Concomitant substance abuse remains a very difficult problem. Traditional treatment programs (12 step programs, self-help groups) are frequently ineffective. Psychosis inhibits self-awareness and substance abuse exacerbates psychosis. Whether the drug of abuse is a sedative, an opiate, or a stimulant, the consequences can be severe. Programs to treat the dually diagnosed patient have recently emerged. However, without substantial environmental change (avoiding people, places, and things associated with substance use), the risk of relapse remains great. Ongoing monitoring of drug and alcohol use is essential in detecting early abuse and predicting relapse of the psychosis.