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 good 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 undertrained 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.

© Copyright 2011 by Elvita Kondili, LPC. All Rights Reserved. Permission to publish granted to GoodTherapy.org.

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

  • Leave a Comment
  • Cole

    May 26th, 2011 at 11:37 PM

    Well,some countries have started treating addicts as victims and not criminals and it is best if the same policy is adopted everywhere.Labeling addicts as criminals is only going to make things even difficult for them.Also,treating them with care and compassion is bound to yield better results.

  • Jenna

    May 27th, 2011 at 4:35 AM

    My only problem with this is that I would hate for sufferers from addiction to now start self diagnosing and concluding that they also have some form of mental illness when this may or may not be the reality of their individual situation. I get it that more substance abuse counselors need to have more training in recognizing mental illness, but then you also have to train them that they may not be qualified to deal with every issue that comes out and seek more appropriate treatment for the client.

  • Michelle Mendoza

    May 27th, 2011 at 12:20 PM

    Finding a good counselor to help with personal problems isn’t as hard as some may think. They are highly educated on the subject, and are more than sympathetic.

  • Constantine

    May 27th, 2011 at 9:23 PM

    @Cole It’s a good thing in the US that absolutely no label can get you charged with a crime.

    I could be an alcoholic, a felon, and a thief and not get charged with a single crime because that’s known about me. It’s the actual events you get punished for, not having a label. (I’m not any of those, btw.)

  • sarah

    May 27th, 2011 at 11:49 PM

    what comes first-mental illness or addiction-is a question that is less important than the one as to how to treat both of these.

    to be honest I think it can happen in any order-it could be the mental illness or the addiction that comes first-different for different people.but what we need to understand is that both of these together present a very dangerous situation and the person would definitely need care and attention.we need to think of ways to have more people covered for safety under such circumstances.

  • Jarvis B.

    May 28th, 2011 at 12:41 AM

    @Cole. They need to decriminalize and legalize more drugs like cannabis and not throw kids in jail for having something that is no worse than the drugs that are already taxed, legalized and available at your friendly neighborhood pharmacy.

    Sometimes they get locked up for just being near drugs that they weren’t even aware were in the house. The ones that are true addicts are just as likely to re-offend once they get out of prison to feed their habit.

    Until drugs are legal, they will always be criminals.

  • Jane

    May 29th, 2011 at 5:37 AM

    If you need help with addiction then does it really matter which came first?

  • Huey Wallace

    May 29th, 2011 at 9:47 PM

    @Jenna-That’s why employers will ask for a doctor’s reference if you say you have such-and-such and they feel it’s going to be a problem or at least has the potential to be.

    Technically, isn’t an addiction a form of a mental illness? What would they tell them anyway?

    You can’t just say “Yeah I have a mental illness” without getting pursued for more details and you can’t hide it either when you fill in an application because that would be dishonest. It would also give them a legitimate reason to fire you.

  • Ellie

    May 30th, 2011 at 6:11 AM

    maybe those with mental illness are more predisposed to become addicted because it is their way of coping with the sickness that has overcome and overwhelmed them.

  • Elvita Kondili

    May 30th, 2011 at 10:47 AM

    Thank you all for your comments and for reading. I agree with you who questioned “does it really matter which came first?”, it’s a good point. It doesn’t, as long as both are treated. The only time it does matter is when understanding which came first helps you cope with your addiction better or helps you make sense of it.

  • C Dale

    August 2nd, 2018 at 2:38 AM

    Thank you for this very good article. I just googled the question and read two very unsatisfactory articles. Yours made sense! My daughter had a Dr refuse to treat her if she didn’t go to rehab first. She did go for the third time! And it turned out the Dr had never been told she had bipolar when she was fourteen! My daughter thought it was “sexier” to be in the program and less of a stigma than being mentally ill. It was a nightmare. And still is.

  • Lee S. Atkins

    June 4th, 2011 at 1:47 PM

    @Michelle– That might be true where you are, but such counselors aren’t distributed evenly across the country.

    Some places might not have one within a several hundred mile radius, meaning there’s no way to get the mental health care they need.

    Or they may have the kind Elvita is talking about that wants to stick with what they know rather than educating themselves. I think I’d prefer to have none.

  • Rebekah R.

