We recently interviewed Daniel*, Dual Diagnosis Lead, and Marissa*, Social Worker at an NHS APA member trust, to explore more about stigma in the context of co-occurring conditions, as part of our Stigma Kills campaign.
What are co-occurring conditions?
Co-occurring conditions (also known as dual diagnosis) refer to when someone experiences both mental health conditions and addiction at the same time. They’re relatively common - research published in 2019 shows that mental health conditions are experienced by 70% of people using drug services and 86% of those using alcohol services in community substance misuse treatment in the UK**.
Many people with mental health and addiction issues often struggle to access appropriate services. Addiction services are typically designed to support individuals when they feel ready to start making changes to their alcohol or drug use. However, this focus can leave those who aren’t ready or able to engage with addiction services without the support they need. If someone feels their mental health is their primary concern, it can complicate access to mental health teams, as alcohol and drug use can impact their mental wellbeing. Marissa was struck by this gap in care, realising how difficult it is for people when they feel there is no right fit for the support they need. This highlights the need for more inclusive services that cater to the diverse needs of those with co-occurring conditions.
Marissa and Daniel have seen how stigma within services can make it harder for people to get the help they need.
They’ve seen Psychiatric Inpatient teams under pressure to discharge people who aren’t seen as very unwell, saying they’re ‘taking up a bed,’ even when their diagnosis isn’t clear and a repeat presentation is highly likely. When they’ve turned to addiction specialists, they have sometimes faced reluctance to accept a referral; in one example, a professional stated that a person’s ‘lack of insight’ was a barrier to their offer of care. This stigma can leave people feeling ignored and unsupported by the services meant to help them.
Marissa and Daniel told us their experience about working with co-occurring conditions.
Marissa and Daniel worked with an individual who had been moved from an inpatient psychiatric unit to a mental health rehab step-down unit, where they began working closely with a psychologist to plan their next steps after discharge. They had previously been passed between services and, despite showing clear signs of mental health issues alongside a history of addiction, had not received the right treatment due to their complex presentation.
During their sessions with the psychologist, this individual felt safe and able to open up about their views on people with mental health conditions, shaped by their own first-hand experiences. They spoke of feeling unable, or too afraid, to discuss this openly. Describing themselves as ‘mental’, they revealed mental health symptoms they had lived with for many years but had never felt safe enough to share. They also expressed feelings of shame and guilt about their behaviour, which had led them into a cycle of addiction as a way of coping. Services often fell into the trap of seeing this as ‘someone else’s job’ until Marissa made a commitment to explore how this cycle could be broken, before it was too late.
These sessions with Marissa, along with support from Psychology, helped to clarify a diagnosis and highlighted how stigma and shame had prevented them from accessing the right support in the past. It took incredible courage and trust for this person to disclose these deeply personal feelings—something that doesn’t happen quickly or in settings like A&E. It requires time, psychological safety, and a supportive environment. This is why services must be designed to consider the longer-term journey that people are on, rather than focusing on short-term fixes.
As Marissa explained,
"With every case, you need time—but with co-occurring conditions, stigma makes it even harder. When people are assessed for the first time, they’re not going to share what they hate about themselves or all their trauma, even though these are often at the heart of the issue. We need to create services that allow these stories to unfold, without the pressure of fitting into rigid service specifications."
Daniel added,
"We encounter complex cases trying to be supported by complex service arrangements, all of which can create a disjointed, short-term approach. Often people with co-occurring mental health, alcohol and drug use are having a hard enough time, yet require almost superhuman resilience to cope with life whilst at the same time navigating these complex service arrangements."
Learn more about ending the stigma around co-occurring conditions: www.stigmakills.org.uk/co-occurring-conditions
*Names have been changed.
**Weaver et al (2003) Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. The British Journal of Psychiatry Sep 2003, 183 (4) 304-313
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