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Those who struggle both with serious mental
illness and substance abuse face problems of
enormous proportions. Mental health services
are often not well prepared to deal with patients
having both afflictions. Often only one of the
two problems is identified. If both are recognized,
the individual may bounce back and forth between
services for mental illness and those for substance
abuse, or they may be refused treatment by each
of them.
While the picture regarding
dual diagnosis has not been very positive in
the past, there are signs that the problem is
being recognized and there is an increasing
number of programs trying to address it. It
is now generally agreed that as much as 50 percent
of the mentally ill population also has a substance
abuse problem. The drug most commonly used is
alcohol, followed by marijuana and cocaine.
Prescription drugs such as tranquilizers and
sleeping medicines may also be abused. The incidence
of abuse is greater among males and those in
the aged 18 to 44. People with mental illnesses
may abuse drugs covertly without their families
knowing it. It is now reported that both families
of mentally ill relatives and mental health
professionals underestimate the amount of drug
dependency among people in their care. There
may be several reasons for this. It may be difficult
to separate the behaviors due to mental illness
from those due to drugs. There may be a degree
of denial of the problem because we have had
so little to offer people with the combined
illnesses. Caregivers might prefer not to acknowledge
such a frightening problem when so little hope
has been offered.
Substance abuse complicates
almost every aspect of care for the person with
mental illness. First, these individuals are
very difficult to engage in treatment. Diagnosis
is difficult because it takes time to unravel
the interacting effects of substance abuse and
the mental illness. They may have difficulty
being accommodated at home and may not be tolerated
in community residences of rehabilitation programs.
They lose their support systems and suffer frequent
relapses and hospitalizations. Violence is more
prevalent among the dually diagnosed population.
Both domestic violence and suicide attempts
are more common, and of the mentally ill who
wind up in jails and prisons, there is a high
percentage of drug abusers.
Given severe consequences
of drug abuse for the mentally ill, it is reasonable
to ask: "Why do they do it?" Some
of them may begin to use drugs or alcohol for
recreational use, the same as many other people
do. Various factors may account for their continued
use. Probably many people continue their use
as a misguided attempt to treat symptoms of
the illness or the side effects of their medications.
By "self-medicating," they find that
they can reduce the level of anxiety or depression
-- at least for the short term. Some professionals
speculate that there may be some underlying
vulnerability of the individual that precipitates
both mental illness and substance abuse. They
believe that these individuals may be at risk
with even mild drug use.
Social factors may also play
a part in continued use. People with mental
illnesses suffer from what has been called "downward
drift." This means that as a consequence
of their illness they may find themselves living
in marginal neighborhoods where drug use prevails.
Having great difficulty developing social relationships,
some people find themselves more easily accepted
by groups whose social activity is based on
drug use. Some may believe that an identity
based on drug addiction is more acceptable than
one based on mental illness.
This overview of the problem
of drugs and mental illness may not be a very
positive one. However, there are some encouraging
signs that better understanding of the problem
and potential treatments are on the way. Just
as consumers and families have faced other very
troublesome problems in the past and developed
adequate responses to them, they can also learn
to deal with this one in a way that their lives
become less troubled and better treatment is
received.
Treatment Programs
For Those with Dual Diagnoses
As many have probably discovered,
service systems have not been well designed
with this population in mind. Typically a community
has treatment services for people with mental
illness in one agency and treatment for substance
abuse in another. Clients are referred back
and forth between them in what some have called
"ping-pong" therapy. What are needed
are "hybrid" programs that address
both illnesses together. Development of these
programs locally requires considerable advocacy
efforts.
Limitations Of
Traditional Drug Treatment Programs:
Treatment programs designed for people whose
problems are primarily substance abuse are generally
not recommended for people who also have a mental
illness. These programs tend to be confrontive
and coercive and most people with severe mental
illnesses are too fragile to benefit from them.
Heavy confrontation, intense emotional jolting,
and discouragement of the use of medications
tend to be detrimental. These treatments may
produce levels of stress that exacerbate symptoms
or cause relapse.
Characteristics
Of Appropriate Programs: Desirable
programs for this population should take a more
gradual approach. Staff should recognize that
denial is an inherent part of the problem. Patients
often do not have insight as to the seriousness
and scope of the problem. Abstinence may be
a goal of the program but should not be a precondition
for entering treatment. If dually diagnosed
clients do not fit into local Alcoholics Anonymous
(AA) and Narcotics Anonymous (NA) groups, special
peer groups based on AA principles might be
developed.
