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Why Mental Health Systems Should Be Organized Under Alcohol and Drug Systems

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Why Mental Health Systems Should Be Organized Under Alcohol and Drug Systems

Why Mental Health Systems Should Be Organized Under Alcohol and Drug Systems - Mad In America



While I was in charge of the public systems for both mental health and addictions in Oregon, I found it a challenge to maintain an equal focus on alcohol/drug problems compared to mental health. One big reason for the emphasis on mental health was that the mental health budget was big, about 6 times greater than that for addictions. And that doesn’t even count the hidden funding for psychiatric drugs which probably added another 30 or 40% to mental health —atypical antipsychotics are a lot more expensive than Antabuse.

Although there was a huge difference in state financial support for the two areas, it always seemed to me that the social consequences were just as large and challenging in addictions as in mental health. Partly for that reason, when asked to recommend a new name for an integrated office blending the two previously separated program areas, I chose to put addictions first — the Addictions and Mental Health Division. The state legislature agreed and it became the agency’s name and, at least for the time being, still is. It may have been only symbolic but it was an attempt to stop seeing alcohol/drug services as the "little brother."

Having stepped back and out of the line of fire now for several years, I’ve become more aware of the ways in which addictions seems to be a better conceptual umbrella than I’d considered in the naming process. Consider that the dynamics of "denial" and "enabling" are powerful themes in addictions treatment. Denial is the marked tendency for people struggling with addictions to believe that their drinking or drug use is really under control and that everyone around them is over-reacting. Enabling is the flip side of that coin in which those around them unwittingly play into the denial and without consciously trying actually makes it easier for an addicted person to keep using.

I think these concepts may need just as much emphasis in mental health service--but with an interesting twist: these dynamics seem more applicable to many providers rather than to the people trying to get help for themselves. What if we began to see that the nearly overwhelming reliance on psychiatric medications as a form of substance abuse?

In this way of looking at the issues, it may be that the over-reliance on medications makes enablers of those who open the portal to a cornucopia of prescription use, misuse and abuse. There may also be a close parallel to the addiction dynamic of denial. The evidence of overuse of psychiatric drugs has been there for a while but what well-intended medical professional would acknowledge doing anything to contradict the maxim, First Do No Harm?

But ask this question: Is it any easier to withdraw from neuroleptics than from alcohol or heroin? I'd say the answer is withdrawing from antipsychotics and antidepressants is more difficult. As far as I know, there's no such thing as a week's detoxification from neuroleptics or antidepressants as there is with booze. And if you think of extended rather than acute withdrawal, the reset time for going off a range of psychiatric medications can be even longer than for the process with alcohol and street drugs. We all know people or have experienced this ourselves--it often takes years.

The denial process about this underlines the problem. Denial of what should by now be fairly obvious seems as powerful in the mental health provider community as in the drug addicted community. While more and more mental health workers (including, fortunately, an increasing number of psychiatrists) are waking up to blind beliefs in what the pharmaceutical companies have promoted, there are still far more mental health "prescribers" who write prescriptions, often for polypharmacy, without themselves having an informed appraisal of the risks for dependence.

There are certainly differences in the substances involved. Except for benzodiazepines, the neuroleptics and antidepressants and mood stabilizers don't exactly give you a high. But some of the effects are the same when a withdrawal phase begins—one’s physiology and psychology have made their adjustments and most people feel even worse for an extended period of time when going off both kinds of mind and mood altering drugs.

Maybe I was right in a way that I didn't recognize at the time--Mental Health would be better off subsumed under Addictions. Perhaps then we could begin to think more clearly about our dilemmas in mental health such as modeling our approaches even more on the recovering community’s perspectives. For example, I learned a great deal about the importance of recovery working with blue collar workers in an outpatient program in Southern Oregon when I first moved into a professional post-graduate position. I learned that peer support is nothing new in the alcohol/drug world. Whether that comes in the form of 12 step programs or other support groups, there is far less reliance on long-term treatment from professionals or certainly "case managers."

There are aspects of the addictions world I wouldn't want to replicate any more than we’re already doing. Forced treatment and compliance with legal sanctions is fairly well accepted there--and maybe understandably given the immediate dangers that drunk driving or drug-related crimes represent.

