be used to check for this condition.

General anxiety is often confused with a different anxiety disorder called post-traumatic stress disorder (known as PTSD). Signs of this can include both depression and anxiety symptoms, along with exposure to a traumatic event that the client likely tries to avoid thinking about. Anxiety symptoms can be even more severe with PTSD, and the client might have flashbacks, nightmares, and intrusive memories of the traumatic event. One commonly used screen for PTSD is the PCL-5 (or PTSD Checklist for DSM-5).

Treatment Options

As you can see, these conditions can make it very difficult to manage everyday life and may easily complicate or worsen a substance abuse disorder. It's generally recommended that substance abuse and mental health issues be treated together because of their complicated relationship. Fortunately, there are several standard treatments that are helpful for multiple conditions.

Cognitive Behavioral Therapy (CBT)

Variations of cognitive behavioral therapy, or CBT, have been shown to help with a variety of mental illnesses as well as substance abuse issues. CBT is particularly effective for depression and anxiety disorders. Therapy can be delivered in individual, family, or group sessions. A few types of CBT therapies are specific for PTSD as well, such as prolonged exposure and cognitive processing therapy.

Motivational Interviewing

Motivational interviewing is a technique to help clients identify their goals and take steps to achieve them, without feeling overwhelmed or too pressured. It's often used for substance abuse and other mental health conditions. It can be combined with a variety of other treatments as well.


Medication is sometimes recommended for more severe mental health disorders, especially for those who have a strong biological cause such as schizophrenia or bipolar disorders. Counselors typically work in conjunction with a physician when clients need medication, usually working alongside a psychiatrist who specializes in mental health medications.

Medications are also sometimes used to compliment counseling in substance abuse treatment. For example, there are pills that can decrease the urge to drink, or help clients gradually wean themselves off pills. Most doctors require clients to also participate in counseling while taking these medications. Sometimes supervised detox is necessary for a few days to help clients quit highly addictive substances in a safe environment.

Support Groups

Traditionally, counselors and legal systems have suggested or even required clients to participate in 12-step groups such as Alcoholics Anonymous while they get mental health treatment. Others feel this takes away from the voluntary nature of these groups and don't believe clients should be pressured to join them. However, 12-step groups are often abundant and free when mental health treatment may be more difficult to access.

Considerations For Providers

It's helpful for therapists to have training in and a basic understanding of a variety of mental health conditions, as well as an understanding of the differences in substances. Clients struggling with benzodiazepines will have a very different experience than those quitting meth, for example.

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