Clients with a dual diagnosis
have to proceed at their own pace in treatment.
An illness model of the problem should be used
rather than a moralistic one. Staff need to
convey understanding of how hard it is to end
an addiction problem and give credit for any
accomplishments. Attention should be given to
social networks that can serve as important
reinforcers. Clients should be given opportunities
to socialize, have access to recreational activities,
and develop peer relationships. Their families
should be offered support and education.
Advocacy For Effective
Treatment
If no appropriate programs
exist in the community, families of dually diagnosed
persons may need to advocate for them. References
listed below describe a number of experimental
programs that can serve as sources of information.
Advocacy should also be directed at research
and training. One program (Sciacca, 1987) uses
an educational approach and recognizes the tendency
for dually diagnosed individuals to deny their
problem. The client does not have to recognize
or publicly acknowledge that he or she has a
problem. Clients meet in a group and talk about
the issue of substance abuse, view videotapes
and involve themselves in helping others. Only
later do members get around to talking about
their problem and the potential for treatment.
A non-confrontational style is maintained throughout.
Rather than send participants to AA or NA, members
of these groups are invited to visit the agency.
Eventually some of Sciacca's groups do go to
AA and NA.
Recognizing The Problem
As mentioned, many families
do not recognize that their mentally ill member
also has a substance abuse problem. This is
not surprising because many of the behavioral
changes that lead to suspicion of drug problems
in other people already exist in persons with
mental illness. Therefore, such behaviors as
being rebellious, argumentative, or "spacey"
may be less reliable clues in this group. Observation
of some of the following behaviors, however,
may put families on the alert:
• Suddenly having money
problems
• Appearance of new friends
• Valuables disappearing from the house
• Drug paraphernalia in the house
• Long periods of time in the bathroom
• Dilated or pinpointed eyes
• Needle marks
Of course, there are also
those individuals who react strongly to drugs
and alcohol and whose unusually chaotic behaviors
leave little doubt regarding the use of drugs.
Addressing The Problem
This may or may not involve
confronting the individual. It is usually best
not to immediately and directly accuse the individual
of using drugs because denial is a likely response.
Unless one has irrefutable evidence, the person
is entitled to be presumed innocent. What one
can object to are behaviors, whether or not
they are known to be influenced by drugs, which
are interfering with family life.
These behaviors may take any
number of forms: apathy, irritability, neglect
of personal hygiene, belligerence, argumentativeness,
and so forth. Since the problem of drug use
is a very serious and complicated matter, it
should be addressed in a careful deliberate
manner. It is best not to try to deal with the
individual when he or she appears to be under
the influence of drugs or alcohol, nor when
family members are feeling most emotionally
upset about the situation. Avoid making dire
threats such as calling the police, resorting
to hospitalization, or exclusion from the home
unless you really mean to do it. There is a
risk that you may say things under the stress
of the situation that you don't mean. It is
important that your relative knows where he
or she stands with you and that you mean what
you say.
Developing A Plan
Of Action
Since it is likely to be difficult
at best, select a time when things are relatively
calm to decide what to do. Involve as many members
of the family as possible and develop an approach
all can agree upon. The following set of guidelines
may help you come up with a plan:
1. Be sure
that all members agree on what the problem is.
What exactly have members observed that has
to be dealt with? Is it some unacceptable behavior
that might be caused by drugs or is there clear
evidence of drugs? What is the evidence?
2. Generate
a number of possible solutions to the problem
with the goal of acting on the one(s) that all
agree are the best one(s). Of course, families
will differ a great deal in what they think
is possible in their situation. What follows
is a list of possible actions a family may consider:
o Relate your
concerns to your relative's psychiatrist or
therapist.
o Confront him or her with your observations
and request very specific changes in behavior.
o Plan ways to reduce access to money that might
be going for drugs.
o Do anything possible to reduce his or her
needs for or interest in social groups that
use drugs.
o Confront the person with clear evidence that
he or she is using drugs and suggest treatment.
3. Come to
an agreement about what may be the best approach
to try first.
4. Develop
very specific steps to carrying out your plans.
Decide what role each member will have in implementing
the plan. If there is a decision to confront
the person directly about drug use, be prepared
to give the evidence.
If you choose to confront,
state calmly that you believe drug use is occurring,
provide the evidence, and what you want the
person to do about it. Refuse to argue with
the person. Have a definite plan in mind, including
a contact with an available treatment center,
telephone numbers, etc., so you can proceed
immediately if he or she should agree to treatment.
