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Dual Diagnosis and Mental Illness (Schizophrenia and Drug or Alcohol dependance)
Copyright 1993 National Alliance for the Mentally Ill
Families who have mentally ill relatives whose problems are compounded by substance abuse face problems of enormous proportions. Mental health services are 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 be bounced 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 at this point, there are now signs that the problem is being recognized and there is an increasing number of programs trying to address the treatment needs of people with both problems. Research studies are beginning to help us understand the scope of the problem. 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 age bracket of 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 of all, of course, 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. 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.
We realize that this overview of the problem of drugs and mental illness is not a very positive one. However, we believe there are some encouraging signs that better understanding of the problem and potential treatments are on the way. Just as families have faced other very troublesome problems in the past and developed adequate responses to them, we believe that they can learn to deal with this one in a way that their lives become less troubled and their relatives begin receiving better treatment.
Treatment Programs For The Dually Diagnosed
As many families 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 is 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 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 needs 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 at the end of the paper describe a number of experimental programs that can serve as sources of information. Advocacy should also be directed at research and training. An example of a recommended program is one conceptualized by Sciacca (1987). It uses an educational approach and recognizes the tendency for dually diagnosed individuals to deny their problem. The patient does not have to recognize or publicly acknowledge that he or she has a problem. Patients 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 nonconfrontational 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.
Family Management And Coping
It is difficult enough to cope with problems presented by a relative's mental illness, but when substance abuse is also a problem, family stress can be multiplied. These families need all the help they can get to help them cope with the additional burdens they face.
Recognizing The Problem
It was stated earlier than 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 rebelliousness and argumentiveness or being "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.
Confronting The Problem
Confronting the problem 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, argumentiveness, 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.
Develop 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 hypothetical family who might come up with some of the following suggestions: -- Relate your concerns to your relative's psychiatrist or therapist. -- Confront him or her with your observations and request very specific changes in behavior. -- Plan ways to reduce access to money that might be going for drugs. -- Do anything possible to reduce his or her needs for or interest in social groups that use drugs. -- 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. State calmly that you believe drug use is occurring, provide the evidence, and what you want the person to do about it. Refuse to get in an argument 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 we have 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 just feels too painful, too bewildering, too overwhelming to face. The family may feel terribly angry at the 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.
Feeling angry and rejecting unfortunately does not help the situation and delays 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, creates chaos throughout the household. A great deal of fear and uncertainty may prevail as behavior becomes more irrational and violence or threats of violence increases.
Members of the family may feel guilty because they feel their relative's substance abuse is in some way their fault. It is important, first of all, 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 his 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 dually diagnosed relatives. This subset of families in the local Alliance of the Mentally Ill 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 Alcoholic Anonymous (Al-Non) and/or Narcotics Anonymous (NA) groups. These support groups have proven to be immensely helpful to some families. Finally, it is important to say that families 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 efforts some of the painful emotions will subside, members will feel more serene, and life can be worthwhile again.
Twelve Things To Do If Your Loved One Is Addicted To Drugs And/Or Alcohol
1. Don't regard this as a family disgrace. Recovery from an addiction can come about just as with other illnesses.
2. Don't nag, preach or lecture to the addict/alcoholic. Chances are he/she has already told him or herself everything you can tell them. He/she will take just so much and shut out the rest. You may only increase their need to lie or force one to make promises that cannot possibly be kept.
3. Guard against the "holier-than-thou" or martyr-like attitude. It is possible to create this impression without saying a word. An addict's sensitivity is such that he/she judges other people's attitudes toward him/her more by small things than spoken words.
4. Don't use the "if you loved me" appeal. Since the addict/alcoholic is compulsive and cannot be controlled by willpower, this approach only increases guilt. It is like saying, "If you loved me, you would not have tuberculosis."
5. Avoid any threats unless you think it through carefully and definitely intend to carry them out. There may be times, of course, when a specific action is necessary to protect children. Idle threats only make the addict/alcoholic feel you don't mean what you say.
6. Don't hide the drugs/alcohol or dispose of them/it. Usually this only pushes the addict/alcoholic into a state of desperation. In the end he/she will simply find news ways of getting more drugs/liquor.
7. Don't let the addict/alcoholic persuade you to use drugs or drink with him/her on the grounds that it will make him/her use less. It rarely does. Besides, when you condone the using/drinking, he/she puts off doing something to get help.
8. Don't be jealous of the method of recovery the addict/alcoholic chooses. The tendency is to think that love of home and family is enough incentive for seeking recovery. Frequently the motivation of regaining self respect is more compelling for the addict/alcoholic than resumption of family responsibilities. You may feel left out when the addict/alcoholic turns to other people for helping stay sober. You wouldn't be jealous of the doctor of someone needing medical care, would you?
9. Don't expect an immediate 100 percent recovery. In any illness, there is a period of convalescence. There may be relapses and times of tension and resentment.
10. Don't try to protect the recovering person from using/drinking situations. It's one of the quickest ways to push one into relapse. They must learn on their own to say "no" gracefully. If you warn people against serving him/her drinks, you will stir up old feelings of resentment and inadequacy.
11. Don't do for the addict/alcoholic that which he/she can do for him/herself. You cannot take the medicine for him/her. Don't remove the problem before the addict/alcoholic can face it, solve it or suffer the consequences.
12. Do offer love, support and understanding in the recovery.
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. Khantzian, E.J. (1985) "The Self-Medication Hypothesis of Addictive Disorders: Focus on Heroin and Cocaine Dependence," American Journal of Psychiatry, 142: 11, 1259-1264.
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. Ridgely, M.S., Osther, F.C., Goldman, H.H., & Talbot, J.A. (1987) "Chronically Mentally Ill Young Adults with Substance Abuse Problems: A Review of Research, Treatment, and Training Issues." Mental Health Policy Studies, University of Maryland, School of Medicine, Baltimore, Maryland 21201.
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. Reference
Diamond, R. Increasing Medication Compliance in Young Adult Chronic Psychiatric Patients. In B. Pepper & H. Ryglewicz (Eds.) Advances in Treating the Young Adult Chronic Patient. New Directions for Mental Health Services, Number 21. San Francisco: Jossey-Bass, 1984 F
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