    June 5th, 2011 at 1:27 PM

    If substance abuse can lead to mental illness or vice-versa, then why aren’t substance abuse counselors trained in spotting mental problems?

    Or are they ignoring them on purpose to suit their own agendas?

    Questions need to be asked. Thank you Elvita for the article.

  • Elvita Kondili

    June 8th, 2011 at 5:28 AM

    Thank you for your comments. @Rebekah – I don’t think substance abuse counselors do this on purpose or out of “secret” agendas. I think the issue comes from the education and training requirements to become a substance abuse counselor, for instance in most states you can have a certification in substance abuse counseling without having a master’s degree. I may be wrong here but I am not aware of a certification in mental health; to practice as a mental health (or professional) counselor you have to have a master’s and be licensed. To be fair some states do have license options for substance abuse counselors and very rigorous experience and training requirements but not all. Generally speaking, as a substance abuse counselor you are required to have training in counseling techniques and theory but often information on mental health is limited or non-existent. On a positive note things are changing largely due to SAMSHA’s (the Substance Abuse and Mental Health Administration) TIP publications (which are free) on co-occurring disorders and integrating mental health treatment in substance abuse treatment. Unfortunately, AA and NA and counselors who base their treatment philosophy largely on 12 step recovery program are slow to catch on (if not outright resistant).

  • Elvita Kondili

    June 8th, 2011 at 5:39 AM

    @ Huey-I understand your concern. Somehow it’s OK to have a mental illness but not OK to have a substance abuse disorder. Regardless, a professional, at some point gave you a diagnosis which comes from DSM-IV -Diagnostic and Statistical Manual of Mental Disorders which has separate categories for mental health, substance abuse, personality disorders, developmental disabilities and so on. So the separation may have come from there as well. However I have a feeling we, as a society, judge depression as an illness and alcoholism as a choice. We could have a long discussion as to why but ultimately that’s where education comes in.

  • Elvita Kondili

    June 8th, 2011 at 5:50 AM

    @ Cole- agreed! Great point!

    @ Jenna – absolutely, you make an excellent point. Thank you for reminding me that as counselors we can not possibly be good at treating everything and should refer people out to experts who can. However, this doesn’t mean we shouldn’t be able to identify issues and view our clients in their complexity. And if we don’t know what to look for, then how can we identify issues that may be detrimental to someone’s success?

  • taylor walden

    June 13th, 2011 at 1:29 AM

    It’s hard to say which should be treated first, but I think the substance abuse needs to be resolved before anything else. My reason being that you can keep people away from drugs, but you can’t take away their mental problems as easily. I’m a layman though so what do I know. :) Just thinking aloud.

    Elvita, thank you for the terrific energy you put into this article and your replies to the comments! It’s very helpful and interesting.

  • Oeuf-er It

    May 12th, 2016 at 8:42 AM

    I am just a shell of my former self. I am cracking under tons of pressure, feeling like I’m going to break every day. My thoughts are scrambled, and I can’t look at anything with a sunny side up these days. My temper boils hard at the slightest trigger. My anxiety these days is no yolking matter. My rival coworker is beating me at every turn, and I’m afraid he’ll end up taking the cake. If you have any advice to give, it would be eggcellent.

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  • Tara

    January 30th, 2023 at 2:25 PM

    Thanks for this great article. I’m a psych RN who struggles with my own mental health issues (though not addiction to substances). I discovered my CPTSD on my own at age 55 (when therapists, psychologists, medical doctors and psychiatrists had misdiagnosed me for years). My understanding is that addiction IS a mental illness – we call it Substance Use Disorder if the addiction is to a substance. I truly believe that it is the 12-step mentality that pervades our culture that has well-educated practitioners continuing to treat people with addiction differently. Our system is very, very broken and those with the power to fix it aren’t interested. Looking at the work of Gabor Maté and Pete Walker, I believe virtually all mental illness (including all addictions) are the result of complex trauma… and keep in mind that the trauma doesn’t need to be that bad to be THAT BAD for someone who has experienced it over years.

    For recovery/healing/getting better (whatever you want to call it), we need to start treat the root cause of the problem (undiagnosed complex trauma) instead of encouraging people to bypass their pain by trying to slap bandaids on gaping wounds. We’re doing it all wrong. We’ve been doing it all wrong for over 80s years. We really should know better by now!

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