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

Robert Nikkel, MSW
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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.

13 COMMENTS

  1. This idea raises the tacit concept of there being two kinds of drug addictions, one good and one bad. Alcohol and illicit drug abuse is considered bad and psychiatric drug addiction is deemed acceptable and is even encouraged for some people. The morality used here is dictated by who is to benefit from addiction. Certainly those forced to endure neuroleptic suffering do not benefit any more than those abusing cocaine do. Both are the cause of functional disability for many people but the fox in this case is guarding the chicken coop.

    When greed led many in the medical profession to start writing scripts of opiates on demand for cash, the government stepped in and clamped down on it. Its about time the equally immoral practice of forcing drug addiction on those who know better than to live life in a constant stupor to stop.

  2. Bob – Our drug laws have the unhappy effect of worsening the quality of widely publicized information about anything that is or gets suggested to be immoral or simply wanton, for no reason, for recreation, for erotic enhancement, don’t you think? That makes a complicated analysis due for the prevailing attitudes, since these well-meaning moralists want not to examine the other side of their judgmental behavior when it comes to how prohibitionistic motivations retard progress in the development of treatment programs and prevention itself. But as hard as the analysis becomes once it has to take on the issue of skewed perceptions, the data for it exists everywhere you look.

    Relatedly, the massive and undiscussed entitlement of behavioral healthcare workers, whose employment benefits include not having to answer to the economic forces that confront those without state mandates, always able to rely on the court ordered treatments to give the profession their name and influence instead of earning it from proven results, has to factor into the reduction in the quality of information on mental disorders, both as it is collected and interpreted. I’d like to see the allied mental health industries having to fight for their respect before the law much more and making their commitments to patient advocacy as explicitly revealed as they do their backing of each other and the status quo in legal matters, as well as in standards of labelling for anyone whose ideas differ from theirs.

  3. Bob,

    Wow, I completely agree. Psychiatric drug use should be looked at through a similar lens to illicit drug use and/or alcohol abuse…providers often give these drugs out as a first line treatment with little discussion of side effects or the exit plan…and the field of psychiatry has not even adequately studied the withdrawal process from psychiatric drugs…often the rebound psychosis or discontinuation syndrome is interpreted as underlying symptoms of “mental illness”and a reason to keep people on these drugs…sometimes for life…

    Great article!

    Cindy

  4. Psychiatry creates addicts by putting little children on amphetamines and Ritalin .
    Just goto any drug and alcohol treatment center in the US and ask the clients if they were medicated as kids. Most of the time with the younger ones in there 20s its a majority.

  5. I agree totally Robbert. Here in South Africa state hospitals have become a dumping ground for people who have mental reaction to street drugs, and instead of being helped to detox and to get some form of therapy they are put on psych meds and labeled schizophrenia or what ever. We have been told by the staff in one ward that 90% of the people in the ward were there because of drugs and or alcohol. Many families wanting to help their children or loved ones end up in the psychiatric system, and once there, there is no talk about the drug/substance problem and the person now becomes a psychiatric case. Here we have seen it that people are kept in closed wards for months. They lie in the floors, no recreation, no books, nothing. No gardens, neglected buildings.

    And on the other hand, drug rehabs that are all private are absolutely impossible to afford for general public.

    We are indeed faced with a tremendous issue since drugs is an ever growing problem in our country and the world.

    • Amari, thank you for your comments and observations about what’s going on in South Africa. I’m afraid it’s not entirely different here in the US either. One of the first things I learned when I was doing alcohol/drug counseling was that alcohol and street drugs could mimic any mental health symptom or disorder. Maybe it’s better than a few years ago but very few mental health workers get much training in alcohol/drug work. One of the standards in mental health should be the ability to conduct a careful interview to collect accurate information about alcohol/drug use–and that would include the use of psych drugs too. We’ve known for a long time now that at least half of the people who have mental health challenges also have had or are having problems with alcohol/drug use too. Of the guys who end up in jails and prisons, it’s probably closer to 90% according to studies conducted by Linda Teplin. For women it may be even higher–and that doesn’t count the PTSD that’s almost always there. And you’re right–drugs don’t seem to be going away in this world.

