Co-occurring Disorders

“I really want to make changes in my drinking and use of drugs.” “I am constantly bombarded by thoughts… I can’t explain them - they won’t stop.” I don’t mean to do the things that I do, but I am always getting in trouble.” “I know I want to stop, and I have tried, but it’s not working.” Make no mistake individuals with a substance diagnosis and a mental health diagnosis know that something is not right and that they need help. However, getting help is another story, because society as a whole does not agree with what needs to be done.

In 2005, the literature showed that in co-occurring disorders treatment plans, they “Lacked specificity; lag behind current practices, sometimes reflect a disagreement about important details; may not apply specifically to co-occurring disorders; lacked empirical support” (Reedy & Hall, 2008, p.50). By 2008, the National Association of State Alcohol and Drug Abuse Directors, created a four quadrant model to help caretakers, therapist, counselors, and others to place individuals with a co-occurring diagnosis in either one of four quadrants. Why? Because it is hard to create a standard of care that is universal among individuals with co-occurring disorders due to the variety of diagnoses. For example, an individual might have an anxiety disorder and an alcohol addiction or depression and a gambling addiction. The possibilities are endless, and the interventions and treatments are going to vary based on the diagnosis.  So, some people might say, “Service providers need to collaborate;” “Case management is suggested;” “Fully integrated care” is needed, but others saw a need to integrate services, and they are moving to a more united front.  The four quadrants allow treatment providers to place an individual in a quadrant, and then the provider can prepare a treatment plan for the individual.

According to Reedy and Hall (2008), “… agencies need to implement careful and thorough screening and assessment procedure” (p. 45). While it appears there are improvements being made in this area, some providers are not trained to do thorough assessments/screenings. Providers need to be effectively trained to screen for co-occurring disorders. Providers need to “View co-occurring disorders as the norm rather than the exception” (p.48). Assessment and screening forms in the mental health field and the substance abuse field should include questions regarding both fields. The article implies that if information is not shared about the client between agencies, then the client is not receiving adequate care and the chances of having some type of improvement are minimized and less effective. So, “ideally” treatment plants for individuals with co-occurring disorders would include a “fully integrated” treatment plan (Reedy & Hall, 2008, p.50).  Perhaps, a reason for the inadequate care is the lack of “dully” credentialed individuals, but that does not mean that the individuals that are taking care of the patients can’t be creative in the treatment plans and referrals that they make.

While researchers are trying to decide what the standard of care is, we are lacking empirical studies that could help providers treat the younger generation. Children and adolescents with a mental illness and substance abuse problem impact our educational System – through lower grades, lower attendance rates, and a higher probability to drop-out of school. The American Academy of Child Adolescent Psychiatry (2007) published statistics that showed some children 12 and older were using illicit drugs, tobacco, marijuana, and vicodin (p. 2). According to Substance Use and Academic Outcomes, substance use “impairs cognitive development which, in turn, reduces academic achievement and disrupts academic progression” (King, 2006, p. 1) Substance use has an effect on an individual’s cognitive development. The effect can be likened to having a brain problem; “Addicts can articulate very well the consequences of their behavior. But they fail to act accordingly. That’s because of a brain problem… (likened to) damage in the ventromedial area which causes a disconnect between what you know and what you do” (Gladwell, 2005, p. 60).

            Mental illness is thought to be a brain disorder as well; although, not all people are willing to accept a mental health diagnosis due to the stigma that surrounds it. Children that have an ADHD diagnosis have an inability to “control their behavior and/or pay attention;” whereas, children that are depressed have a problem with their “ability to think, feel, and behave in a normal manner” (NIDA, 2007, p. 1); are you seeing similarities? Substance use and mental illness impair a child’s ability; this in turn, can have an effect on their social life, the desire to achieve, and their behaviors displayed. These impairments will have an impact on their ability to learn, and the educational systems ability to help them; without appropriate supports. 

What does the future hold for children and adolescents with a dual diagnosis? The future looks grim; without appropriate supports their worlds will continue to spiral downhill. Their academic outcomes will likely be met with failure and/or extremely challenging. This will cause a lack of desire to try – educationally. Socially and behaviorally the individually will not be “normal,” and thus they will be shunned by the majority of society. Chances are all of this will lead to a high probability of being incarcerated in the future. So, what are appropriate supports for adolescents?

