On the Role of “Adverse Adult Experience” in Co-Occurring Disorders
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For many years substance use disorders and mental illness were generally construed as issues that were best treated separately. It was common that patients in psychotherapy for mental health issues, upon revealing significant substance use problems, would be referred out for substance use treatment and told to return when their substance use issues were treated—presumably rendering them “ready” to do the work of psychotherapy. As our understanding of the interconnection between “psychiatric” and “addiction” issues has improved, the treatment system has begun to change. But has that change gone far enough? Here, Dr. Ross Ellenhorn advocates for a broader view of both our understanding and treatment of the inextricable connection between mental health, addiction and the life circumstances into which they are embedded…Richard Juman, PsyD
The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that approximately 43 percent of individuals with mental health symptoms also have a co-occurring substance misuse issue. Yet decades of research on co-occurring or dual diagnosis disorders have garnered very few answers about the nature of the relationship between these two behavioral concerns. We have, in other words, a chicken and an egg, and we know they’re related—but we don’t know how. In more scientific terms, we can be quite confident there is a correlation between psychiatric symptoms and substance misuse, but we don’t have a similar confidence about causation. That is a significant problem, since understanding the cause of this relationship would lead to more effective treatment.
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One possible reason we can’t locate the cause is that we’re looking in the wrong place. The behavioral health professions have a long history of “attribution error.” This is a tendency to see the root of certain behaviors solely as internal psychological factors, while ignoring external factors that may influence causation.
Attribution error is a “What is wrong with the person?” rather than a “What is happening around this person?” stance.
In regard to co-occurring issues, as we zero in on these two seemingly skull-bound pathologies, adopting a “What is happening around this person?” perspective can give us clues to the missing link in our understanding of the relationship between mental health issues and substance misuse.
Clue One: The Dysphoria Model in Dual Diagnosis Research
A review of the dual diagnosis literature shows minimal scientific support for the concept of “self-medication” in it purest form, which posits that a person abuses substances to relieve psychiatric symptoms. However, the “dysphoria” model, which proposes that an individual suffering from psychiatric symptoms uses substances to quell unease and dissatisfaction with life, carries some significant scientific validity. Most of the research on the dysphoric experience of people diagnosed as mentally ill relates this dysphoria to their poor social state. This stance is our first clue in the pursuit of a better understanding of the relationship between mental illness and substance abuse. This perspective also coincides with emerging theories and approaches in the substance abuse field.
Clue Two: Emerging Ideas in the Addictions Field about Social Pain
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“Not why the addiction, but why the pain?” That simple question, posed by Gabor Maté, represents a small but vivid voice in addiction theory. Questioning the long-unchallenged argument of a “chemical hook” as the sole cause for addictive behavior, and instead, viewing addiction as the result of experiences related to our early attachments and attachment traumas, this voice is gaining in volume in an increasingly hospitable environment. The resurgence of attachment theory in the mental health and addictions field, and the focus on early trauma, partly sparked by the studies on Adverse Childhood Experiences (ACE) and their relationship to numerous physical and behavioral pathologies, have laid the groundwork for this new voice.
The notion that misuse of substances is related to solving painful experiences clearly fits within the dysphoria model. Yet when we limit our view to problems in early attachment, we’re taking an approach that regards attachment issues as causing damage continuing into adulthood, irrespective of whatever is happening around a person. Thinkers other than Maté take a more social view of how we are fulfilled in our attachments as adults — seeing our integration in a community, our sense of purpose as adults, and our feeling of belonging as central to our well-being, while viewing the lack of these resources as the root of addictive behavior. Bruce Alexander is likely the most famous of these theorists. His “rat park” studies have become a central metaphor for a new movement in the addictions field. As the well-known story goes, when laboratory rats led “happy,” connected lives, their cravings for drugs decreased.
Clinical observations of human beings show similar findings. Purpose and contribution to society, it appears, have a powerful sobering effect. Much of this new focus on environmental factors is supported by the work of neuropsychologist Carl Hart. In Hart’s experiments, crack cocaine users are offered small financial incentives (food vouchers) contingent on abstinence. Most choose the vouchers over another hit of cocaine. For Hart, people misuse substances because there are no alternative reinforcers in their environment. “The key factor is the environment,” Hart states, “whether you’re talking about humans or rats.” Echoing this view is neuropsychopharmacologist David Nutt, who states that, “Addiction always has a social element, and this is magnified in societies with little in the way of work or other ways to find fulfillment.”