But it's time for mental health systems to take a second look at how alcohol/drug systems think about things, especially the open admission of the challenges in moving away from a drug-based life and culture. Maybe then we could see more clearly the way in which mental health systems have demonstrated just as much denial and enabling behaviors in our slow but steady evolution to the 15 minute medication check approach. But are we ready for such humility? I am going to be hopeful that we are.
Robert Nikkel, MSWRobert Nikkel, MSW

Policy for Recovery: As a former state mental health and addictions commissioner, Bob Nikkel writes about policy and practice changes that are needed to promote recovery and reslience while decreasing the over-reliance on psychiatric medications in community and hospital treatment settings.
 

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Nikita said:
When I was in hospital there were a couple of recovering alcoholics there amongst us.I didn't like that, I was mentally ill due to causes complex and distressing, not least abuse and verbal and emotional violence.Being lumped together with suffering addicts didn't help me feel good.Their problems are nothing like ours,after all all they have to do to get better is stop drinking,why should resources meant to help those of us who through no actions of our own breakdown go towards helping those who choose to be addicts.They made me feel uncomfortable and I also felt unsafe, these men were so obviously addicted to the booze, shaking from their withdrawals and almost always involved with women who were also alcoholic and their drinking partners and i was meant to be alongside them healing and keeping them company.i resented them cos it felt they were given higher importance and priority.I do not think that addiction should be treated alongside mental illness at all,I think they should be kept separate,addiction is not mental illness, certainly alcohol addiction is different from say problems with food disorders etc And schizophrenia and Bi-polar etc are nothing to do with alcohol addictions!
i think it's complex.

Addiction/alcoholism i think can be primarily considered to be a health condition, & i think it crosses into many mental health areas.

A lot of people are also dual diagnosis - by some counts 50% of those suffering with diagnosed mental health conditions have co-morbid addiction issues.

Eating disorders are interesting, i think there are strong correlations with addictive behaviours/traits - the mechanisms are very similar.

At the core of all addictions are certain behaviours/emotions/experiences/responses & others aspects that i think do share commonality with a lot of areas - we're living in a very addictive culture - with materialism, sex, & many other behaviours & traits as to how a lot of people are living & functioning.

Drug/Alcohol dependency/abuse is i think a symptom of a deeper condition.

What do you suggest we do as regards to genuine dual diagnosis?

What do you think about the observation in the article that there are those (some) who are suffering addictive aspects to their mental health conditions with dependency on psychiatric medications/poly-pharmacy?
 
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Kerome

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Nikita said:
When I was in hospital there were a couple of recovering alcoholics there amongst us.I didn't like that, I was mentally ill due to causes complex and distressing, not least abuse and verbal and emotional violence.Being lumped together with suffering addicts didn't help me feel good.Their problems are nothing like ours,after all all they have to do to get better is stop drinking,why should resources meant to help those of us who through no actions of our own breakdown go towards helping those who choose to be addicts.They made me feel uncomfortable and I also felt unsafe, these men were so obviously addicted to the booze, shaking from their withdrawals and almost always involved with women who were also alcoholic and their drinking partners and i was meant to be alongside them healing and keeping them company.i resented them cos it felt they were given higher importance and priority.I do not think that addiction should be treated alongside mental illness at all,I think they should be kept separate,addiction is not mental illness, certainly alcohol addiction is different from say problems with food disorders etc And schizophrenia and Bi-polar etc are nothing to do with alcohol addictions!It was like during the 70's and 80's hospitals kept victims of rape who ended up with mental illness in institutions alongside men who were rapists who were also diagnosed mentally ill.That should not have been allowed to happen.I say alcoholics should have their own services and budgets.
I generally agree that it would be better to give them separate budgets and facilities, but not sure if it is practical. On the surface of it the symptoms can be similar, with psychosis and delusions and sitting and shaking. So a physically based physician might say the treatment should be similar as well. But I think you're right the approach to curing people should be quite different.
 

