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Blamed and Ashamed: The Treatment Experiences of Youth With Co-occurring Substance Abuse and Mental Health Disorders and Their Families

How Do the Data From the National Co-Morbidity Survey Fit With the Experience of Youth and Their Families?

Blamed and Ashamed!

There are individuals who have no mental health problem and who become involved with the use of alcohol and drugs because they want to change the way they feel. These single-disorder individuals start out feeling o.k., but want to feel even better. Then substance abuse and addiction can make them feel much worse.

But for depressed or anxious, shy, fearful, or hyperactive children and adolescents, the motivation for drug use is very different. They are trying to just feel normal.

Mental health symptoms can be temporarily relieved by ‘medicating’ with alcohol, marijuana, or cocaine. However, as drug effects wear off, the post-intoxication rebound tends to worsen the original bad feelings, causing a double motivation to use more and more drugs and alcohol.

The Continuum of Abuse:
The earlier alcohol and other drug abuse starts, the shorter and faster the road to abuse and dependence:

• Experimentation: Almost all drug abuse begins this way. Young people are curious, feel invulnerable, and just want to see what it’s like.
• Recreational alcohol and other drug abuse: If experimentation progresses, the young person will be using, with friends, once or twice a week...or every day.
• Habitual use: With continued recreational use, vulnerable individuals, especially those with a mental health problem, increase the amount and frequency of use.
• Drug abuse: When alcohol and other drug abuse becomes so frequent and important that it interferes with school, family life, and personal development, the person has reached this level.
• Drug dependence: If the situation grows even more serious, the individual’s body craves the drug, and avoidance of the pain of withdrawal becomes an additional motivator for drug use. Now the central focus of the person’s life is the acquisition and use of drugs.

Many people who are familiar with the concept of the continuum of abuse do not know that the length of time it takes to go from one stage to the next varies with the age of first use.

• Someone who begins experimenting in their twenties may not become dependent until their fifties, if ever.
• Someone who begins recreational use at 16 may become dependent by 20.
• A child, beginning to use drugs at 10 or 11, may become dependent within just two years.

This information has been substantiated in study after study, looking at a wide variety of drugs, from nicotine and alcohol to cocaine. That is why, from a public health and family perspective, we should do everything we can to delay children’s first use of any intoxicating substance, including tobacco. (Figure 2)

Do mental health and substance abuse problems in childhood and adolescence affect the maturation of the individual?

We often see that the early development of anxiety, depression, thinking problems, behavior problems, when compounded by early use of drugs and alcohol, interfere with the development of a mature, stable, functional personality and sense of self. I have identified several common personality immaturities that may result from childhood and adolescent mental health/alcohol and other drug abuse problems. Each is normal in a young child:

• Low frustration tolerance: Trouble working hard, and sticking to it, when gratification is not immediate.
• Lying to avoid punishment.
• Hostile dependency: A dependent person, unable to do things on their own, may have trouble developing a confident, independent self. Continued dependency may be expressed as hostility toward the very people whose help they need, such as parents. Hostile dependency, although often directed against others, may really be directed against the self. In extreme cases it can lead to a suicide attempt.
• Limit testing: All children test limits; that is a normal part of childhood. It is a troublesome form of immaturity when it persists into later adolescence and adulthood.
• Alexithymia. Children and older people with this condition are unable to verbalize their feelings effectively. As a consequence, they may act out their feelings, just as young children do. Rather than verbalizing anger, they may strike out physically. Rather than talking about their fears, they may avoid, run away, and hide. Instead of talking about feelings of hopelessness and depression, they may act out by attempting suicide. People with alexithymia can’t soothe themselves or ask for help. Learning to talk about feelings is a key step in recovery.
• Present tense only: Very young children only live in the present. They do not have a sense of future, cannot anticipate consequences of their own behavior, and have not become able to learn from past experiences. Adolescents who have no clear sense of past and future can repeat the same mistake over and over again.
• Rejection sensitivity: Young children, and many people with co-occurring disorders are so eager to please, have friends, and be accepted, that they may agree to do things that they don’t really want to do. They may seek approval by trying too hard to please. If their efforts fail, they may feel terribly rejected, withdraw, and not try again. They can be very thin-skinned.
• Dualistic: Young children, when they first learn the difference between right and wrong, put every action into one or the other category: Something is either Right or Wrong. As a consequence, moderation is a problem. A slip—having a glass of wine at a birthday party—may be so wrong that they might as well go ahead and get drunk. Dualism can turn a slip into a relapse. Dualistic judgment toward a counselor or a parent can cause condemnation; that person is now useless and hopeless.

A model for personality development: The Maze

Everyone’s life consists of an unending sequence of conflicts and problems (Figure 3). The individual whose development goes along a positive track learns, with the help of parents, to climb the steps and enter the maze: It represents the struggle of learning to resolve conflicts and problems. When the person finally makes it out through the maze, no matter how long it takes, there is an increase in maturity and competence. Every time you make it through you have increased your self-esteem and effectiveness.

A troubled youth may drop into the drug intoxication evasion loop and out of the maze. While in the drug-evasion loop there are many problems and conflicts; nothing gets resolved. Remember, it is the resolution of problems and conflicts that leads to maturity.

The interactivity between mental health problems and substance abuse problems:

One reason that we cannot treat these problems separately is that they are interactive within the individual. The brain of a person with a mental health problem may be exquisitely sensitive to being disorganized by even tiny amounts of alcohol, marijuana, cocaine, or amphetamines. For all practical purposes, such individuals are ‘allergic’ to drugs, in the sense that a little goes a very long way.