Clearly, there is a movement afoot, one that sees addictive behavior as both a means to quell pain related to attachments, and understands that addiction always has a social element. For thinkers like Alexander, these two ideas—attachment pain and trauma, and our immediate environment—go hand-in-hand. “Human beings,” writes Alexander, “only become addicted when they cannot find anything better to live for and when they desperately need to fill the emptiness that threatens to destroy them.” The idea that when we lack satisfying relational options in our environment, we tend to seek euphoric means through chemicals for relief, is our second clue.
Clue Three: Social Pain and Mental Illness
Hart masterfully ties the microscopic world of neuroscience with his own story and interest in a larger view regarding the devastating effects of poverty, racism and unemployment in African-American communities. For him, many of these communities offer little “alternative reinforcers.” While people diagnosed as mentally ill come from all walks of life, their social experiences are typically marked by a significant decrease in these positive reinforcers, too.
If we ask about psychiatric patients, “Why the pain?” the answers are tragically countless. As World Health Organization research clarifies, people diagnosed as suffering from psychiatric symptoms are at “greater risk for decreased quality of life, educational difficulties, lowered productivity and poverty, social problems, vulnerability to abuse, and additional health problems.” Five to six million U.S. workers aged 16 to 54 years “lose, fail to seek, or cannot find employment” due to mental illness.
Years of research on “social distance” shows that people generally distance themselves from others described as mentally ill, and that they often distance themselves even more from these people than from those described as criminals. Other research shows the effect of such distancing, with two-thirds of people affected by a mental illness describing themselves as feeling lonely “often” or “all of the time.” These are the ingredients for both dysphoria and an environment lacking the important reinforcer of interpersonal connection and purpose. For these people, stigma, ostracism, purposelessness and isolation are as detrimental, if not more detrimental, to a person’s functioning than actual psychiatric symptoms. This is our third clue: People who have been diagnosed as suffering a psychiatric issue are at acute risk for dysphoria. No matter their social class or the resources that surround them, their mental illness creates a class of its own, an environment with little options for gratifying basic human needs, and thus a fertile ground for substance use.
Clue Four: Social Psychological Research on Social Support, Isolation and Lack of Purpose
What does it mean for two-thirds of a group of people to identify themselves as feeling lonely “often” or “all of the time”? The unanimous answer, in multiple social psychological studies, is that it has a devastating effect. Social isolation ties with smoking, lack of exercise, high blood pressure and obesity in its negative impact on physical health. Most research on this connection between loneliness and health suggests that the stress induced by isolation is the mediating factor. To put it another way, social support is a “stress buffer.” When we don’t feel connected to others, life becomes stressful.
Social psychological research has clarified that a sense of purpose, too, is a stress buffer, and that people who lack purpose typically experience low morale, with morale defined as the ability to move forward in the face of difficult odds. With their tendency to “lose, fail to seek, or … find employment,” that means people diagnosed as mentally ill are at greater risk of feeling a sense of purposelessness and the resulting stress and low morale, as well as a deep sense of loss of personal agency and pride.
Stress is not the only negative state we can assume is experienced by people identified as mentally ill. In fact, we have an answer to Maté’s question regarding “Why the pain?”
A significant amount of social science research reveals a direct connection between social rejection and actual physical pain. In fact, MRI scans show that regions of the brain that respond to physical pain also respond to social rejection, and that this phenomenon is found specifically when someone is rejected, not in other distressing emotional situations. In other words, we are truly—not only figuratively—hurt when someone rejects us. Forced into the status of “outsider” is thus a painful experience, both psychologically and physically.
It is fair to say that people diagnosed and identified as mentally ill are at risk of what I would call Adverse Adult Experience, something that may be more of an emotional state than the characterological attachment traits created by Adverse Childhood Experiences, but that is nonetheless real and debilitating.
Putting the clues together, we now see that “co-occurring” is actually a misnomer. The syndrome is, in fact, tri-occurring, as the typically painful and stressful social experiences associated with a diagnosis of mental illness are a central reason why such people tend to turn to drugs and alcohol. Understanding this must inform how we treat the problem.
