In this talk, Dr. Ellenhorn argues that the term “co-occurring” for simultaneous substance abuse and mental health issues is often a misnomer. In its place, he proposes a model in which the problem is actually tri-occurring, the third element in this triangle being, what he calls, psychosocial trauma. Through repeated attempts at treatment, the experience and internalization of stigma, and often a succession of personal problems caused by their psychiatric experiences, people diagnosed with psychiatric issues often lose hope in their future and doubt their own fortitude to face problems. With this in mind, addictions treatment for people who also suffer from psychiatric issues should aim for the triad of clinical, addiction and psychosocial recovery. In fact, Dr. Ellenhorn describes addictive behavior and psychosocial pain as the key relationship in this triad — seeing the loss of hope, connection, purpose and belief in a future caused by social losses as the overwhelming determinants in a person’s willingness to change.

Central to Ellenhorn’s critique is a widespread assumption that pervades behavioral health treatment in general: that access to psychosocial resources—like work, community, and autonomy—must follow symptom reduction or behavioral stability. In fact, these resources are not rewards for improvement; they are the very medicine that fosters it. Too often, our systems tell people to “wait until you’re well before you receive this medicine.” Ellenhorn argues for reversing that logic—creating models of care that deliver meaningful support whether or not someone appears ready, because that support is what makes readiness possible. It’s about clinicians, not clients, being ready, in other words.