It is important to avoid a moralistic tone about
drug use. It is better to focus on the consequences
that you have observed for the person and for
his or her family.
If the family decides that
the problem is serious and the individual is
likely to be lax about compliance with the family's
reasonable requests, then negative consequences
may be considered for failure to comply. This
must be weighed very carefully. It is not easy
to think of negative consequences for adults
that one can enforce and, as said before, it
is never wise to make threats that you don't
intend to carry out. For the usual misbehaviors,
the person should be asked to make amends or
the person may lose a privilege he or she enjoys.
When problems get so severe that other members
are at risk, the person may be forewarned that
he or she will be asked to leave.
Then the family must follow
through. This works better if alternate housing
can be arranged ahead of time so that the streets
do not become the only option. Families often
ask if the family should insist on total abstinence
from all drug use. While authorities in the
field point out that abstinence is by far the
safest option, some families may find that tolerance
of occasional use or agreement to cut back may
get reasonable cooperation whereas insistence
on total abstinence will result in denial and
inability to communicate further on the subject.
Recreational drugs and alcohol and prescribed
medications might have serious interactive effects.
Clients and families need to be fully informed
about these possibilities.
Support And Self-Care
For The Rest Of The Family
Coming to terms with chemical
dependency of a mentally ill relative does not
come easily. For a time, it may just feel too
painful, too bewildering, too overwhelming to
face. The family may feel terribly angry at
the ill person and blame him or her for seeming
so stupid, so weak-willed as to add problems
of substance abuse to an already highly disturbed
life. Feelings of anger and rejection, unfortunately,
do not help the situation and can delay rational
thinking about how to approach the situation.
Parents and siblings may be hurt because the
addicted person blames others for his or her
problems and breaks trust by lying and stealing,
and in general, by creating chaos throughout
the household. A great deal of fear and uncertainty
may prevail as behavior becomes more irrational
and violence or threats of violence increase.
Members of the family may feel guilty because
they feel their relative's substance abuse is
in some way their fault.
First, it is important to
realize that substance abuse is a disease. The
person who is truly addicted is no more able
to take control of this problem without help
than he or she is able to take control of their
mental illness. Thinking of this problem as
a disease may reduce the sense of anger and
blame. Family members may learn to take negative
behaviors less personally and feel less hurt.
People may cease blaming themselves and each
other for a disorder that no one could have
caused or prevented. Coming to terms with substance
abuse in someone you love will take time. It
will be easier if the family can close ranks,
avoid blaming each other, agree on a plan of
action, and provide support to each other.
It is also important to seek
support from other families who are dealing
with similar problems. This subset of families
in the local NAMI affiliate may find it beneficial
to meet separately at times to provide support
in a way best done by other people who also
have the problem. Families may want to investigate
their local Al-Anon and/or Narcotics Anonymous
(NA) groups. These support groups have proven
to be immensely helpful to some families.
Finally, families should realize
they cannot stop their relative's substance
abuse. They can, however, avoid covering it
up or doing things that make it easy for the
person to continue the denial. Families can
learn what they can do about the problem, but
they must be realistic that much of it is out
of their hands. With great effort, some of the
painful emotions will subside, members will
feel more serene, and life can be worthwhile
again.
Further Reading:
Brown, V.B., Ridgely, M.S., Pepper, B., Levine,
I.S. & Ryglewicz (1089) The Dual Crisis:
Mental Illness and Substance Abuse, American
Psychologist, 44, 565-560.
Evans, K. & Sullivan,
J.M. (1990) Dual Diagnosis: Counseling the
Mentally Ill Substance Abuser, New York:
Guilford Press.
Minkoff, K. & Drake, R.
(Eds.) (1991) Dual Diagnosis of Major Mental
illness and Substance Disorder, New Directions
for Mental Health Services No. 50, Jossey Bass:
San Francisco.
Sciacca, K. (1987) Alcohol/Substance
Abuse Programs at New York State Psychiatric
Center Develop and Expand, (Mimeo). Write
to the author for this and related papers at
Harlem Valley Psychiatric Center, 299 Riverside
Drive, New York,NY 10025.
Sciacca, K. (1987) New
Initiative in the Treatment of the Chronic Patient
with Alcohol/Substance Abuse Use Problems,
Tie-Lines, 3, 5-6.
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