By Sheryl Bruce
A person who has a dual diagnosis is considered to have two diagnoses at the same time. In the area of mental health it usually means the co-occurrence of substance use and mental illness.1 It refers to a wide range of mental illnesses and addictions. For example, someone with schizophrenia who abuses cannabis has a concurrent disorder; as does an individual who suffers from chronic depression and who is also an alcoholic.” 2 According to the Canadian Mental Health Association (CMHA),” it is difficult to say conclusively how many people have a concurrent disorder because existing studies examine different populations and utilize differing screening tools. Furthermore, people with concurrent disorders are frequently misidentified, as diagnosis can be more difficult because one disorder can mimic another. For sure we know that relapse rates for substance use are higher for people with a mental disorder, as are the chances that symptoms of mental illness will return for those with a concurrent substance use problem.”3 The CMHA notes that “What is known conclusively, however, is that people with mental illness have much higher rates of addiction than people in the general population. Similarly, individuals with an addiction have much higher rates of mental illness than people in the general population”. 4 The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been revised and the term ‘‘substance abuse’’ has been replaced with ‘‘substance use disorder’’ (SUD). SUD is defined by a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by two or more of the following symptoms within a twelve month period:
- Substance is often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire, or unsuccessful efforts, to cut down or control use.
- A great deal of time is spent in activities necessary to obtain, use or recover from the substance’s effects.
- There is a craving or strong desire/urge to use.
- There is recurrent use resulting in failure to fulfill major role obligations at work, school or home.
- There is recurrent use despite persistent/recurrent social or interpersonal problems caused or exacerbated by the effects.
- Important social, occupational or recreational activities are abandoned or reduced because of substance use.
- Recurrent use in physically hazardous situations.
- Use is continued despite knowledge that a persistent/recurrent physical/psychological problem is likely caused/exacerbated by use.
- Tolerance change: 1) need for markedly increased amounts to achieve desired effect or 2) markedly diminished effect with use of same amount.
- Withdrawal: either 1) characteristic withdrawal symptoms or 2) other substance used to relieve or avoid withdrawal symptoms.
There are four categories of patterns: loss of control (symptoms 1-4), social changes (5-7), risky use to self or others (8 and 9), and change in physiology (10 and 11). Substance use is rated on a spectrum from mild (presence of 2-3 symptoms), moderate (presence of 4 or 5 symptoms), to severe (6 or more symptoms from the above list).5 The National Institute on Drug Abuse says that “drug addiction is a mental illness because it changes the brain in fundamental ways, disturbing a person’s normal hierarchy of needs and desires and substituting new priorities connected with procuring and using the drug. The resulting compulsive behaviors that weaken the ability to control impulses, despite the negative consequences, are similar hallmarks of other mental illnesses.”6 With reference to treatment, The Centre for Applied Research in Mental Health (CARMHA) recommends that for Mood and Anxiety disorders7 , with the exception of Post traumatic stress disorder, the best practice is to sequence the interventions to be used beginning with the substance use problem and closely monitoring the mental disorder. Adjustments will be made if the mood disorder does not improve.6 If SUD is accompanied by Post Traumatic Stress Disorder PTSD7 , then the cases are treated at the same time with Cognitive Behavior Therapy (CBT). For Schizophrenia and substance use7 , they recommend that interventions are all done at the same time: Motivational interviewing, CBT harm reduction, and psychosocial rehabilitation and support.6 With Substance use disorder and Borderline Personality Disorder7 it is recommended that treatment is planned and implemented concurrently using dialectical behavior therapy (DBT).
The National Institute for Mental Health in the United States also notes that persons with mental illness do need to stop their misusage of drugs and alcohol for the treatment of the illness to be effective. 8 Foster Pavilion, a treatment agency for Anglophones uses motivational interviewing (MI). MI helps the person using drugs to become ready to make changes. It is a process that allows the person to evaluate themselves and see what problems they are experiencing. Trained counselors develop their readiness to stop using. They use a series of questions to increase awareness in the individual of the negative impact drug use has on their lives. Those with a primary diagnosis of a mental illness may feel that they have good reasons to use their preferred drug: they may be worried or strained and they say that marijuana stops them from thinking or worrying. In fact many people with mental illness say that it helps in some ways to deal with their symptoms. Marijuana may work to block their symptoms, but over time they will experience some negative results. Family members worry and start to complain. Typically family members notice things that the person using drugs does not notice; for instance a lack of motivation can be apparent to the family but not the ill person. The negative effects start to build up slowly over time so that the person may not readily notice that they are less able to manage their lives. Things that may alert them to their dilemma are the following: spending too much money, neglecting jobs or family; spending too much time looking for drugs and/or taking drugs and they may notice that they are arguing with family more or isolating themselves. They start putting their job, family and relationships in jeopardy. It is when the user is able to see that they have more negatives than positives that they will start to make real changes. Foster offers evaluation, head start group sessions while waiting (Motivational counseling), recovery management - weekly sessions, outpatient semi-intensive and short term residential programs. They also have an Entourage group for family members. The francophone community has Centre Dollard-Cormier. They deal with reduction of misdeeds. They do not focus on abstinence; they focus on helping the individual to develop selfcontrol through small changes. Centre Dollard-Cormier has three programs as well: for youth up to 24, adults and for the entourage. They do an evaluation over the phone then at the first appointment there is a three hour evaluation that includes physical health. They provide emergency services and a detox center. As well, they adapt their services to homeless persons and people fifty-five and over. They help with housing, work, social activities and they have support for up to three months while the client readapts to community living. During a training I attended there I noticed that they were training new employees who were ex-users. It is always good to have a mentor “who knows the way out”. Centre Dollard-Cormier has a great website with all kinds of information and links to published findings.
