"This would be so much easier if he was just a regular old, garden-variety drunk!" she says, covering her eyes as if trying to contain the thoughts swirling in her head.
She's a middle-aged mom in my office, overwhelmed by the challenge of navigating her adult son's complex issues. She continues, "Setting boundaries wouldn't feel so confusing if I knew his drinking was just 'bad behavior.' But he's always struggled with life!"
Let me note here: when a parent is envious of the idea that her child might be dealing with only alcoholism—something that would devastate most parents on its own—we know the situation must feel dire.
What does dual diagnosis mean for families?
In addiction treatment, dual diagnosis, also known as co-occurring disorders, traditionally refers to having both a substance use disorder and another mental health condition, such as depression, anxiety, bipolar disorder, eating disorders, post-traumatic stress disorder, or borderline personality disorder. For families trying to determine how to respond to these overlapping challenges, the situation can become incredibly confusing.
Substance use alone can leave families questioning everything:
"My wife says she's sober, but I can tell she's not herself. Is she lying again?"
"I'm afraid my grandson is using the gas money I give him to buy meth."
When another mental health condition is also in the picture, the uncertainty can feel even greater:
"Our son is already battling depression and seems so fragile. How can we confront him about not paying this month's rent? We're terrified that the next thing will push him over the edge."
"I know our daughter is using drugs to self-medicate her anxiety. Without that Xanax, I'm not sure she'd ever get out the door to work!"
Families often struggle to distinguish between helping and enabling. They walk a fragile tightrope, afraid of triggering another crisis, worsening their loved one's emotional state, or ending up at the emergency room. The result is often paralysis. No sudden moves. Walk on eggshells. Hope today goes better than yesterday.
I call this Low-Beams Thinking. Imagine driving down a winding country road at night with only your low beams on. You can see what's immediately ahead, but not the larger landscape. All you can hope is that you can react quickly enough when the next obstacle appears.
Dual diagnosis can push families into this reactive existence, but it doesn't have to define their lives. What if we switched to High-Beams Thinking? What might we see if we could look beyond the next crisis and take in the bigger picture?
Here are five things I want families to understand.
1. Be Reassured: You Are Not Responsible for Diagnosing Your Loved One
It's tempting to try to explain our loved one's behavior by assigning a diagnosis. Anyone who has raised a toddler or teenager understands the impulse to diagnose their kid with "This-Can't-Be-Normal-Disorder!"
When families come to see me about an addicted loved one, I often hear descriptions like, "He is SO bipolar!" Their loved one may indeed have bipolar disorder. But often, the family is simply trying to communicate how unpredictably their loved one's moods can fluctuate.
Family observations can be incredibly valuable. People struggling with addiction may not always report the full scope of their situation accurately, for a variety of reasons. Those closest to them may notice important changes in behavior, mood, and functioning. Your role is to share your observations and experiences, when appropriate.
It is the job of clinical professionals to distinguish which behaviors are caused by substance use versus underlying mental health conditions. In doing so, they will likely consider personal and family history, patterns of functioning, medical variables, and specific diagnostic criteria.
You may know your loved one better than anyone, but you don't have to carry the burden of having all the answers.
2. Labels Aren't Always Helpful
We live in a highly medicalized society. Healthcare systems and insurance companies often require a diagnostic code just to get through the door. But mental health diagnoses are not always as straightforward as identifying an infection through bloodwork or a fracture through imaging. A mental health diagnosis groups symptoms that tend to occur together. Although these labels can guide treatment, diagnosing is not always an exact science.
If your loved one has attended multiple treatment programs, you may have heard different professionals suggest different diagnoses: "This therapist thinks it's bipolar disorder, but the last one thought it might be borderline personality disorder." That inconsistency can leave families confused and questioning, "So what's the path forward?"
I understand both the value and the limitations of diagnostic labels personally. In my early twenties, after a year of feeling paralyzed, terrified, and convinced I might die, a clinician identified my symptoms as a panic disorder. The diagnosis brought everything into focus. I felt validated, and finally hopeful that relief was available. In my case, it was empowering.
In other circumstances, however, labels can create shame, fear, or even doom. And when substance use is also involved, it can feel like a messy ball of wax. The truth is, until substances are removed from the equation, it's quite difficult to tell underlying mental health conditions from intoxication, withdrawal, or complications from addiction.
The goal isn't to dismiss diagnoses. It's to recognize that a label can be useful without telling the whole story. While uncertainty is hard, it can be helpful to make space for some diagnostic uncertainty as the different pieces of the story come together.
3. Treating Substance Use Often Comes First
Families may understandably sympathize with the reasoning behind a loved one's reluctance to stop using: "I'll get sober once I feel better."
Perhaps you've watched them suffer and believe they are using substances to manage emotional pain. That pain deserves attention. But substance use can mimic or intensify mental illness.
In many cases, a more effective treatment progression is to:
Stabilize substance use. Establish abstinence when possible (with medical supervision when withdrawal could be dangerous).
Assess symptoms during recovery. Determine what difficulties persist once substances are no longer driving or distorting the picture.
Develop coping skills and address symptoms. Help the person develop alternative resources to cope with emotional distress.
Explore underlying causes. Once the person has sufficient stability and support, treatment can then address issues such as trauma.
Think of drugs and alcohol as a funhouse mirror. They distort the image, making it difficult to see how someone is actually feeling or functioning. Removing that distortion helps clinicians establish a clearer baseline. Sometimes symptoms that initially appear to indicate a separate mental health disorder improve significantly with sobriety. Other times, they persist and require ongoing treatment. It can take weeks or months to understand the difference.
