Authors: Kathleen Sciacca, M.A. and Agnes B. Hatfield, Ph.D.

From: Lehman, AF, Dixon LB (ed). "Double Jeopardy: Chronic Mental Illness and Substance Use Disorders," Gordon and Breach Publishers, Chapter 12, 1995.

People who have multiple disorders of severe mental illness, drug addiction and alcoholism "dual diagnosis" have the same severity of addictive disorders as do people who have addictive disorders alone.

They also experience exacerbation of both their mental illness and their addictive disorder due to interaction effects. Their families experience the disruptions evoked by addictive disorders alone.

This is in addition to the stressors of coping with a serious mental illness. Although many studies (Hatfield, 1990; Lefley,1987; Marsh 1992) have shown that families of mentally ill relatives, in general, report enormous amounts of stress due to mental illness, there are few studies that have looked at the added burden due to substance abuse problems.

One study (Kashner, Rader et.al. 1991) reported that substance abuse contributes to family conflict, erodes social support, and generates high levels of expressed emotion, thus disturbing the vitally needed caregiving network.

A dually diagnosed individual can throw the best of families off balance. Therefore, it is important to provide services for families.

Our divided systems of care for mental illness, drug addiction and alcoholism include our educational programs and clinical training. As a result, there are serious gaps in services for the dually diagnosed (Ridgely, Goldman & Willenbring,1990), and for their families. This has also effected the development of advocacy groups.

One example, is the "National Alliance for the Mentally Ill" (NAMI). NAMI is an advocacy group that began from grass roots movements of families with mentally ill relatives in the 1970's and has since grown to over 1,000 local chapters (Grosser, Vine, 1991: pp.282-290).

The "family movement" has a strong influence on research and treatment of individuals with severe and persistent mental illness (U.S.News and World Report, 1989).

However, as recently as 1984 when pioneer programs were developed for the treatment of persons with mental illness and substance disorders in the psychiatric facilities (Sciacca, 1987), many family members accepted a mental health system and a substance abuse system that did not address their relative's addictive disorders.

In a recent national survey of family perspectives on meeting the needs of people with mental illness conducted by NAMI (Steinwachs, Kasper, and Skinner,1992) 18 per cent of the respondents indicated that getting drunk or using drugs occurred in their families. Of these families 62 per cent found this a serious problem.

It is important to note that the 18 per cent substance abuse reported in the NAMI study is a much smaller prevalence rate than most other studies report.

For example the Epidemiologic Catchment Area (ECA) study conducted by the National Institute of Mental Health (Reiger,Myers,et.al.1984) found that 47% of individuals with a diagnosis of schizophrenia or schizophreniform disorder were abusing drugs.

In a national survey conducted by the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) (Ridgely,Osher,& Talbot,1987), it was reported that at least 50 per cent of the 1.5 to 2 million Americans with severe mental illness abuse illicit drugs or alcohol as compared to 15 per cent of the general population.

The lower rate reported in the NAMI study may be explained in one of several ways. Members of NAMI are not fully representative of all families with mentally ill relatives.

It is possible that there is less substance abuse in their relatives. It is equally possible that families see the mental illness as the primary source of disturbance and overlook the substance abuse.

Some families may not be able to distinguish problems due to mental illness from those due to substance abuse. Still others may deny the problem out of shame, guilt or embarrassment. A growing awareness of the problems and some solutions to the provision of treatment of persons who are dually diagnosed is under way.

Much has been written about the problems of substance abuse among mentally ill patients. These patients have been characterized as systems misfits with poor outcome, more relapses, more acting out behavior, and more likelihood of being homeless (Minkoff and Drake,1991).

Dually diagnosed patients experience interaction effects that compound their distress and disability (Evans and Sullivan 1991). These patients tend to respond to their distress by exhibiting highly disturbing acting-out behaviors (McCarrick, Manderschied, et.al. 1985)

Despite these serious consequences, the family movement has not attained the degree of knowledge about addictive disorders as they have about mental illness. There is a need for education that demonstrates that addictive disorders are illnesses.

Understanding mental illness as a disease that is not caused by families was necessary to successful advocacy for the mentally ill. The same advocacy must happen for those who are dually diagnosed, through a clear understanding of the addictive disorders. Families of the dually diagnosed continue to experience frustration resulting from a service delivery system that does not meet their needs, or the needs of their relatives.

The purpose of this chapter is to discuss some of the issues and problems, and to outline a model program "MICAA-NON" for families of the dually diagnosed. We will begin by clarifying some of the areas that effect the delivery of services.

Next we will report on our family survey, the Maryland study, which provides a family perspective of the issues. This will be followed by an outline of a pioneer program and some assessment considerations.

ISSUES THAT IMPEDE SERVICES FOR THE DUALLY DIAGNOSED AND FAMILIES.

Both families and providers encounter difficulty in accessing comprehensive services for the dually diagnosed. The underlying issues are the same nationally.

They include:

1. Divided bureaucracies across discrete disorders, mental illness, drug addiction and alcoholism and segregated admissions criteria, treatment programs, services, and reimbursement;

2. Providers are educated and trained to deliver services for singular disorders, and are not prepared to provide services for unfamiliar symptoms (Ridgely, Goldman,& Willenbring,1990); and,

3. Treatment approaches across these discrete disorders are different in method and philosophy and are in direct contrast and incompatible (Sciacca,1991).

The more impermeable issues are the contrasting treatment methods used by providers in the different fields. Traditional treatment methods for drug addiction and alcoholism are usually intense and confrontational.

They are designed to break down the patient's denial or resistance of his or her addictive disorder. Admissions criteria to substance abuse programs usually require abstinence from all illicit substances.

Potential patients are expected to be aware of the problems caused by substance abuse, and motivated to receive treatment. In some programs the use of medication unacceptable.

This automatically excludes people who take prescribed medication for their symptoms of mental illness. In contrast, treatment methods used for serious mental illness are supportive, benign and non-threatening. They are designed to maintain the patient's defenses which are often fragile to begin with.

Criteria for admission into mental health services rarely require that patients are aware of their substance abuse problems and motivated to accept substance abuse treatment. Patients entering the mental health system are generally not seeking treatment for their substance abuse problems.

Within the mental health system we encounter patients who actively abuse drugs and alcohol, and deny such use. Respondents in our Maryland study selected denial of the problems of substance abuse (77 %) as the most problematic behavior they encountered in their dually diagnosed relative (see table I).

These differences perpetuate the gaps in services and eliminate the dually diagnosed from existing services. The traditional substance abuse services will not accept patients who have a serious mental illness either because they do not meet the readiness criteria, or because they are not prepared to provide services for symptoms of mental illness.

If accepted into a substance abuse program that is not modified, the dually diagnosed patient may experience difficulty when participating in an intense, confrontational program. Traditionally, the mental health system attempts to eliminate the dually diagnosed patient on the basis of substance abuse at the point of admission.

For patients within the system, services are interrupted or terminated on the basis of rules that address addictive behaviors. Families who do not understand the addictions as disorders will accept these determinations. Without knowledge of the necessity of professional treatment, family members are not likely to perceive their relative's entitlement to addiction treatment.

The result is frustration and hardship for families who bear the burden of caring for a relative who does not receive the benefits of professional help, or the pain and fear involved when a family can no longer provide primary care.

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Copyright, 1996 Kathleen Sciacca

Article excerpt reprinted with kind permission of Kathleen Sciacca.

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