Which Came First The Chicken or the Egg?

Estimated read time: 12 min

Which came first the mental health diagnosis or the substance abuse?

When I was about 20 years old, I had my first brief encounter with a mental health therapist. To this day, I don’t remember what credentials the woman had. At the time, I didn’t think much of the one or two sessions I attended before declaring myself cured. 

Then, I was pretty sure that mental health was on the same level as fortune telling. Counselors and their ilk were specifically trained con artists who looked for tells like a poker player checking out his adversaries. Then, instead of going all-in on the right hand as a poker player would, a counselor, upon earning your confidence with a few predictions, bleeds your bank account dry with weekly sessions because, after all, you are never really cured. (If you fully don’t understand the irony check out my profile under the Our Story section of our blog.)

Yes. I was that incredibly naïve and cocky, and it would take decades before I realized and fully understood the importance of mental health and what it means to have a mental health diagnosis. Perhaps, if I could have pried my clamped-shut mind forcefully enough to open just a crack, I may have saved myself decades of suffering.

When I made it to that first appointment, one I didn’t know had been set for me nor one I would have thought to plan, I was a grief-stricken mess soaked in booze. My best friend had been killed by a drunk driver and my solution was to drink until I couldn’t think or remember. It didn’t work, but that didn’t stop the attempts.

I walked into the office after being summoned from a college class. In the 45 minutes that followed, I had, in my mind, convinced the counselor I was fine despite the alcohol fumes flowing from my mouth, and, somehow, signed myself up for a test to help me predict what career field might suit me best.

When I got the results back after the second session, I was absolutely sure that counseling was a crock. The job list that best suited me, according to the STUPID test, included teacher, mental health counselor, and preacher. At the time, I had deemed myself perfect for aerospace engineering. I never saw that counselor again. I also swore off seeing any counselor for any reason forever.

Forget that I dropped out of school for six months shortly after, and enrolled as an English major on my return, which led to a teaching career before I earned a master’s in mental health counseling. Counselors were con artists. (On a side note, I took a similar test as a part of one of my classes for my master’s degree and got the same crappy list again.)

Flash forward 20 years and I began bouncing in an out of therapist’s offices. I initially sought help to cope with a disastrous marriage in which I was at least 50 percent, if not more, of the problem. I was looking for proof that none of the problems around me was my fault, and in my mind, I needed no fixing. Oddly, all the therapists wanted to do was help me fix myself. Like so many times in my life, I sought help to fix a problem outside of me but kept getting advised that if I fixed me, the rest would fix itself.

While I won’t bore you with each stop at an office, each lie I told about how often, where, and why I drank, and what condition I was in, mentally, when I went to said appointment. When I was the most honest, I received a diagnosis of generalized anxiety disorder, and according to more than one psychiatrist that was the root of my boozing.

The solution most often given to me was to take the correct medication and my need for booze would go away. The problem, if you know me, is that I am an alcoholic, and the booze was not going to just go away. In fact, in some cases, the meds they gave me made drinking almost seem like a requirement. Most people I am sure pop a couple of Klonopin with their afternoon 12-pack.

Finally, despite all of my half-hearted attempts, I decided to put the alcoholic question to rest by entering treatment, where I discovered that I was a whole lot of alcoholic. Once the booze was taken away, the panic part of my anxiety began to ease and I could function fairly normally. I still suffer from anxiety at a diagnosable level with a helping of avoidance disorder. So far it has been treatable without the need for medication, but in some cases, a return to counseling has been helpful.

As often is the case, when people, usually Earth People, get curious about addiction and they find someone who has a dual diagnosis, the question gets asked. Which came first: the mental health diagnosis or the drugs and booze? 

The answer is a little complicated. (The answer to why Earth people might not be the best people to ask these questions can be found in the article, “What Earth People Say Might Kill You.”

First, let me say that my personal mental health diagnosis and resulting issues are very mild compared to others I have met in recovery who are living life as normally as anyone. Second, while I am a mental health counselor, I don’t have all the answers to anything. I am still learning. In the discussion that follows, I only feel qualified to share my own experience as I have not completed a lot of research into the question. Still, I do feel compelled to stress my own experience as a guide for others because it worked for me.

I often hear people in AA meetings say they “never felt normal, even as a child.” To the layman, this may point to a mental health issue from a very young age followed by attempts to “self-medicate” with drugs and alcohol.

The problem is that addiction itself is a mental health issue. Therefore, trying to figure out if the description given by people in recovery about their early lives can point to a mental health diagnosis beyond addiction is impossible to discern.

Secondly, due to the way the brain develops, it is nearly impossible to diagnose a child with a serious mental illness, especially if you are not working specifically with children.  Most mental illnesses do not become hard-wired until the age of 18, making it difficult to provide an accurate diagnosis.

The next problem I have is the idea of “self-medicating” with drugs and alcohol to resolve a problem, especially a mental health problem. The idea of “self-medicating” a mental health diagnosis was probably cooked up by an alcoholic who needed an excuse for drinking. When an alcoholic drinks, there is exactly one reason: he or she is an alcoholic.

“Self-medicating” also seems to imply that if correct medication is given, the person will stop abusing drugs and alcohol. I can personally attest that this is not the case. I am not sure who came up with the idea, but the issue I have is that it takes the focus off of one major component of recovery from any health equation—removing the drugs and alcohol.