Portage (another service) serves clients in both languages and it has three special programs; one for dual diagnosis-schizophrenia and substance use disorder; another for adolescents; and another for mothers with children. For adolescents they offer in-treatment for six months: learning about their difficulties and developing dignity. They focus on family values with the goal of developing a positive life. They have group therapy and the help with adjustment to community after treatment. Check out their website for more specifics. - www.portage.ca Clients are often referred to self-help groups to maintain their progress. There are some that will only go to self-help groups. Some of the self-help programs focus on abstinence versus reduction of the habit. Focusing on abstinence can deter users if they are not ready to start reducing their drug use and focus on their goals. Self-help programs are good for reducing isolation and building support. Alcoholics Anonymous has an excellent reputation for success, but the person has to be comfortable with the idea of a higher power and they must be willing to work the twelve steps. Help for family: One good resource for the family is to join a self-help group. Al-Anon and Nar-Anon are self-help groups that are specifically available to the family and friends of users and addicts. Family members develop a support network and learn to set boundaries and understand the patterns that are unhealthy in the relationship involving the drug use. Both Centre Dollard-Cormier and Foster have groups for the family members. Family members need to listen to their loved ones. They need to try and understand why they are using. When you understand this, you can help them talk to their physician or psychiatrist about the symptom(s). Work with the persons who are suffering; help them find the resources. When encouraging them to go to AA or other support groups suggest to them to attend a couple of meeting or try several places before ruling them out. Location matters; if the service is easy to get to they are more likely to go. If they feel understood, it will help the process. Please note that they do not have to acknowledge they are an alcoholic or an abuser to benefit. In fact they just need to be minimally motivated to attend and the professionals will help them along. Of course they will get more out of it if they feel it is for them. Remember that you cannot rush the process, but letting them face the consequences of their actions helps.
At a certain point physical consequences become apparent and getting help from a physician is important. Families may panic when their loved one uses after a period of cessation. The ill person will probably feel guilty. You can help by encouraging them to begin again. They can learn what the trigger was that caused the slip and they can start again putting in a new strategy to help when that situation arises. Remember that they are learning all the time and they were successful in the past and they can build on those efforts. Family members need to take care of themselves. A person who has concurrent diagnoses is not going to get better fast. This is a marathon not a sprint. Being overly sympathetic is not helpful, nor is being overly angry. There are psychological processes that are happening to your loved one that do not change overnight. Most people cannot just stop drinking or doing drugs. (Although I have heard of a few that have just stopped, it is not the norm). What can help is making the decision to change and getting support. Families need to believe that the loved one can do it! Even if you do not feel the hope you need to find a way to convey that there is hope. You can understand that they do not feel hopeful but I would suggest saying, “that there is a light at the end of the tunnel it is just that you can not see it. We may not know how to get out of this problem now but there are ways and others have found the way out and you can too; Maybe not alone but with some help.” This means even when the loved one gets discouraged you can help them understand that: “There is a way out of this problem”. The solution is not seen yet, but it is out there and if you keep looking you will find the right resource and support person that best suits them. Please remember that there is interesting and important research ongoing concerning addictions and the mechanisms involved. Tell your loved one to keep searching and that you believe in them and their right to a better life.9
- Centre for Addiction and Mental Health, “Answers to Common Questions on Concurrent Disorders,” Journal of Addiction and Mental Health, September-October 1998, 16.
- Centre for Addiction and Mental Health, “People with Concurrent Disorders,” in Virtual Resource for the Addiction Treatment System, Section 3: Special Populations.
- Centre for Addiction and Mental Health, “Answers to Common Questions on Concurrent Disorders,” op. cit.
- American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 2013.
- http://www.health.gov.bc.ca/library/publications/year/2007/MHA_Working- WithSuicidalClient.pdf 49-51.
- For those inclined there is a great article in APS the Association for Psychological Science Volume1, (2) April 2013 pages 192-212.
- More recently the police have seen that there is a rise of interest in experimenting with prescription drugs that they take from a family member prescription, buy from a dealer, or go to several doctors to increase their prescriptions. Unfortunately street drugs are being mixed with medical drugs and causing fatalities. There is a rise in overdoses due Fentanyl and this summer three local youth died from fentanyl tainted drugs. Young people are not aware of how these drugs are produced and what dealers are willing to do to get them hooked on other drugs while purchasing the less serious drugs. http://www.northislandgazette.com/national/vancouver/321491131.html August 11, 2015. The drug is very potent and can be easily mixed with other substances