  6. What also bothers me a lot is the fact that psychiatry is trying to make addiction into another “mental illness” diagnosis. As a peer worker I do not read charts since I want the people I’m working for to tell me who they are and what they want me to know about them. I do not want to be told who they from the biased charting that goes on at the hands of nursing, psychiatry, and social work. As a peer worker I will not chart since this exercises power and privilege over the person I would write about. But, I just happened to be working with someone and I accidentally saw their chart and this is what caught my eye. There in black and white was written the “diagnosis” of “substance abuse disorder”! I’m not familiar enough with the hated DSM-5 but suspect that this “diagnosis” is most likely listed within its pages. So what do we do when they begin making addictions to substances a “mental illness”?

    • Stephen, first, thank you for your courage in refusing to chart! Now, that can get to be a real problem in the world of policies on documentation and I’m sure you’re finding out enough about that without me saying anything more than I respect your commitment to doing the right thing–relating to people as they are and not as they’re charted to be. I’ve said several times, I would be fired very quickly now if I tried to go back into paid public mental health and addictions work. The issue of whether alcohol/drug problems should be considered diagnoses and problems and mental illnesses is clouded by the traditional AA position that alcoholism is a disease. Much of the 12 step literature is based on this and since I’m not in recovery for alcohol/drug problems, I’m going to stay out of the discussion about whether this makes sense to me or not. The fact is that many peers in the addictions field have defined themselves in this way. If It works for them, it’s not my issue. But your point about addictions being interpreted as “mental illnesses” is a good one in my opinion and we need to be talking about all this a lot more than we have. Thank you for your thoughtfulness.

  7. I have to disagree, with this and the idea that alcohol and drug treatment is better conceptualized than Mental Health treatment.

    For many, many reasons.

    First of all Drug and Alcohol treatment is largely a failure. Most treatment facilities have a success rate of about 1%, which means that after a year of treatment 1 out of a hundred is sober. Treatment facilities actually offer very little to patients, except to limit access to drugs. To make success rates higher they import 12 step panels, and encourage patients to become involved in 12 step groups, this to boost their success rate. A.A. for instance claims a 20% success rate, but it very hard to verify, because participation, is anonymous.

    Hospital staff is largely paraprofessional, people in recovery themselves, with very little formal education or training. With rates at some facilities topping $1000 a day, keeping staff costs low is quite profitable for Hospitals.

    Its also true that drug involved patients are often given other drugs in facilities, as a way of dealing with their drug involvement. This only compounds the problem, and is not really treatment at all its just a faster way of getting patients discharged.

    The terms, that you used, to conceptualize addicts states of minds, like Denial etc., are borrowed from 12 step groups, and don’t really represent a valid conceptualization of addictive thinking. Most addicts are in fact not in denial at all , but are desperately aware of their situation, desperately wanting to get help and not finding it anywhere. It s not usual, for addicts to have 15, to 20 residential treatment episodes and still no clean time.

    Remember that the founder of A.A., was only able to stop drinking by helping others to stop. His book came later on.

    Most insurance companies rely on tools such as ASAM to determine treatment and authorize care, its like the DSM in many ways, but gives them justification to deny care, and skirt the expensive costs that treatment presents for them. It simply does not really address addiction or the need for treatment at all. Its central problem is that there are few capable professionals who can evaluate someone in treatment with it from staff at facilities, so the insurance companies do it for them.

    Which is illegal, because, its like diagnosing someone with information provided by someone else.

    If anything treatment is dominated by money, and has very little to do with actually helping people get well. Studies show statistically that someone is more likely to get well, simply by quitting on their own.