First, it is important for the interview to include “A consensus approach… combining self-report and interview data, along with collateral reports and longitudinal data accumulated by case managers through repeated contacts over time”(164) the authors go on to explain that we must provide interventions that benefit both types of disorders, “For example: provide training in social skills and effective communication, problem solving, stress management, increasing pleasant activities, vocational rehabilitation, and cognitive-behavioral techniques and coping skills”  (Monti, 2002, p.174-176). Children and adolescents might have a hard time expressing all of their thoughts and ideas, so it might be beneficial if they can write in a journal/diary or have materials that are age appropriate.

There are five general principles that people need when interviewing individuals with a mental illness and substance abuse problem. They are: “it is nonconfrontational; (2) it views motivation for change as a dynamic state rather than a static state; (3) readiness to change can be influenced by major life crisis and by therapeutic interventions; (4) building readiness to change may be a long-term process; and (5) key elements include discrepancies, altering the perceived cost-benefit ratio, and enhancing self-efficacy” (White, 1998, p.48).

Children are not the only ones that need help. African Americans are suspiciously, and excessively “undiagnosed, minimally treated, and untreated…” which in turn, leads to “serious practice and policy implications that may mitigate or exasperate the inequalities in health that blacks experience” ( Hatcher, S., Toldson, I., Godette, D., & Richardson, J.., 2009, p.1).

“By the mid-year 2007, Blacks were almost three times more likely than Hispanics and five times more likely than whites to be jailed,” and currently 1.1 million of 2.6 million incarcerated individuals are African Americans in the United States (Hatcher, S., Toldson, 

I., Godette, D., & Richardson, J.., 2009, p.1). This means that the court system has incarcerated some individuals that would fall into the category of having a co-occurring disorder, and that they  based their decisions (rulings) on the moral model: to treat individuals. The deficiencies found in these people are due to a spiritual or character deficit: The individual chooses to do something bad; in turn, they deserve the consequences that result in their actions. By using this type of model, they create a stigma and contribute to the improper treatment of individuals that are incarcerated. This can be seen through the policies that “Play a role in the criminalization of mental disordered persons. Many people with mental illness may be arrested for minor acts that are in fact manifestations of their illness and their lack of treatment” (Hatcher, S., Toldson, I.,  Godette, D., & Richardson, J.., 2009, p.2). The same can be said of individuals with a substance abuse diagnosis.

As long as individuals cannot receive adequate treatment, they will be unable to function in society in an acceptable manner. “A 2001 report of the surgeon general discussed disparities in access, treatment, and quality of mental health care form minorities. Contributing factors associated with mental health in the African American community include: 1. Historical adversity; 2. Impeded access to insurance; and 3. The help-seeking traits of African American, whose traditional attitudes toward mental illness are considered a barrier in that they include stigmatization” (Hatcher, S., Toldson, I., Godette, D., & Richardson, J.., 2009, p.2).

Over the last few years, some courts have started using mental health court and drug court to make a difference. There has been some progress, but there needs to be more changes made within the court system. The laws need to be changed to treat a person using a combination of models rather than one model which just incarcerates the person. Incarcerating them does not treat the underlining condition.

In fact, the changes need to be made and implemented to help individuals before they are incarcerated. That is why it is imperative that these issues be addressed during childhood. The United States stresses physical check-ups for children, but they do not stress mental health check-ups. I would argue that mental health check-ups are just as important as physical check-ups.

There is no “One” intervention and treatment for individuals with co-occurring disorders that is the “Cure”. In fact, it appears that when you look at the interventions and treatments that are utilized among co-occurring disorders there is one similarity – multiple interventions and treatments are used. According to NIDA, there are thirteen principles of effective drug addiction treatment. Alcoholics Anonymous (AA) feels that there are twelve steps to the road to recovery. Then, there are others that believe in a sixteen step program. However, the Frequency of Prayer, Meditation, and Holistic Interventions in Addictions Treatment shows how some programs are “Endorsing the twelve step approach and the use of prayer, meditation, and holistic techniques” (Maharishi, 1994, p.1). What are prayer, meditation, and holistic approaches? How powerful are prayer, meditation, and holistic approaches?

