What are They and How Can They be Dealth With?
Reprinted from "Concurrent Disorders" issue of Visions Journal, 2004, 2 (1), p. 5
Many Visions readers will be familiar with basic information about mental health problems. They may be less familiar, however, with addictions, (or any form of problematic substance use), what they are about, why they so often go hand in hand with mental health problems, or about how to deal with them when they occur together, that is, about concurrent disorders. As background to some of the more detailed articles that appear further on in the issue, this article gives a basic overview of the answers to these questions.
What is Addiction?
Addiction commonly refers to harmful preoccupation with substances like alcohol, or to behaviours like gambling. Technically, addiction is a disorder identified with loss of control, preoccupation with disabling substances or behaviour, and continued use or involvement despite negative consequences.
With respect to substances, it is often more appropriate to speak of ‘problem substance use.’ Many people use substances in a way that is not problematic. For instance, having a glass of wine with dinner, once or twice a week, is a way of using alcohol that is not likely to cause problems. Whether or not use of a substance is problematic depends on many factors, including the substance, the individual, the behaviour involved and the context.
The problems that can develop with substance use fall on a continuum from mild to severe. Someone who drinks too much alcohol every few weekends in a social situation may experience hangovers or slightly diminished overall health and fitness. They may also put themselves at increased risk of injury while they are drinking. However, if the frequency of excessive drinking increases, they could experience more severe problems such as family difficulties, significant physical symptoms, financial problems, and trouble at work.
Addiction and problem substance use are highly stigmatized, and we hear many misconceptions. Among these are the views that addiction is the result of moral weakness or lack of control, or that it is a purely medical condition like any other disease, that can be ‘fixed’ by a doctor. In fact, there are a variety of factors that contribute to problem substance use, and if these factors act together, addiction may develop.
Risk factors for problem substance use include:
a genetic, biological or physiological predisposition
external psychosocial factors such as approving attitudes within communities (including within schools), values and attitudes of one’s peers or social group, and family situatio
internal factors such as coping skills and resources such as poor communication and problem-solving skill
These factors all influence each other, and the individual’s ability to cope with stressful or traumatic events depends on all of them. A degree of rebellious substance use may be a normal part of growing up, but a vulnerability in one or more of these areas could lead ordinary experimentation into problem substance use. For instance, a child of alcoholic parents whose peer group approves of substance use is at increased risk of developing problems arising from substance use. He or she may observe parents using alcohol as a coping mechanism, and have this behaviour reinforced by a peer group that does not disapprove of such use. Alternatively, a person who manifests very few of these risk factors may develop problems arising from substance use as a result of a traumatic experience, for instance, they could become dependent on prescription drugs following a serious car accident.
The facts about substances
Addiction and problem substance use tend to be highly stigmatized, and there is a lot of misinformation around.
The use of mood-altering substances has been a feature of human societies for thousands of years. Substance use has been regulated in various ways; it is only in the 20th century that it has been criminalized
We all use substances, many of which affect mood. Whether we eat something that give us pleasure (such as chocolate or coffee), enjoy a glass of wine to enhance a meal, or take a prescribed medication to control pain from a recent injury, the use of substances is an accpeted part of life
Many people can use substances (whether legal or illegal) in moderation without experiencing problems. Usually when problems arise from substance use, there are a range of other factors at work
Binge drinking on the weekend, over-use of prescription drugs, consuming 'club drugs' at a rave, drinking more than 5 cups of coffee and smoking cocaine are all potentially problematic forms of substance use
Concurrent Substance Use and Mental Illness
Concurrent disorders, that is, substance use along with mental illness, can be due to a number of factors. In some cases, people abuse substances as a way of attempting to treat psychiatric symptoms (or ‘selfmedication’). In other cases, substance misuse may trigger the onset of symptoms, especially in individuals who may be vulnerable to mental illness in the first place. Some research also suggests that people with mental illness and substance use disorders may have underlying vulnerabilities that put them at risk for developing both types of problems.
Whatever the cause, substance use, including addictions, complicates almost every aspect of care for people with mental illness, says Kathleen Sciacca, a New York-based expert on concurrent disorders. In part because people with concurrent disorders face additional barriers to adequate treatment and housing, they are more likely to experience relapses and frequent hospitalizations than people with mental illness alone. Other researchers say the toxic mix of prescription medication combined with alcohol and/or illicit drugs can cause severe drug reactions and may even trigger or worsen psychiatric symptoms.
Additionally, the symptoms of a coexisting psychiatric disorder may be interpreted as poor or incomplete ‘recovery’ from alcohol or other drug addiction.
Despite this gloomy picture, people with concurrent disorders can recover from or learn to manage both issues if they receive appropriate treatments tailored to their needs. According to Sciacca, the key is to avoid the therapeutic approach of traditional addiction programs such as heavy confrontation and intense emotional jolting. This can cause levels of stress that work against recovery for people with mental disorders.
Sciacca recommends a non-confrontational approach that allows people with concurrent disorders to recover at their own pace, for example, through education and discussion in a group setting. She stresses the importance of non-judgemental acceptance of all symptoms and experiences related to both mental illness and substance abuse. Although abstinence from drugs and/or alcohol is the ultimate goal, it should not be required for entering treatment, she adds.
“Clinicians have to convey to the [participants] how hard it is to stop. They have to give [them] credit for any accomplishment. That’s where the focus has to be — on any inch of progress.”
Degrees of use
Substance use falls on a continuum based on frequency, intensity, and degree of dependency:
Experimental: use is motivated by curiosty, and limited to only a few exposures.
Social/Recreational: the person seeks out and uses a substance to enhance a social occasion. Use is irregular, infrequent and usually occurs with others.
Situational: there is a definite pattern of use, and the person associated use with a particular situation. There is some loss of control, but the person is not yet experiencing negative consequences.
Intensive also called 'bingeing' the person uses a substance in a intense manner. They may consume a large amount over a short period of time, or engage in continous use over a period of time.
Dependence: can be physical, psychological, or both. Physical dependence consits of tolerance (needing more of the substance for the same effect) or tissue dependence (cell tissue changes os the body needs the substance to stay in balance). Psychologicial dependence is when people feel they need to use the substance in particular situations or to function effectively. There are degress of dependence from mild to compulsive, with the later being characterized as addiction.
This article was adapted from the The Primer: Fact Sheets on Mental Health and Addictions Issues. The full document, as well as related fact sheets, can be found at mentalhealthaddictions.bc.ca
Kaiser Foundation, BC Addiction Information Centre
Alberta Alcohol and Drug Abuse Commission.Just the Facts: What is Addiction? Edmonton, AB
Health Canada. Straight Facts About Drugs and Drug Abuse.Government of Canada
Ruth C. Engs (Editor). (1990). Controversies in the addiction field Kendal-Hunt: Dubuque
Pacific Community Resources. (2002). Lower Mainland youth drug use survey. Surrey. BC