This is why abstinence or stabilization is often an early treatment goal. However, it doesn't mean mental health care must be put on hold. Many treatment programs address addiction and co-occurring conditions simultaneously through an integrated approach that may include cognitive and behavioral therapies, medication when appropriate, and other supportive interventions.
The key is to match treatment to the person's needs and level of stability. For example, if we dive deeply into trauma work before someone has adequate coping skills, a safe environment, and support for maintaining recovery, this may increase distress and make relapse more likely.
Treating addiction and mental health together requires thoughtful timing, not an either-or approach. Emotional pain matters, but recovery also requires addressing the substance use that may be contributing to it.
Please note: While it's important to educate yourself about effective treatment approaches, we can't always control our loved one's readiness for the type of treatment we wish them to pursue.
4. Suicidal Statements Are Not All the Same—and It's Not Your Job to Figure Out the Risk Alone
When dual diagnosis is present, families may hear words that send a chill down their spine: "I want to kill myself." "I don't want to live anymore." These statements can leave family members terrified and uncertain. Do they mean it? Do they feel this hopeless? Are they saying this for attention? What if we make the wrong decision?
Suicidal statements are alarming and must be taken seriously, but they don't have to hold you hostage. We want to shift from one mindset to the other:
We don't want: "I can't ever say or do the wrong thing, set a boundary, or take care of myself for fear I will cause them to kill themselves."
We want: "I need to know how to respond appropriately, lovingly, and seriously to these comments."
Having the right tools can help us respond with greater confidence and competence.
It's important to understand that people in distress don't always have the words to communicate precisely what they're experiencing. Statements about not wanting to live can reflect a wide range of suicidal thinking. For example, "I want to kill myself" might mean:
"I'm overwhelmed and using strong words to express how upset I am."
"I sometimes think life is too much, but I don't intend to act on those thoughts."
"I wish I wouldn't wake up, but I don't plan to do anything to make that happen."
"I've considered suicide and may act on these thoughts."
"I intend to kill myself and have a plan."
The above is not a reliable multiple-choice assessment or a guarantee of safety. Every suicidal statement should be taken seriously, and level of risk can change over time. However, it does illustrate that immediate risk can vary significantly—and even someone in distress may struggle to understand or communicate exactly what they're thinking.
Rather than panicking or trying to determine on your own whether your loved one is in serious danger, respond calmly and directly.
First, acknowledge what they've said. You might say, "Those are serious words, and I care about you. I want to understand what you're feeling."
Next, ask directly about their safety. Ask whether they're thinking about suicide, whether they have a plan, and whether they intend to act on it. You don't need to avoid the subject out of fear that asking will introduce the idea. You're showing that you care and giving them an opportunity to clarify what they're thinking and feeling.
Finally, involve professional support when needed. If they express suicidal intent, have a plan, cannot commit to safety, or are too distressed to answer clearly, don't try to manage the situation alone. Contact emergency services or a crisis team, or seek an emergency evaluation. In the United States, you can also call or text 988 for crisis support. If danger is imminent, call 911.
Your responsibility is to respond with care and seek appropriate support—not to become the sole judge of whether a suicidal statement is genuine, manipulative, or dangerous.
5. Love Is Unconditional, but Tolerance Doesn't Have to Be
Families often begin conversations in my office by saying, "You have to understand, our situation is unique." And they're right. Their loved one's circumstances may be exceptionally complicated. Perhaps a childhood traumatic brain injury affects impulse control or emotional regulation. Perhaps they're struggling with depression after cancer treatment or carrying the effects of significant trauma.
Rarely do I encounter a situation that feels entirely straightforward. With addiction, complexity is often the rule rather than the exception. And when mental health conditions aren't part of the picture, something else often contributes to the tangled web—conflict within the family, financial obstacles, or cultural pressures.
Perhaps life would feel simpler if our loved one were just a one-dimensional character (the village drunk from an old folk tale) who was easy to blame and distance ourselves from. But instead, our loved one is someone whose story we understand, empathize with, and are invested in.
Let's return to the middle-aged mom who began our story. She is juggling her need for boundaries, her desire not to enable, and her empathy for her son's inner battles. She's terrified she won't strike the balance just right! Here is the peace I wish for her—and every family facing these challenges—to find.
If complexity is the rule, we must learn to live within it. Addiction and mental health conditions can be chronic, involve periods of relapse, and affect the entire family. Understanding these realities can help us shift from trying to fix our loved one to learning to ebb and flow with the tides. We can appreciate the peaceful moments while developing skills to navigate the harder ones. Building those skills is the heart of what we work on together in Empowering Families That Face Addiction, my private online course for families.
Understanding someone's struggles doesn't mean accepting behavior that disregards our own needs and rights. We can empathize with their pain without accommodating every demand. We can support their recovery without working harder at it than they do. We can love someone without allowing their illness to run the show.
When our loved one has faced hardship in life, we may carry sadness for them, guilt about our role along the way, or fear for what their future may hold. These emotions can sometimes drive justification:
"I can do this one more thing for him to help him get back on track."
"She can't help taking it out on me; I'm the only person she feels safe with."
But when we put the High Beams on, we can also see this: This is your life too.
Don't lose sight of the fact that your needs matter too. Your peace matters too. Your hobbies, friendships, career, and wellbeing matter too. Not more than theirs, but as much.
If you mold yourself to fit their illness, you lose your own shape. You also may not be empowering them to navigate a world that won't always mold itself to them when you're not around.
Not sure which patterns are keeping your family in Low-Beams Thinking? My free 15-minute mini-session walks you through the "co-addiction stew," the four predictable ingredients that pull loving families off course, so you can start to see the bigger picture in your own home.
This post is educational and isn't a substitute for therapy or a mental health evaluation. For guidance specific to your situation, please talk with a licensed professional in your area. If someone's life is at risk, call 911, or call or text 988.