From my personal experience as an alcoholic, treating any mental health issue while a person is still in active addiction is problematic and irresponsible at best. I like most addicts will lie (gasp) about our drug or alcohol use.

I lied because I didn’t want to check boxes that might force me into a situation where I couldn’t drink. Oddly, that is exactly what I needed. The other problem with treating a mental illness other than substance abuse first when dealing with an alcoholic or addict is that often, the drugs or lack of drugs, mimic symptoms of a host of other diagnoses.

In my case, my nervous system was shot. I jumped at any slightly loud noise, had constant shakes when I didn’t have booze in me and was lost in trying to correct bad decisions I had made that were so far in the past there was no way to resolve them.

Depending on the time of day you saw me, I could seem to be suffering from crippling anxiety, seem relatively normal, or trapped in the depths of depression. Most of the time, my whole demeanor was of someone who was suffering from crippling anxiety and panic attacks or, you guessed it, alcohol withdrawals.

Unfortunately for my counselors and psychiatrists, I was barely able to keep up a façade of being relatively sober during sessions by drinking just enough to avoid the shakes before each appointment. Had they ever bothered to get a blood alcohol level from a blood sample, the gig would have been up. Still, there may have been little they could do.

The ball would have been in my court. (Mental health care, like medical care, is not required, and even more so than medical care, often only administered during a crisis.) I could have sought another provider or swore off getting help so I could continue to drink.

Had the professionals had a complete picture, maybe, just maybe, I might have admitted I needed help to stop drinking and sought in-patient treatment. In any case, the attempts made by the mental health professionals I met to medicate me out of my alcoholism by fixing my other symptoms failed miserably.

And it makes sense as to why their plans were doomed from the start. First, who knows if I even took the medication correctly. Being a good alcoholic: if one pill works, two works better. With the chemicals swimming in my stomach already, who can be assured the medication, if taken correctly, worked effectively. Also, a lot of mental health medications cannot or should not be taken with alcohol or by daily drinkers. In some cases, the interaction of the medication with booze can result in death.

Another issue I had is a total misunderstanding of alcoholism by mental health and medical professionals. Despite numerous articles and tons of research, the myths about substance use and abuse often outweigh the scientific evidence. I had one psychiatrist tell me that I could control my drinking if I wanted to control it. “It is just a matter of willpower.” I remembered that perfectly when I was being injected with detox meds to assure I would not die when I finally stopped drinking.

When I was two years sober and sitting in a class of soon-to-be mental health counselors, the instructor had to continually repeat that there was no way to accurately diagnose or treat someone in active addiction until the drugs are removed long enough for the clients to be stable.

How long it takes to truly be stable is a matter of debate, and what stable looks like can be very different for individuals. There is a bit of euphoria that tends to happen to alcoholics in early sobriety. For more on that, read the article, my wife and fellow Grateful Nut wrote about Pink Clouds.

Still, several students argued that the best way to remove the drugs from the equation was to treat the symptoms. When I disagreed, one student told me that I had obviously never been around people in addiction. “When you finally get to be around some of these people you will see.” I didn’t correct her. I just quietly wondered if she would recognize an alcoholic if she met one.

The problem is obvious, alcoholics and addicts act and look like anyone else. And, they will lie to cover their addiction. So, what can we do? That starts with you.

If you are questioning whether you are an addict or alcoholic, you already know the answer. If you think a loved one is an addict or alcoholic, the answer is most likely the same. When verifying the “yes,” you just whispered to yourself, look for a trained professional in substance abuse treatment. At least, you will be working with a specialist. I mean you wouldn’t go to a dentist to have knee surgery.

If paying for an appointment seems silly at this point, check out a local AA or NA meeting and listen to the people share during the meeting. If you hear a lot that makes sense, welcome to the club!

If you are not questioning whether you have a problem with alcohol or drugs and instead are seeking mental health advice for another reason, putting the booze and drugs down before you start will be helpful in case the drugs and alcohol are masking or exacerbating another mental health condition.

My main point is simple. When it comes to people who have a significant mental health diagnosis along with alcohol or substance abuse, it doesn’t matter which came first. It is the chicken and the egg argument, but in this case, lives are at risk.

Think of treating a mental health diagnosis like medical issue in the emergency room. If a patient comes in with a bullet wound to the abdomen and a fractured arm, there will not be a lot of debate about which injury happened first. Surgeons will rush to treat the wound that is most likely to end a patient’s life quickest. Then, work on any other injuries that they find. And, just as is the case with a physical injury where healing and rehabilitation take time, mental health treatment does not end after one visit.

Similar to the case of our fictitious emergency room patient, treating the substance use disorder of an alcoholic or addict should be the priority. That is the bullet wound. Once those chemicals are removed, medical professionals and patients have a better shot at fixing any underlying issues.

Otherwise, it is the equivalent of slapping a band-aid on that bullet wound and putting the broken arm in a sling, and sending the patient home with a follow-up appointment in two weeks. No one would consider that acceptable care. Likewise treating an underlying illness while being slapped in the face with a crisis that goes untreated is unacceptable.

Failing to treat alcoholism and addiction may not be as obvious as failing to treat a bullet wound, but it can be just as deadly.

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