People diagnosed with both a mental illness and an addiction are falling through the cracks of the public health system because of a lack of coordinated services
Reprinted from "Concurrent Disorders" issue of Visions Journal, 2004 2 (1), pp. 19-21
Leo Turok hears voices. It started when he was 16 and studying at Lord Byng Elementary. Soon, the paranoia began keeping him in his room at home and away from friends at school.
He quit school before graduating. Every six months or so, when the suicidal urges became too great, he’d admit himself into UBC’s emergency ward. He would return to normal quickly, so it wasn’t until he was 19 that Turok was diagnosed as having schizophrenia. He spent three months at UBC’s psychiatric ward stabilizing and adjusting to his new drug regime. After leaving the hospital, Turok went to a mental health services support home in Kitsilano where he lasted all of three weeks before being forced out for antisocial behaviour.
A friend offered to move into a West End apartment with Turok, but again, anti-social behavior – mostly paranoia that friends were trying to harm him – drove his friend away. Turok moved into a bachelor suite, still in the West End, and started dabbling in street drugs. The apartment soon became a flophouse for homeless drug users he met on Davie Street and the Downtown Eastside.
Turok was registered with the West End Mental Health Clinic and was still showing up for his bi-weekly medication injection when he began taking more street drugs, mostly speed and crack. A clinic street nurse noticed the pattern and told Turok’s mom Olga.
No one was sure what to do about it. Soon Turok stopped going to the clinic. When he couldn’t pay his rent, he moved briefly back to his Vancouver home, where he would demand to be locked in his room so no one could harm him. Olga took her son back to UBC hospital. From there, he was sent to Riverview Hospital, where he stayed 13 months before being refused service for repeatedly escaping and using drugs.
From Riverview, Turok had nowhere to go but the Downtown Eastside, to the city’s three homeless shelters – The Lookout Emergency Aid Society, 346 Alexander St.; Triage Emergency Services and Care Society, 707 Powell St.; and the Haven, 128 East Cordova St. – where his drug use worsened and the voices in his head increased. Now, when 24- year-old Turok calls his mom, it’s to arrange a quick meeting at McDonald’s, where she brings him fresh clothes that he changes into in the washroom.
“We went to McDonald’s last Sunday,” said Olga, her eyes tired, semicircular rings of worry permanently etched below them. “He looked rundown and as usual, he just stared, but I took him shopping so he could be around me. I’m not sure where he’s living.”
Turok is one of an estimated 34,000 British Columbians with ‘dual diagnosis’ [concurrent disorders] – a mental health problem coupled with an addiction. Dual diagnosis patients, many of whom live in the Downtown Eastside, represent about half the total number of people suffering a serious mental health disorder province wide.
Despite the large and growing numbers, there are only six long-term care beds specifically set aside for those with a dual diagnosis in Vancouver, all of them in a support home in the Downtown Eastside that opened three years ago as a pilot project. The average stay in the six beds available to dual diagnosis sufferers is between six to 18 months, but turnover is high because of behavior problems.
Advocates for such individuals complain there’s little co-operation or cross-training between mental health and addiction services – addiction workers are not trained to deal with mental illness and mental health workers don’t know how to deal with addiction.
The solution, say parents like Olga, is more money and service co-ordination to save their sons and daughters from themselves.
On Powell Street, a block east of Oppenheimer Park, there’s a nondescript two story white building owned by the Lookout Society that houses a string of social services. A beggar sits on the ground in front of the building, a metre from the doorway, perhaps targeting the many professional health care workers based in the Downtown Eastside.
Inside the building is the Vancouver Coastal Health Authority’s Dual Diagnosis Program. You need to climb two grubby flights of stairs before a purple photocopied sheet of paper taped to the wall tells you the program is located at the end of the hall to the right. The door is locked, and you have to speak through an intercom system on the wall to get in.
Launched in 1996, the Dual Diagnosis Program treated 800 people last year, and survives on $500,000 a year with four full-time staff and one part-timer. Clients are referred from hospitals, detox centres, mental health teams, residential treatment centres, family doctors and psychiatrists.
Treatment lasts between six and 18 months and helps clients identify when they’re ‘crashing’ or spiralling downward through depression, paranoia, substance abuse and other problems. Staff work with clients, most of whom have mood disorders (like manic depression), posttraumatic stress disorder or personality disorders, on preventing relapses and dealing with conflict in their interpersonal relationships, including managing their anger.
Alcohol is the most common addiction, followed by heroin and crack, although most use a variety of drugs.
Coordinator Pohsuan Zaide says the dual diagnosis team’s task is enormous – the wait to get in is between six and eight weeks. “I could have 10 staff and we’d all still be busy. But this is what I have to work with and I’ll do what I can. No one’s looking to do miracles, we just try for some positive outcomes for patients. If we can give people hope and give them back some self-esteem and pride, then we’ve succeeded.”
Determining whether the addiction or mental illness came first is often a ‘chicken-and-egg’ issue, she said. “If you’ve been using alcohol and drugs for 25 years, you’ll likely develop depression or an anxiety disorder. Or if you have a mental illness, you are easily abused and introduced to drugs, especially here [in the Downtown Eastside].”
The concept of dual diagnosis arose in 1986 when an acronym – PISA or psychiatric impaired substance abusers – was coined to describe an addiction co-existing with either a personality disorder, chronic mental illness or post-traumatic stress disorder. The usual treatment was to determine which of the two was the ‘primary’ disorder, then focus on one.
But Ken Minkoff, a Massachusetts- based psychologist, advocated a new approach: treating both disorders simultaneously, then finding out how the two are related for each individual and getting that person to help devise a recovery program.