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Nikita said:
I don't know if you are correct CPU that addictions and mental illnesses have similarities.You seem to be keen on blurring the distinctions.I don't think in the context of mental illness itself being dubious as to whether it is a proved illness or not you can then go on to call an alcoholic whose main problems stem from drinking as mentally ill too.The mentally ill person is not ill unless massively overdosed on recreational drugs like I did from mental illness.I had dabbled in cannabis use but exhibited mental illness symptoms way after I stopped it.That isn't addiction anymore but mental illness.Alcoholics continue to drink and there is a known cure,stop drinking, we with mental illness aren't so lucky,why should our resources and hospital places thin on the ground as they are be taken by an alcoholic?I am interested to know if this duel diagnosis thing is anything more than a cost cutting exercise?
What causes alcoholism/addiction?

i was in severe addiction/alcoholism for 17 years - am now over 13 years T-Total (despite the odd slip) - i also experienced multiple episodes of severe psychosis & certain mental health difficulties have continued, despite sobriety. In my own case i accept the schizophrenia diagnosis & the addiction - it's dual diagnosis. As i said above, around 50% of people in contact with mental health services/people with mental health disorders are also dual diagnosis.

Of course alcoholism is open to debate as everything is - But it's generally considered to be a disease/medical/health condition, & in some countries as a psychiatric condition -

Alcoholism - Wikipedia, the free encyclopedia (same for addiction).

i've been around a lot of people in addiction, active & in recovery. The vast majority of them i've come across around 12 step recovery i don't think have major secondary mental health conditions, a lot of issues do clear up with long term sobriety - But i have also met, known & know people who do very much have secondary severe mental health difficulties.

Why should alcoholics/addicts not be entitled to as much help & support as anyone else anyway?

i think Gabor Mate sums up a lot of truth in these areas, & certainly points to a lot of the commonalities within addiction/mental health.

Gabor Mat
 
Gajolene

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Guess I am lucky in that regard, where we live the rehab unit is not even in the same building as the psych unit. The lines do get blurred though for people with comorbid conditions and mh isn't treated untill detox from substance abuse is assured. This is so medications can work properly, and I understand why they do this.
 

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Guess I am lucky in that regard, where we live the rehab unit is not even in the same building as the psych unit. The lines do get blurred though for people with comorbid conditions and mh isn't treated untill detox from substance abuse is assured. This is so medications can work properly, and I understand why they do this.
From what i've seen of services in the UK there is incredibly little that addresses dual diagnosis. What happens usually is that either everything gets blamed on alcoholism/addiction, or it all gets blamed on a mental illness. The later see drug use/abuse usually as self medicating & often deny addiction issues. Very few people with dual diagnosis issues acknowledge & genuinely address both - & even more rarely get any proper understanding/support for it all.
 

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Nikita said:
I am not saying CPU that alcoholics and addicts don't deserve and shouldn't get treatment.Just that mental illness is a separate condition from alcohol addiction or drug addiction and should have separate facilities resources,not mixed in with us who are mentally ill through no actions of our own.The approach to solving addiction isn't the same as dealing with mental illness.Why should those of us who are ill be mixed in with those addicted to drugs and alcohol.The last thing I want is to be in hospital with someone desperate for an injection of heroin or a bottle of whiskey who would kill to get it!
You seem to be implying that addiction/alcoholism is the fault of the individual?

Your not answering the dual diagnosis question? Nor the question about medication addiction areas?

In America i think i'm right in saying addiction/alcoholism is seen as a mental health condition/mental illness. Same with all these areas, it depends on many different understandings & perspectives as to what comes under mental health. Yes, some people will say that alcoholism/addiction isn't a mental health condition - But there are also those that say no 'functional mental health condition' is.

There are in fact a lot of cross overs in general areas of treatment for addiction & other mental health conditions.
 
Gajolene

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That's a bit of a chicken and the egg question, which came first. Experiences are uniquely different for individual circumstances. In my case addiction was a self medication to deal with already existing mh. Not a good decision but all I knew to do in my youth at the time, along with genetic predisposition to alcoholism in my family.
 

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That's a bit of a chicken and the egg question, which came first. Experiences are uniquely different for individual circumstances. In my case addiction was a self medication to deal with already existing mh. Not a good decision but all I knew to do in my youth at the time, along with genetic predisposition to alcoholism in my family.
Yea - i could have called all my past drinking/drug taking self medicating as well - some people did.
 

