This reflective paper explores the emotional and professional challenges of working with service users experiencing dual diagnosis, those living with both mental illness and substance misuse. Drawing on person-centred principles and clinical experience within a community mental health setting, the author discusses the tension between empathy and accountability in the therapeutic process. The paper argues that fostering empathic accountability, a balance of compassion and responsibility, supports service users in taking ownership of their recovery while maintaining dignity and agency. The reflection concludes by proposing empathic accountability as a key ethical and relational stance for practitioners working with individuals seeking to move out of addiction.

• Homelessness

• Dual Diagnosis

• Empathic Accountability

Wink R (2026) Promoting Empathic Accountability When Working with Service Users Affected by Dual Diagnosis. J Subst Abuse Alcohol 13(1): 1105.

As my client walked out of the door, I noticed I was harbouring a great deal of frustration. I could not believe what had happened after all the progress my client had made. Over one hellacious weekend, they were back where they started, back at rock bottom. After nearly a year of abstaining from drugs and alcohol, it appeared the client had turned a corner and was beginning to live the life they had long desired. One lapse, however, and everything seemed to collapse again.This feeling has, in truth, been simmering within me for much of my time working as a Psychological Therapist in a Community Mental Health Team that supports clients who are homeless and can also be categorised as dual diagnosis. The expression “architect of my own downfall” often applies to many of the service users my team and I work with, though the foundations of their difficulties are rarely of their own making. Their lives are built upon the unstable ground of complex trauma, neglect, and untreated mental health conditions. Everything is shaky, and at times nothing quite makes sense.

I work in Great Yarmouth, a much-maligned seaside town on the east coast of England. There are elements of this town that act almost as a vacuum, drawing vulnerable people back into an abyss where everything is taken and nothing is gained. Drugs are easily accessible, and exploitation is rife. Despite the town’s “end of the road” feel, substances always seem to find their way in. Corner shops stay open until the early hours, selling cheap cider and super-strength lager, fueling cycles of dependency that devastate so many lives here.The frustration I have felt over the past few years has periodically forced me to go back to basics as a therapist. This is a strategy I have employed at various points in my career whenever I have felt close to burnout or stuck in my work. I remind myself to return to the core conditions of therapy. I think of Carl Rogers.

Empathy, one of Rogers’ key core conditions, is about standing in the client’s shoes, to try and see the world through their eyes, to understand their frame of reference. It requires the therapist to communicate this understanding in a way that allows the client to feel truly seen and heard. This kind of listening is not passive; it demands effort, presence, and emotional risk. It requires reaching a point of relational depth, where the encounter becomes authentic, human, and mutual [1]. It is a challenge to enter a world one has only a superficial awareness of. I do not identify as an addict, yet as a fellow human being, I recognise my own addictive tendencies, toward distraction, work, comfort, or avoidance. This is a theme that also chimes a lot in the work of renowned addiction expert, speaker and author Dr Gabor Mate. Mate’s prominence in the popular psychology world of podcasts and YouTube talks has brought several of his ideas and concepts to a mainstream audience. Although I have worked with addiction in past roles, nothing could have fully prepared me for the intensity of this work in this role. Developing empathy and maintaining a non-judgemental stance with this client group is an ongoing process that takes place during moments of self reflection and consistent monthly clinical supervision. Regular supervision and routine daily self-care have kept me in a place away from the burnout that I have witnessed with other workers in this sector. In time, working empathically with service users builds trust. The therapeutic relationship deepens because of this empathic connection. For many people I work with in Great Yarmouth, this may be the first time someone has genuinely tried to understand them rather than judge them. Yet, paradoxically, being seen in this way can be terrifying. When a client has spent years surviving by hiding their pain, the process of being understood can provoke a powerful urge to flee. Escaping has been their default response for so long that even compassion can feel threatening.

I am constantly tested by clients in the throes of addiction. Many struggle with alcoholism or crack cocaine dependency, substances that are both physically and psychologically ruinous. The limits of empathy are regularly tested when a person self-destructs or commits acts that cause harm to others. Yet, behind these actions is often a deeply wounded self, defined by shame, guilt, and an ingrained belief in their own brokenness. “What’s the point of even trying to change?” they ask. For someone who has been rejected, punished, or dismissed their whole life, the idea of being worthy of care is profoundly alien. Convincing them that they have intrinsic worth is perhaps one of the greatest challenges in therapy. 

