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.