Dave's Progress. Chapter 111: The Problems of Dual Diagnosis.

A "dual diagnosis", in the mental health field, is usually applied when a patient/service user presents with both a mental health condition and a substance abuse problem. It is often the case that those experiencing mental illness can "self-medicate" with alcohol or other drugs. Conversely, the consumption of such drugs can lead to mental illness. The professional is then left with a serious dilemma- is the mental illness driving the substance abuse, or is the substance abuse driving the mental illness? It is often difficult for mental health staff to know the answer to this question, and treating those who abuse alcohol, for example, can be a lot more difficult than those who present with a mental health condition alone. What is known, though, is that instances of those presenting with substance abuse and mental health problems is on the increase. If I recall correctly, in a meeting of the steering group for the treatment of psychosis in my area, an outreach worker suggested that something like 60% of people coming in to mental health services also had some form of substance abuse issue. We were also told at the Pathways Group in a talk by Paul Hammersley (a lecturer, CBT counsellor and leading member of the CASL campaign) that substance-induced psychosis was on the increase.
Mental Health practices, then, would appear to have a serious problem on their hands, one which, if my own experience and what I have read is anything to go by, they are not doing all that well in dealing with.
As a service user I have come to understand just how difficult it is to treat those who have both substance abuse and mental health problems, but what truly scares me about this issue is the apparent amount of prejudice amongst mental health staff against patients who present with such issues. Indeed, those, particularly, who are seen as having a substance-induced problem, seem to be seen by many as not "genuine" cases, in that it was an act of their own will which brought them to that situation. I have even had it relayed to me by one psychiatrist that many see such patients as "not their problem", or they have a "problem with" treating them because they view their condition as self-inflicted, whereas "genuine" mental illness is never a matter of such choice.
My own experience of mental health services would seem to confirm such worries. Despite a history of depression, mania and psychosis, I came to be seen, somehow, at one point in my treatment, as simply a drunk. True, I was drinking heavily at the time, but in the absence of any medication at all, alcohol was my only coping tool. Since I have been on medication and have got better, my problem with alcohol has abated. But at the time, I felt I was being treated by mental health services as some sort of social pariah. I was spoken to in ways that, as someone who was genuinely ill, and as it was later admitted, should never have happened. There also seemed to be glaring contradictions in my treatment. Where I was once sectioned whist under the influence of alcohol, when I came to actually try to get in to hospital later on in the same condition, I was told bluntly that I could not be assessed whilst drunk. This had not prevented my sectioning before and also one psychiatrist telling me, upon my protests that I was not a danger to myself or anyone else, that I was a danger to myself because I drank. Why the contradiction? Why the resentful attitudes towards me? I can only see it as a confirmation that many in mental health practice do indeed harbour prejudices against those who have substance misuse problems. But what is to be done when 60% of those entering mental health services have some form of substance abuse issue? Are they to be treated with similar contempt?
It is not just me, it seems, who is saying this. Professor Graham Thornicroft (yes, my favourite guy is back!) states, in his book about stigma, "Shunned", that:
"In a British study using case vignettes, consultant psychiatrists were asked to assess the influence of a past diagnosis of alcohol dependence on their views about what treatment they would recommend. Psychiatrists reviewing the vignette with the diagnosis of alcohol dependence were more likely to rate the patient as difficult, annoying, less in need of admission, uncompliant, having poor prognosis and more likely to be discharged from follow-up."
Indeed, I was so upset by my own experiences that I once wrote to Dr. Lisetta Lovett at Keele Medical School regarding what had happened. She returned by saying:
"I agree with you that health professionals as well as society are very intolerant of conditions perceived as self-inflicted such as alcoholism. It is not easy to change public attitudes but professionals should be just that...professional in their attitudes, that is non-judgemental."
In the end, I had to go in to private treatment, at a great expense to my parents. I was detoxed, diagnosed and medicated within two weeks and since then, apart from one blip, I think, I have only gotten better. The whole charade which I went through under NHS care went on for around, if I remember correctly, 18 months. Something, ladies and gentlemen, is obviously wrong with that.
I hope that mental health staff would take what happened to me as a cautionary tale, and to consider just why they may be so dismissive of those who abuse alcohol or other substances. After all, with an increasing number of people turning to the bottle or other drugs in their desperation and despair, it is perhaps unlikely that you will never come in to contact with such patients.   
 

Comments

klahanie said…
Dear David,
This is indeed a most thought provoking posting. Now, you and I have had a chat about what you allude too. Thus, I'm going to just add a point.
To me, it should be rather obvious that alcohol abuse, addictions to any drugs, can be considered, in its own right, a form of mental illness. In fact, self-medicating can exacerbate an ongoing and potentially underlying mental health concern. It's something more of the professionals within the field should take into account.
Anyway, thanks for this enlightening article, David.
With kind wishes, Gary.
bazza said…
Hi David. When I was training to be a counsellor we learnt about dual-diagnoses. I think it's a well-recognized fact that there are 'addictive personalities'; certain people are much more likely than others to become addicted to something. But are mental health issues of other types related to this? I accept that addiction can be viewed as an illness but is a person with, say, bipolar disorder more likely to become an addict of some kind?
It's an interesting thought.
Bazza’s Blog ‘To Discover Ice’
David said…
Dear Gary,
Yes, we have both had experience of what I speak of. In fact, I think it is a bit of a rarity to find someone who has not abused some drug at some time in order to cope with or mask a mental health condition. And,as you say, it is something that mental health professionals should take in to account. One hopes, then, that the prejudice many seem to harbour concerning this issue is on the wane.
Thanks for the comment, Gary.
Take care and very best wishes,
David.
klahanie said…
Hey David,
Thanks for your response. And yes, I'm still awake!
David said…
Dear bazza,
As far as I know, having a mental illness does not predispose you to becoming addicted to some substance or other. I do know, however, that many, perhaps in the absence of proper medication, "self-medicate" with alcohol or other drugs. To the sufferer, such self-medicating may be perceived as aleviating symptoms, whereas in fact it can make things a lot worse. Alcohol, for example, is a depressant, and so if you are already depressed, can make you even more so. Cannabis can make you paranoid and lead to hallucinations. But does this mean you are "genuinely" psychotic? This is why it is sometimes so hard for professionals to decide what comes first, the mental illness or the substance abuse problem.
I would hope, though, that having a mental illness does not mean that you are also automatically more likely to become an addict.
Thanks for the intersting thought, bazza.
Hoping you and yours are well and happy,
David.
David said…
Dear Gary,
Just woke up at around 3 am, so thought I would see if I had any comments, and sure enough, your good self and bazza have been kind enough to leave your thoughts.
But if you are reading this, Gary, please try to get some sleep!
Maybe I should sing you a lullaby? Or maybe NOT!
Hope you get some well deserved zzzzz's.
All the best,
David.

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