Another of Rogers’ conditions, unconditional positive regard, reminds me of the importance of taking a non judgmental stance. Over the years, I have learned to hold this stance consistently, even when a client’s behaviour provokes feelings of frustration or disappointment. My role is not to condone destructive behaviour, but to see the human being beneath it. If I can build a therapeutic relationship rooted in empathy and compassion, where the client feels accepted enough to explore their inner world, then change becomes possible. This is when clients begin to reflect, to learn, and to consider new ways of being. When they start to accept themselves, self-awareness grows, and with it, the possibility of personal transformation. When therapy truly works, reflection leads naturally toward accountability and personal responsibility. This is where profound change can occur. Yet in this client group, such moments are rare and hard-won. I often analyse my efforts, wondering why, after thirteen years of practice, I sometimes feel as uncertain as I did in my early training days.

Defining success with this client group requires nuance. For some, success means maintaining sobriety for a sustained period; for others, it might mean engaging consistently with services or simply attending sessions despite ongoing substance use. Yet, when I think of the clients who have truly transformed, a pattern emerges. They have taken accountability for their actions, their choices, and their recovery. They begin to experience personal growth. They reclaim control of the wheel of their own life, navigating with greater awareness rather than reacting automatically. To paraphrase Viktor Frankl et al. [2], they discover the freedom to choose their attitude, to choose a different path for themselves. This internal shift, this change in perspective, marks the beginning of recovery. It is not merely about abstinence, but about a renewed sense of meaning and agency.

Empathic accountability is the meeting point between compassion and responsibility. It recognises that addiction and mental illness often stem from trauma, disadvantage, and emotional pain. It does not deny the profound impact of these factors—but it also refuses to collude with the idea that recovery is impossible. To practice empathic accountability is to say, “I see your suffering, and I understand why you struggle. But I also believe in your capacity to change.” It invites the client to take ownership of their recovery, not through guilt or coercion, but through a renewed sense of self-worth. I believe that even when working within other therapeutic modalities, such as Interpersonal Psychotherapy (IPT) or Dialectical Behavioural Therapy (DBT), the principle of empathic accountability can still be effectively integrated. For example, in IPT, the focus would be on encouraging clients to take greater responsibility for themselves and to improve how they communicate within interpersonal relationships. In DBT, the emphasis would be on valuing and protecting the self, such as using distress tolerance skills to prevent self-harm.

As I reflect on that moment when my client relapsed after a year of sobriety, I see now that my frustration came not from judgment but from grief, a grief for the potential I had seen, and for the fragility of recovery. Yet perhaps this moment was not a failure at all, but part of the longer arc of accountability that recovery demands. I am often taken back to the early days of my psychotherapy journey, which began with voluntary work for the Samaritans, a registered charity that provides emotional support to anyone in distress, struggling to cope, or at risk of suicide across the United Kingdom and Ireland. Much of the work at that time was conducted over the telephone. Despite this, I held a strong personal belief that every life was worth living. The challenge during each call, especially when supporting someone experiencing suicidal thoughts, was to help them hold on, to look into the metaphorical mirror and recognise their own worth. People with a dual diagnosis presentation live at the intersection of immense pain and profound potential. To support them effectively, we must embody empathic accountability, an approach that neither excuses destructive behaviour nor condemns the person behind it. Instead, it invites clients to see themselves as capable of growth, worthy of care, and responsible for their choices. Accountability, when grounded in empathy, becomes an act of empowerment. It says: You are more than your addiction. You are not defined by your diagnosis. You have the power to choose differently. As therapists, our task is to hold this belief consistently, even when our clients cannot. Through this balance of compassion and responsibility, change becomes possible, not imposed from outside, but emerging from within. True healing lies in the space where both coexist, the place where understanding meets responsibility, and where even the most wounded individuals can begin, slowly but surely, to move out of their addiction and reclaim their lives.

1. Rogers CR. The necessary and sufficient conditions of therapeuticpersonality change. J Consulting Psychology. 1957; 21: 95-103.
2. Frankl VE. Man’s search for meaning. Washington Square Press. 1984.