Dr. James Gagne is a medical doctor who specializes in internal medicine and addiction medicine. Recently, while he was reviewing the scientific literature about Dual Diagnosis, he stumbled across a startling statistic: Half of the people who have a psychiatric illness are also chemically dependent, and half of those who have chemical dependency also have a psychiatric illness.
The combination of chemical dependency and mental illness is known in clinical circles as a “Dual Diagnosis” or “co-occurring disorders” situation, and it could have a huge impact on the recovery path for impaired people and their families.
“If you think about it, this damage makes sense,” says Dr. Gagne about the impact of alcohol and drugs on the nervous system.
“They wouldn’t be used if they didn’t affect the nervous system. That’s how they get you high.” But harm to the nervous system often accompanies the euphoria. These aftereffects can linger long after the thrill is gone and the person has returned to a sober state.
In addition to physical illnesses, people with addictions can struggle with a variety of mental health disorders, including depression, anxiety and bipolar disorder, along with psychosis and delusional behavior, says Dr. Gagne. Sometimes the psychosis is permanent.
Usually not, Dr. Gagne says, but on occasion some conditions do seem to fade when a primary problem is addressed. As an example, he discusses a case in which a person with a bipolar disorder had the explosive onset of binge drinking, brought about by a manic episode. Once that bipolar disorder was treated appropriately, alcohol use stopped. Other people who take drugs like cocaine or meth experience episodes of drug-induced psychosis — paranoia and hearing voices or seeing things that aren’t there. These symptoms may also fade when they stop using for an extended time. People like this technically have a Dual Diagnosis problem, but treating one may help the other to abate.
“To treat patients with both addiction and psychiatric illnesses, you must figure out what’s going on and provide appropriate care,” he says. “But these treatments take more time, because you have to manage both illnesses at once.”
Appropriate care must begin with a thorough assessment in which practitioners have the opportunity to uncover all of the issues that are in play, and the treatment program must be tailored so that the right therapies are provided at the right time. Unfortunately, Dr. Gagne says, care for psychiatric illness is rarely available in treatment facilities that specialize in addiction. Similarly, most programs that specialize in psychiatric illnesses don’t have the skills to treat addiction. Psychiatric providers often emphasize medications and hand out those medications upon request, he says, rather than setting appropriate limits with people who have a history of abuse.
People with addiction combined with serious psychiatric disorders typically need a different type of care. “Quality makes a difference in outcome,” he says. “Quality and not glamor.”
He points to an article in The New York Times that suggests that many treatment facilities are slaves to tradition and don’t use science-based techniques at all. They promote 12-Step techniques like Alcoholics Anonymous that are effective in some people but by no means work in everyone. Some emphasize blaming and chastising their patients. Others are spas with beautiful surroundings and great food but little actual treatment. They somehow overlook scientific studies that show that a more comprehensive approach works best, such as a gentle but intensive treatment that combines 12-Step programs with learning coping and self-management skills. Many people also require effective medication management or trauma work to help them heal from past emotional distress.
“Good treatment is expensive, and it’s more effective than a tradition-bound, ‘my way or the highway’ strategy,” he says. “A more nuanced approach requires additional resources, mainly because there is more care involved.”
Dr. Gagne disagrees with people who have addictions as simply being in denial, as this sort of thinking is often paired with techniques in which the impacted person is either blamed or punished for that denial.
“This works for a few. Most people just find that annoying,” Dr. Gagne says. “A better way to look at it is that people are ambivalent. They want to quit and they don’t.”
On the one hand, an addict’s drug of choice may seem beneficial or even helpful; it provides him or her with a euphoria they cannot reach any other way. They get to turn off painful emotions temporarily. Not surprisingly, people aren’t eager to give up “their best friend,” says Dr. Gagne. If they started using early in life, they might have arrested their emotional development to such a degree that the only way they can cope with the ups and downs of life is by using drugs. On the other hand, the cost to the addict’s health, job, marriage and family becomes intolerable. Calling that “denial” is grossly oversimplifying the reality of the situation, he says.
A better solution? “Motivational enhancement, and I just love it,” says Dr. Gagne.
The process begins with an interview in which the person is asked to recount all of the health problems, physical issues, social impacts and other changes the addiction has caused. “They have to walk through all of the things that have happened,” Dr. Gagne says, “and they’re often really shook up when they’ve described the whole thing.”
Then, the questions begin. “You lay out the contradictions between their belief system and what’s actually happening. You just pretend as if you’re confused, and that you just need a little clarification in order for it to make sense,” he says.
The therapist takes a supportive but inquisitive role here. Dr. Gagne compares it to playing “Name That Tune,” in that the therapist is providing a number of very subtle clues about how serious the addiction has become, and the person has the opportunity to name that addiction for the very first time through a sense of dawning awareness.
“Here’s the question: ‘If you agree you have a problem, why shouldn’t we treat it?'” says Dr. Gagne. It allows people to develop a sense of control over their illnesses, but it also allows providers to avoid the blame game and to shift behavior in a supportive way.
“People who abuse drugs often do nasty things, and families take the brunt of that abuse,” Dr. Gagne says. Families under this kind of relentless pressure tend to respond by either cutting the person off from the family altogether, or they respond by enabling the addiction and keeping the person safe. Neither is a great option, he says.
Families that cut ties might do so because they’re frustrated at the lack of progress the person is making in treatment, but this might be disrespectful of the nature of recovery from addiction.
“Treatment is effective, but some people require a few trips,” he says. “It’s not something that everyone learns quickly. They might go in and out of treatment a few times before they really get it.” This is especially true for the basic short-stay treatments often favored by insurance companies.
Families that give up might not understand that addictions tend to be chronic conditions that for a while they may alternate between periods of recovery and healing and periods of relapse. Addictions must be managed with constant care, and sometimes people with addictions slide back into behaviors they thought they’d left behind. Cutting someone off sometimes means plunging them back into a world of despair that could trigger a relapse. But prolonging an addiction by enabling destructive acts or saving someone from consequences could be just as destructive, he says.
“This is a fatal illness,” Dr. Gagne says. “If they are determined to kill themselves, don’t enable them. They can handle that process without help. Don’t rescue people from the consequences of their own behavior, and set appropriate limits.”
Dr. Gagne encourages families under pressure to get in touch with an interventionist. These professionals can help families to stage a conversation about addiction that might prompt the person to enter a treatment program. They can also provide counseling that could help the family to heal, whether or not the person accepts the need for treatment. When families are in situations in which they just don’t know what to do or how to help, working with an interventionist could be vital.
If you’d like to know more about how to work with an interventionist or you need more information on how treatment might be helpful for you or for someone that you love, please call us.
According to the National Survey on Drug Use and Health, 2010.
Integrated Treatment of Substance Abuse & Mental Illness