Dual diagnosis: When mental health and addiction collide

By Dan Wolf, Houghton House Director and psychologist specialising in substance abuse and addiction issues. This is an adaptation of an article Dan wrote that was first published in the October 2025 issue of Dischem’s Better magazine.

Understanding dual diagnosis

Addiction and psychiatric conditions tend to go hand-in-hand. Understanding and accepting this key truth — what we call “dual diagnosis” — is the first step toward recovery and a life free from addiction. 

Here’s a scenario I’ve seen play out many times: a patient comes into our rehabilitation facility surrounded by friends or family who are worried about their substance abuse or addiction problem, only to learn that’s only half the story. As it turns out, the patient also has an underlying psychiatric condition, such as depression or bipolar disorder. 

Naturally, this dual diagnosis interacts with their addiction. In many cases, addiction is rooted in the patient using substances as a means of self-medicating their mental health issues. Individuals with emotional regulation issues frequently use substance abuse as a (maladaptive) coping mechanism when life gets overwhelming.

I’m often asked whether the addiction or the mental health condition comes first. My answer is that the person comes first, meaning that we need to examine these problems holistically and address them concurrently. Ultimately, it doesn’t really matter which problem came first — both must be addressed. 

Neither the care team nor the person affected must focus on only addressing one of the two issues. Overlooking one half of the equation tends to prolong the recovery journey considerably.  

Unfortunately, dual diagnosis is a widespread problem. Research shows that around half of individuals with a mental health condition also struggle with addiction. In my personal experience of running a dual diagnosis unit for the past 30 years, almost all our patients have some level of both. It’s exceedingly rare that someone is struggling only with their addiction to a substance.

The dual diagnosis treatment process

While there are various approaches to treating dual diagnoses, we’ve found that it’s best to address both diagnoses simultaneously.

Evaluation and diagnosis

A psychiatrist typically issues a dual diagnosis, often with the assistance of an addiction support team. Getting an accurate diagnosis can be tricky when the patient is an active drug or alcohol user or in the process of withdrawal. Both the effects of the substance and withdrawal effects can temporarily mimic serious psychiatric conditions. 

Treatment plan and detox (if needed)

Armed with a provisional diagnosis, the care team spearheads a treatment plan for the patient, taking both diagnoses into account. Initially, it may be necessary to use a medical detox or replacement therapy. This helps us get someone off drugs or substances and through the worst of the withdrawal stage. 

Medication management

Targeted drugs for psychiatric conditions will likely be needed to stabilise the patient and then maintain that stability in the long term. The care team works to ensure that all the interventions work together safely and well, since some medications are not a good fit for addicts of certain substances. 

Abstinence, addiction counselling, and psychotherapy

The core principle of most addiction treatment strategies is abstinence. This basically means keeping the person away from the substance or habit, as far as is reasonable. This might take the form of individual and group therapy, or a 12-step programme like Alcoholics Anonymous or Narcotics Anonymous.

At the same time, we integrate psychiatric and psychological care for the patient’s mental health condition into their recovery plan. 

Ultimately, one wants to integrate the individual into a culture of recovery informed by a psychiatric perspective that considers the patient’s long-term mental health as a whole. 

Accountability and relapse prevention

Treatment for a dual diagnosis like this is usually not a once-off process. Many, many people relapse at least once. 

Lasting recovery requires developing a certain capacity for tolerating discomfort and honouring your commitments. You may need to drastically change your ways of thinking and acting to sustain your recovery. 

This can be challenging for many people. 

Accepting responsibility

We encourage people to adopt personal responsibility in their lives and do the work to move from a state of dependence to one of independence or interdependence. 

We encourage patients to take responsibility for the position they find themselves in, rather than blaming their problems on other people or their environment. While there are often contributing factors beyond the individual’s control in their addiction story, taking ownership is a key part of recovery.

Community support

Accepting responsibility for your problems doesn’t mean you have to face them alone. In fact, finding appropriate support and asking for that help is a key part of recovery. 

Part of taking responsibility is learning to recognise and accept what you can and can’t do on your own. 

We often see a fierce resistance to the kind of vulnerability required to admit you need help and support. However, this resistance can be overcome with therapy and ongoing support.

Through challenges to recovery 

Accepting that you or someone you love has a substance use disorder can be tough, and a dual diagnosis even more so.  The process contains some significant challenges that are helpful to be aware of. 

Firstly, confronting the issue and being prepared to have a direct conversation about it may be immensely difficult for many people. The person may be resistant and insist they don’t have a problem. It can help to insist that they agree to at least undergo a professional assessment to ‘prove’ it.

Secondly, whatever support and intervention a dual diagnosis patient may need, help is available. There are inpatient and outpatient rehabilitation programmes available in South Africa, many of which are covered by medical aid. Many non-profit organisations also offer free support.

In many cases, the patient (or their loved ones) struggles to take responsibility for their recovery and treatment journey. There are many resources and opportunities for recovery, but at the end of the day, the buck stops with you. 

It’s likely that somewhere along the line, the patient might relapse or regress. This is where having a sophisticated and multi-faceted care team and support network can be really helpful. 

Ultimately, it’s possible to overcome all of these challenges. I’ve seen many successful cases where patients with dual diagnoses effectively manage their conditions in the long term. They adopt an attitude of recovery and independence that changes their lives in a meaningful way.

Receiving a dual diagnosis may seem scary and complicated, but we’ve been privileged to witness many success stories at Houghton House.