Minkoff’s work spawned the creation of programs like Vancouver’s Dual Diagnosis Program, but most
sufferers still fall through the divide between mental health and addiction services, often because of multiple relapses.
“The problem is there’s no consensus between the two systems. The mental health people say go away and quit your addiction and then we’ll treat you. Or the addiction people say we can’t treat you when you’re on psychiatric meds,” said Zaide, who holds a Master’s degree in counselling psychology from UBC. “You just can’t operate separately any more or pass the buck. They end up costing the health care systems more anyway, because they keep using the emergency rooms and psych ward beds and are likely to try suicide.”
Zaide advocates better funding and licensing for recovery houses for addicts, with better-qualified staff to deal with dual diagnosis. Currently, anyone can establish an addiction recovery house, usually based on the Alcoholic Anonymous 12-step program. Residents who also have a mental health problem, however, are often asked to leave because of their behaviour, which is not recognized by untrained staff as being driven by mental illness.
Last month, the office of the Mental Health Advocate of British Columbia closed as part of provincial government cutbacks. Responsibility for listening to the concerns of [people with mental illness] was passed on to Gulzar Cheema, Minister of State for Mental Health and MLA for Surrey-Panorama Ridge.
The day Mental Health Advocate Nancy Hall left her job, she released a stinging report on the state of the province’s mental health system, focusing on statistics showing a significantly increased risk of premature death among those with a psychiatric diagnosis, likely from suicide or conditions that stem from addictions.
One of her recommendations was for an Assistant Deputy Minister to focus solely on mental health and addiction issues.
“We need to provide training to community mental health teams, hospitals, Riverview Hospital, Forensic [Psychiatric Institute] and physicians to ensure patients receive concurrent help for the two disabilities,” wrote Hall. “Few peoplewith both an addiction and mental illness get effective treatment for either problem. People with dual diagnosis and their family members report difficulty in getting help.”
“Even when they are long-stay patients at Riverview Hospital or the Forensic Psychiatric Hospital, there is no routine care provided for their addictions.” [Editor’s note: Riverview Hospital now has a concurrent disorders program. To read a description of the program, see Step Softly, a publication of the Tri-Cities Mental Health Centre, Volume 1, Issue 2, Page 3.]
One Vancouver mom, Heidi Richards, has filed a complaint with the BC Human Rights Commission claiming the Vancouver/ Richmond Health Board – now the Vancouver Coastal Health Authority – discriminated against her son Adrian by not treating his drug problem while he was receiving mental health care, and not providing suitable housing options. Adrian was a former Riverview patient who has schizophrenia and is now a drug addict, living at Triage in the Downtown Eastside. He developed his addiction after being forced out of support homes due to his behaviour and ultimately ended up on the Downtown Eastside, where drug dealers target newcomers.
Roderick Louis, a former Riverview patient who has become a patient advocate, said when he visits the Downtown Eastside, he usually sees at least a dozen former Riverview patients wandering the area. Most are drug addicts. Some are prostitutes.
“A lot of them have grown up in a decent neighbourhood and developed schizophrenia, have been stabilized and then discharged without support and funnelled right downtown to the only emergency shelters in BC,” said Louis, brother of Vancouver city counsellor Tim Louis and founder of the Patient Empowerment Society, which pushed for patients’ rights at Riverview. “They run out of money and quickly learn to make money either by selling drugs or their body. They are right smack in the middle of the biggest prostitution and drug addiction university in the province. It’s ghettoizing the mentally ill.”
Louis believes providing the mentally ill with rent subsidies would go a long way toward getting them out of the Downtown Eastside and away from the drug culture.
But Zaide says centralizing mental health and addiction services in the Downtown Eastside is not necessarily bad for clients. “Some clients say where we are located is a good reminder of where they’ve been and where they don’t want to be. Some people’s addictions get triggered, but you can get drugs anywhere. You have to take responsibility for your recovery and stop blaming others.”
“Sometimes, there’s not much you can do if someone is an adult and adamantly refuses to get help.”
The Patient Empowerment Society has met with Cheema to suggest he form a multi-ministry mental health group to coordinate mental health, addiction, housing and other government services used by the mentally ill. “You just need someone with gumption in the Premier’s office saying ‘let’s link these things up,’” said Louis, who, along with other advocates, is calling for better funding and staffing for treatment and recovery facilities for dual diagnosis sufferers.
Cheema admits the existing treatment system for dual diagnosis patients is not co-ordinated and that people are “falling through the cracks,” but says groups shouldn’t expect any new funding.
Cheema argues recent streamlining of the province’s health regions into five super-regions, plus the recent transfer of addiction services from the Ministry of Children and Family Development, will help solve the problem by better coordinating addiction and mental health services.
“We’ve taken the first steps but the issue is complex. I’m working closely with health services to make sure there’s a coordination of services and hopefully we’ll get results,” Cheema said.
Louis is unconvinced, claiming the Ministry of Health Services is one of several ministries [overseeing issues] including social services, housing, [the legal system] and education, that [affect] dual diagnosis sufferers and need to be included in any co-ordination efforts.
“Collapsing 52 health regions into five won’t improve services. A [person with schizophrenia] sees a doctor for one hour a month, but for the other 29 days and 23 hours they are having to deal with things like food and rent and transport and trying to get some training,” said Louis. For Olga Turok, her greatest concern is that a focus on dual diagnosis patients will come too late for Leo. “He calls every few days and I think he stays in the Downtown Eastside or with friends somewhere near UBC. Sometimes, he seems to be in control and it looks promising, but every time there is disappointment. It’s played a lot on my nerves and I’ve had my own depression and sleeping problems but it’s my priority. Something has to change.”