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Nikita said:
It may appear that generalized to you Cpu but it depends on the area in which you live.In the hospital in Milton Keynes many patients with mental illness diagnoses also had addictions to drugs and often smoked cannabis on the wards.Also alcoholics were in there to get dry and some patients had post natal depression and objected to being lumped together with what they called the mentally ill and alcoholics and drug abusers.We all have our sensibilities whereas the doctors and services lump us all together as defective in some way or another.You should have seen the horror on the face of this woman who had just had a baby six weeks ago,she had been shown round to come in as a private patient,they showed her to her room and five minutes later one of the psychotic patients started long term howling and banging her head on the wall outside said private patients room.You'd never seen anyone's nose stuck so high in the air,she immediately left her room and got herself discharged.She said to me she didn't belong here as she wasn't like the rest of us.I said so to one of the nurses and she said post natal depression is a mental illness.So go figure.We all see our own situations as more valid and more worthy.I am not saying I do.I just think drug addiction is way different to what you have to deal with with mental illness and require different approaches to treat and different amounts of compassion whereas with addiction a 'tough love' approach may be more in order.Definitely different facilities is more ideal,like the private sector provides rehab for alcoholics and addicts as there are specifically tailored programs.
There are areas of the country do try to treat people with alcohol problems and duel diagnosis,it is not true what you say that they don't Cpu!
Tough love is a controversial one - The Likely Cause of Addiction Has Been Discovered, and It Is Not What You Think

i didn't say nowhere/no-one treats dual diagnosis - But there is very little that genuinely does.

Everyone being lumped together under the same 'mental health umbrella' is i think ridiculous as well, for many reasons.
 

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Nikita said:
AA advocates individual responsibility doesn't it.It is a choice to drink, albeit driven by biological addiction and psychological addiction and need too.It isn't the case of being out of control and out of our hands like a psychosis, alcoholism is it?Or is alcoholism in your view as much driven by social environmental factors out of an individual's control as mental illness is.To me and in my life i see the cause of my illness as circumstantial and due to severe familial neglect and abuse over many years.Is someone getting addicted to drink the same as that.I can see in some instances there is a case to apply duel diagnoses certainly.But a straightforward alcoholic, what other treatment is there but for the individual to take responsibility and stop drinking.I cannot stop anything or determine for myself whether I go into psychosis or not.
i think it's complex & that there are many shades of grey. But yes, in the case of a straightforward alcoholic/addict it is as simple (doesn't mean easy) as stop doing it & recover - i agree.

Dual diagnosis is what it states - some people have addiction & a severe mental health condition.

i think the aetiology for addiction/alcoholism does have it roots usually in childhood development - & within social/environmental factors - i'd apply the same bio/psycho/social/spiritual model to it all as i do to mental health.

Despite all the criticism of psychiatry - i think the main general diagnostic categories do hold some water & are different conditions.

How much within mental illness can the individual do anything about? i think to various degrees & in various ways, dependent on the individual, there is stuff that people can do. i also think a lot depends on overall circumstances & support/understanding - But would also say we're not wholly victims of circumstance. Very complex & individual question.
 
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Having read the article about the cause of addiction or 'bonding' being isolation
I wonder if the same thing may be true of much mental illness
sort of.

I know that all through my mental illness I have had friends and social contact and stuff
But I felt isolated
a) My girlfriend had left me, so I lost that most intimate bond
b) I was struggling at work - and I felt it was my fault.
c) Many of the friendships we have don't allow us to be open and tell it like it is. Or perhaps I mean that we are friends, but we are not bonded to each other. We have our own lives and aspirations and the friendship just means meeting up for one purpose. There is only a tenuous bond

Just thinking aloud
 

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Nikita said:
The question the thread examines is whether drug/alcohol addiction should be treated alongside mental illness, I say regardless of whether the causes are similar or whether some have duel diagnoses, they should not,they should be separate facilities and treatment programs because while there are similarities and overlap the differences in treatment,causes, etc are there.
What do you do with dual diagnosis? [50% of the mentally ill] Have a 3 tier system?
 

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