What happens to the social life of the person with co-occurring disorders?

As can be seen from the sociogram (Figure 4), a person’s relationships with others vary in type and intensity:

• At the fifth level of our social network we have acquaintances. They sell us a cup of coffee in the morning, or cash our paycheck at the bank.
• At the fourth level we have casual friends. We do not keep in touch with them on a regular basis, but are glad to see them when we cross paths.
• At level three are our good friends. We stay in touch, and they care about us.
• The second circle contains those few friends who are our most trusted intimates. These are the individuals who we know will never intentionally hurt us and can be counted on to go out of their way to help us if we are in trouble. You are rich if there are three people, other than family members, in your second circle.
• The inner circle shows the private zone. It is shared with no one. The shaded portion refers to the part that is repressed and is not even accessible to the person, while the unshaded portion refers to the part that is suppressed, remembered, but secret; not shared with anyone else.

When someone with co-occurring disorders first comes into treatment, often there is no one in their second circle and few if any in their third circle. Their social network may be nearly empty until we get to the fourth level; casual friends.

The person with mental health and alcohol and other drug abuse problems may experience their drug of choice as their best friend; it seems to fill the emptiness in their heart. Beginning drug abuse treatment, which requires or involves abstinence, may lead to feeling much worse. The ‘best friend’ is gone, and the emptiness within is devastating. For this reason, substance abuse programs must address loneliness, sadness, the sense of loss, and the depression that often accompany early recovery. Otherwise, the person may be motivated to leave treatment and rush back to drug or alcohol use, because they cannot bear their depression and loneliness.

Who says that treatment for co-occurring disorders must be integrated?

In 1999 the National Institute of Drug Abuse produced a slender but powerful booklet: Principles of Drug Addiction Treatment. We do not have space here to list the 13 principles enumerated by NIDA, arising from their vast database of research studies on substance abuse treatment. But item 8 states: “Addicted or drug abusing individuals with co-existing mental disorders should have both disorders treated in an integrated way.”

Item 13 of the booklet is equally important: “Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment.”

How often is treatment for co-occurring disorders integrated in actual practice?

Unfortunately, the answer is: rarely. Many young people find themselves trapped in a situation in which there is not even integration between mental health inpatient and outpatient treatment. And, after residential substance abuse treatment they may find that their outpatient program is not integrated with the residential program. Worst of all, it is most difficult to find fully integrated treatment, in which one team deals with all the client’s treatment and support needs and includes the family in the process.

There are three distinct approaches to treating individuals with co-occurring disorders.

• Sequential treatment: This is the traditional approach, in which the person is first treated in a mental health or substance abuse agency, and then, presumably after effective treatment has been accomplished, the individual is referred to the other kind of agency. In fact, this doesn’t work. This failed form of treatment, for reasons of tradition, history, and separate funding streams, continues to be common throughout the country.
• Parallel treatment treats the person with co-occurring disorders at the same time in two different agencies. If the two agencies attempt to communicate with each other, the treatment is then referred to as collaborative.
• Integrated treatment provides treatment for the mental health and alcohol and other drug abuse problems in one place. The treatment team consists of individuals from varied clinical backgrounds who have been cross-trained to work together. The team develops a long-term treatment plan, in which the goals and different modalities of treatment are sequenced: Everything cannot be done at once.

There is considerable controversy among funding, licensing, and treating agencies as to whether or not integrated treatment is really necessary for all but a few people. Agencies prefer parallel or collaborative treatment because it requires less change. The Blamed and Ashamed report makes it clear that adolescents and their families prefer/demand integrated treatment. Thus, we have a conflict between the treating agencies and those they serve.

Five distinct problems have been noted with parallel/collaborative treatment approaches:

• The young person and their family is caught between the different treatment philosophies and values of the mental health and substance abuse agency.
• It is difficult if not impossible to coordinate two different treatment and recovery plans.
• Treatment is more expensive because of duplicated services.
• Parallel and collaborative treatment fragments the person and is not holistic.
• Dealing with the interactivity of the disorders is virtually impossible when different treatment teams are working with one individual, even if the treaters make a sincere effort to keep in touch with each other.

The tragedy of the current approach: Shifting young people with co-occurring disorders into the criminal justice system.

Everyone has to be someplace. When, in today’s society, the public mental hospitals have virtually been shut down, when there is nowhere else for the person with co-occurring disorders to be, the final ‘three hots and a cot’ are provided by our society in jail.

The best approach to solving the problem of locking up young people with co-occurring disorders in jails and prisons would be prevention, early intervention, and integrated treatment:

• Offering early treatment for children with mental health problems.
• Offering integrated treatment to adolescents with co-occurring problems.

But we are nowhere near that point today. As a stopgap measure, we should be working now to divert young people, before they get to jail. We have three chances. Diversion can be done at:

• Arrest
• Arraignment
• Sentencing

If diversion-to-treatment has not succeeded in time, and the client ends up in jail, we must insist on

• Treatment during incarceration.

But treatment during incarceration is not enough. Relapse rates are very high if, after treatment in jail has taken place, the individual is released to the street without adequate supervision, support, housing, educational opportunities, and vocational opportunities.

What must be done? A goal for all of us to share:

Our wonderful community, the United States of America, must re-invent itself and its systems of services for every citizen, from the infant to the elderly. We must offer support and treatment to every individual, affording that person the opportunity to succeed to the full extent of her or his efforts and abilities. We must provide preventive, supportive, educational treatment and rehabilitative services. We must also support overburdened families, so that the wonders of our technology, our wealth, and our concern for each other benefit all of us.

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