            Let’s take a look at prayer, meditation, and holistic approaches, as applicable in the article. Prayer is a common technique that is used by individuals with a mental health diagnosis and a substance abuse diagnosis. “Spirituality is recognized as a potential important part of treatment” (Maharishi, 1994, p.1), as such it is encouraged if an individual has a spiritual belief. Meditation varies across the intervention and treatment practices. The three categories that were found in use were: “(1) Devotional meditation…; (2) other spiritual approaches that eschew thinking and contemplation…; (3) secular modification … secular meditation, relaxed awareness and focus of attention are used in a manner similar to that of Eastern spiritual meditation traditions” (Maharishi, 1994, p. 3). The article discussed the holistic techniques that were used, and it placed them in four categories: “(1) nutrition, exercise, relaxation and physical health; (2) recreation and adventure-based activities; (3) religious and spiritual practices; and (4) the use of specific modalities” (Maharishi, 1994, p.4). Is there power in prayer, meditation, and holistic approaches? Obviously, some people are influenced by prayer, meditation, and holistic approaches and others are not.

In order for a person to benefit from the treatment that they receive, they need to receive knowledge in regards to the Alcohol and other drug dependencies, along with information about their mental health diagnosis. The individual will have to work through the “Stages of change: pre-contemplation, contemplation, preparation, action, and maintenance” (White, (1998), p. 38-40). The individual should be given a diary to move between the stages. According to Addiction Intervention, it promotes moving between the stages by “(1) consciousness raising (increasing information about self and problems); (2) dramatic relief (experiencing and expressing feelings about one’s problems and solutions) and; (3) environmental re-evaluation (assessing how ones problem affects the environment and others)” (p. 43). It’s not easy to examine oneself; to look at the flaws and imperfections with an open mind and a willingness to change. It is even harder for a person with a co-occurring disorder.

When an individual takes action to stop the addiction, they are plagued with the symptoms of their mental illness diagnosis or vice versa.  Individuals with a co-occurring disorder have to fight the stigma society places upon them, and they have to fight the addiction and mental illness. That is a lot to place on anyone’s plate. Statistically, the chances of recovery for an individual with a co-occurring disorder are low. But, as time goes on and improvements are made (technology advances); the hope is that we will be able to help more individuals with a co-occurring disorder.

I have enjoyed the research and information that I have gathered this semester for this class (and the lectures). I look forward to the classes that I will take next semester and the knowledge that I will gather. I plan on putting the knowledge to good use within the mental health field and addiction field.

 

References

Child and Adolescent Mental Illness and Drug Abuse Statistics. (2009, March 18). American Academy of Child & Adolescent Psychiatry. Retrieved from http://www.aacap.org/cs/root/resources_for_families/child_and_adolescent_mental_illness_statistics

Gladwell, M. (2005). Blink. New York, NewYork: Back Bay Books.

Hatcher, S., Toldson, I., Godette, D., & Richardson, J.. (2009). Mental Health, Substance Abuse, and HIV Disparities in Correctional Settings: Practice and Policy Implications for African Americans. Journal of Health Care for the Poor and Underserved: Special Issue: Health Disparity Critical Issues, 20(2A), 6-16.  Retrieved October 15, 2010, from Research Library. (Document ID: 1777631601).

Maharishi Ayur-Veda; O'Connell, D. F.; Alexander, C. N., (1994). Introduction: Recovery from addictions using Transcendental Meditation. Alcoholism Treatment Quarterly; 1994 Vol. 11, p1-10, 10p. Document Type: article; DOI: 10.1300/J020v11n01; (AN ATQ.AA.A.OCONNELL.IRFAUT) Database: EBSCO Publishing Citations

King, K., Meehan, B., Trim, R., Chassin, L. (2006). Substance Use and Academic Outcomes: Synthesizing Findings and Future Directions. Addictions, December; 101(12): 1688-1689. doi: 10.1111/j.1360-0443.2006.01695.x.

Monti, P., Kadden, R., Rohsenow, D., Cooney, N., Abrahs, D. (2002). Treating Alcohol Dependance : A Coping Skills Training Guide. (2^nd ed.). New York, New York: The Gilford Press.

Reedy, A., & Hall, J. (2008). Treatment issues with substance use disorder clients who have mood or anxiety disorders. Mental Health & Substance Use: Dual Diagnosis, 1(1), 44-53. doi: 10.1080/17523280701741738.

White, R., & Wright, D. (1998). Addiction Intervention. Binghamton, New York: Hayworth Press.