Navigating the Complexity of Dual Diagnosis in Outpatient Settings

Mental health professionals are increasingly encountering clients with co-occurring mental health and substance use disorders—what is commonly referred to as dual diagnosis. Yet despite the frequency of this presentation, many clinicians remain underprepared to manage the complexity it brings. In a compelling and deeply personal webinar, psychologist Dr. Dennis Ortman sheds light on this challenge, offering both statistical insight and clinical wisdom drawn from decades of experience.

Understanding Dual Diagnosis

Dr. Ortman’s journey from Catholic priest to clinical psychologist has given him a unique lens through which to view suffering, transformation, and healing. Raised in an alcoholic family, and shaped by his own work with Al-Anon and the Adult Children of Alcoholics program, Ortman has long recognized the deep, often overlooked link between psychological wounds and substance use.

His introduction to the dual diagnosis population began during his clinical training in the 1990s. His first patient was a young woman struggling with depression and marijuana abuse. Ortman’s supervisor at the time, like many in the mental health field, assumed that treating the depression would cause the substance use to resolve itself. It didn’t. That experience launched Ortman’s lifelong exploration of dual diagnosis and how to address it more effectively—especially in outpatient care.

The Scope of the Problem

Citing the landmark Epidemiologic Catchment Area (ECA) study from the 1980s, Ortman emphasizes just how widespread dual diagnosis truly is:

Nearly 25% of those with anxiety disorders also have substance use issues
About 33% of individuals with mood disorders also struggle with substance abuse
60% of people with bipolar disorder have a co-occurring substance use disorder
47% of individuals with schizophrenia experience both

Additional research suggests that among people with mental illness, 29% will also experience substance abuse—nearly triple the rate in the general population. Among those with drug problems, more than half also meet criteria for a psychiatric condition.

And yet, despite these numbers, dual diagnosis continues to be poorly addressed in many treatment environments. As Ortman explains, “It often goes ignored.”

Diagnostic and Treatment Challenges

One of the most profound challenges with dual diagnosis lies in accurate assessment. Substance use can mimic or mask psychiatric symptoms. Cocaine users may appear manic, individuals coming off benzodiazepines may present with panic symptoms, and marijuana users can exhibit psychotic features. Clinicians must learn to ask: Is this a true psychiatric disorder—or is it substance-induced?

Another complicating factor is non-compliance. Clients with dual diagnosis are more prone to relapse and may engage in what Ortman calls the “shell game” of switching substances—alcohol, marijuana, prescription pills—to regulate their mood or escape distress. Without treating both disorders concurrently and integratively, progress is often limited or entirely stalled.

Further, these clients often utilize more healthcare services. They bounce between providers, programs, and emergency rooms in a cycle of partial treatment and recurring crisis. This “revolving door” is a direct result of fragmented care and a lack of integration between mental health and addiction services.

Clinician Barriers and Blind Spots

Dr. Ortman doesn’t shy away from highlighting how therapists themselves may unintentionally contribute to the problem. One of the most overlooked barriers is denial within the helping professions. Studies show that substance use among therapists is higher than in the general population, yet many professionals are reluctant to confront it in themselves—or their clients.

Another obstacle is training. Most graduate psychology programs offer minimal instruction on addiction, often treating it as secondary to mental health conditions. This separation is mirrored institutionally, with federal agencies like the National Institute of Mental Health and the National Institute on Drug Abuse operating independently of one another. The result? An artificial divide in how clinicians are trained and how services are delivered.

Moreover, treatment models themselves can be at odds. The substance abuse field often adopts a disease model emphasizing abstinence and confrontation, while the mental health field tends to use a biopsychosocial approach grounded in empathy, insight, and incremental change. These differing philosophies can lead to confusion and inconsistency, particularly when clients move between providers with differing treatment orientations.

Who Are the Dually Diagnosed?

Ortman categorizes clients with dual diagnosis into three broad groups:

The Wounded – Often dealing with anxiety or depression, these clients self-medicate with substances like alcohol, marijuana, or prescription drugs. They are the “walking wounded” commonly seen in outpatient therapy.
The Crippled – Clients with personality disorders, particularly borderline or narcissistic traits, often use substances to cope with early trauma or chronic emotional dysregulation. These cases tend to be more entrenched and may require long-term, structured therapy.
The Disabled – Individuals with severe mental illness (e.g., schizophrenia, bipolar disorder) who also have substance use issues. Although prominent in the literature, these cases are less commonly seen in standard outpatient practice and often require multidisciplinary care.

Importantly, Ortman warns against underestimating substances like marijuana, which can cause long-term psychotic symptoms and stunt emotional development, especially when use begins in adolescence. Many clients become “emotionally arrested” at the age they began using, lacking the internal resources needed for adult responsibilities.

Toward Integrated Treatment

What’s the path forward for mental health professionals? Dr. Ortman’s insights point toward integration, not fragmentation:

Acknowledge and assess for both disorders early
Recognize substance use as both a symptom and a disorder in itself
Work collaboratively across disciplines and treatment philosophies
Develop your own self-awareness around enabling behavior, blind spots, or discomfort discussing substance use

Perhaps most importantly, therapists must be willing to stay with the discomfort of slow progress and relapse. Recovery for these clients is rarely linear. It requires a stable, compassionate, and informed clinician who sees the full person—not just the diagnosis.