Shifting to youth concurrent disorders: A professional story
Reprinted from "Treatments for Young People" issue of Visions Journal, 2006, 3 (1), pp. 13-14
Eight months ago I made a job change after working for 20 years as a psychiatric social worker in both adult and child psychiatry inpatient and outpatient stings. For the last 11 of these years I was based in an outpatient psychiatry department in a large urban children’s hospital, running a crisis clinic. I made clinical decision every day as part of my job and felt confident about my range of knowledge of childhood and adolescent psychiatric disorders. This article reflects some of the surprising discoveries I’ve made in my new job, and how my previous clinical beliefs about youth drug and alcohol use and mental health have been challenged.
In my current position as coordinator of the Provincial Youth Mental Health and Substance Use Program at BC Children’s Hospital, I have been developing, with my colleagues, a youth concurrent disorders program—that is, a program that serves youth who have both a mental illness and addiction problem. The Provincial Heath Services Authority recently granted ongoing funding to expand the program’s clinical services, as it had been operating for the last two years with only on staff member.
One of my first tasks was to get myself up to speed on assessing substance use in youth. No problem! I thought. I would just learn the substance use assessment questions and tack them on to my mental health questions. I quickly became ware, however, that despite my years of experience, I didn’t really know what a concurrent disorder was in the youth population. Did it mean the problem with drug use came first ant then the mental health problem started? Or, was it the other way around? Did it matter which came first/ Things were beginning to look more complicated than just adding a few questions. Moreover, I didn’t know what I was supposed to do with the drug and alcohol information once I got it. I was firmly in the grips of the dreaded “I didn’t know what I didn’t know” feeling.
Eleven years ago I had been responsible for developing the referral criteria for the crisis clinic. With the blessings of my psychiatric colleagues, I had stated clearly in the criteria that referred adolescents with active substance use were in the “we will not see them” category.
When youth did come through my former “mental health only” door, I would ask them if they used any drugs, expecting a typical response like, “Yeah, I smoke a little pot and sorta get drunk on the weekends.” I would then rapidly move on to ask more about their mental health problems; my comfort zone was only in doing a mental health/psychiatric assessment.
If they told me they were using a lot of drugs and/or alcohol daily, I’d begin to doubt that I could be very helpful. I would immediately start thinking about referring these youth on to addiction services and telling them to come back and see us when they had been “clean” for at least three months. Invariably, this would be the last time we saw them.
Why was this? Was this a service delivery issue? Was this a clinical issue? Had I inadvertently been giving the message that you could only get help from us for one problem, not two? Or that mental health problems and drug use problems were two separate issues and needed two kinds of specialists who weren’t, most likely, going to speak to each other?
When I have attended conferences and workshops, they have been focused either on mental health or on addiction; I have attended just one conference with a specific concurrent disorders focus. It became clear to me that mental health and addictions clinicians spoke two different languages. There were also difference in assessment and treatment approaches, beliefs about change, and so on. It was also clear that we, through separate groups of health care professionals, were seeing the same clients.
Was the lack of a common language part of why it was hard to communicate with each other about our clients? Or was it deeper than that? Was there a level of discomfort with each other that was grounded in no wanting to feel exposed about what we didn’t know about each other’s area? And if we did discover that we were unfamiliar with something form the other’s territory, then what? If I wanted to get more familiar with issues regarding youth drug and alcohol use, would I be welcomed as a colleague, or would I be treated as an “outsider”? If I felt with way, what must the clients, feel like?
Posing these questions to myself made me come to terms with the fact that I was, in some ways, a product of the mental health/psychiatric system training, Even though I had been working in psychiatry for almost 20 years, I had no more than a basic introduction to substance abuse, its treatment or addiction medicine. I had never worked, or been offered an opportunity to work, alongside an addiction medicine physician or an addiction treatment clinician, so never gained a good understanding of how they worked, thought or conceptualized this issues facing their clients
Service delivery to youth has traditionally been provided via referral to either mental health or addiction services, depending on who is ding the referring and what they thought the problem might be. The type of assessment and treatment these young people would receive depended on which “door” they went through. This system has not only led to fragmented service, but has also kept professionals separated from each other in terms of facilitating respectful understanding, acceptance and knowledge exchange.
As I move ahead in my new position, I hope to soften some of the professional barriers between youth mental health practitioners and addiction clinicians, I am now very aware of the clinical reality that if a substance problem exists in a youth, there is a good chance there is a mental health issue that needs to be explored in a comprehensive assessment. Form a personal perspective, challenging my belief system about youth substance use has been a learning opportunity that I didn’t often connect to myself. It is sometimes s healthy to be just a little bit humbled.