Treatments based on this etiology are actually already in place, and shown to be effective. But they are typically ignored when professionals talk about the best way to help people experiencing co-occurring issues.
Integrated Dual Disorder Treatment (IDDT)
Throughout our country, co-occurring and dual diagnosis programs are springing up. In these programs, people sober up, learn new skills for sobriety, deal with their psychiatric issues, and usually leave with an assessment-based plan in hand regarding their goals and expectations. These programs can often be helpful, giving a person a respite from their life problems, and offering new ideas and skills that can be used at home for remaining sober and managing psychiatric symptoms. And their models reflect this orientation: Once a person sobers up, they return to their life at a point of “readiness.”
However, when we understand the problem of dual diagnosis as actually three-fold, there are underlying problems with this basic yet still widespread model. First, if we believe that substance misuse stems from a lack of positive reinforcers in a person’s environment—coupled with the stress and pain of loneliness, purposelessness and “outsiderness” that often come, part and parcel, with a psychiatric diagnosis—then removing them from their environment, without changing what’s happening there, might mean a temporary period of abstinence while away that will likely end when they return home. Second, if we believe the stress and pain that lead to substance misuse for people diagnosed as mentally ill are rooted in feelings of “outsiderness,” lack of purpose, and loss of hope for a meaningful future, then we might be causing them more harm by sequestering them and thereby removing them from opportunities to integrate in their communities. To put it more dramatically, we are taking them from the potentially potent medicine of social integration in order to treat them—like removing a fish from water to save its life. Third, the use of intensive treatment away from home often reflects our country’s paradoxical resource allocation. Families can spend hundreds of thousands of dollars on sequestered care for their loved ones, but often can’t find the right level of services when they return home. And the need for these services is often considerable.
The golden rule for treating dual diagnoses is now well established: Always approach the co-occurring issues of mental health symptoms and substance abuse as interconnected and best treated simultaneously. Most programs achieve this goal by intermixing addiction treatment with mental health treatment. However, viewing the problem as tri-occurring, we see the types of therapies we provide currently as barely adequate, if not weak, since they don't focus on integration into the world as a central part of treatment. We also see that the institutional approach to treatment might be downright wrong for a lot of people, since more intensive treatment is typically provided away from home in sequestered environments. Here enters Integrated Dual Disorder Treatment (IDDT).
IDDT is recommended by SAMHSA as the evidence-based, best-practice treatment for co-occurring issues. The goal in IDDT is to provide intensive and assertive treatment in the community; treatment that can work with individuals typically deemed to require sequestered care. IDDT teams are mobile, working with people where they live. They are multidisciplinary, and include psychiatrists, family therapists, other clinically-trained staff, and substance abuse experts. All the clinical work of these teams is integrated in a whole-person approach, and team members meet daily to review every case. Compared to other treatment models for co-occurring issues, IDDT’s focus is unique: By providing intensive and assertive support to clients in the community, IDDT teams aim to support their return to vocational, educational and family roles as a central part of treatment. Thus, they turn the idea of “readiness” on its head. Believing that people need a social role and sense of purpose in order to recover, they approach the achievement of life goals as an important means to recovery, not something to pursue once a person has had the right dose of treatment. Their job is to find multidisciplinary solutions for keeping a person integrated in the world. Symptom reduction and sobriety are inevitably part of the answer. But they are not terminal goals in themselves. The more global goal in IDDT is psychosocial recovery, the renewal of hope and a sense of fortitude in one’s life that is only achieved by reconnecting with one’s environment.
When we are curious enough to look past what is “wrong” with individuals deemed to suffer co-occurring issues, and we look around the corner at what they see and “what is happening” to them, we find that substance abuse and mental health issues often have a shared cause and result: isolation from the human community. IDDT treats this issue as a central part of care.
Trained as a social worker, sociologist and psychotherapist, Dr. Ellenhorn has spent the last two decades dedicated to the work of helping individuals suffering psychiatric symptoms find the psychological and social means for remaining outside the hospital. He created the first fully operating intensive hospital diversion program in Massachusetts, and created and led one of the first Assertive Community Treatment teams in the commonwealth. He is the founder and CEO of Ellenhorn, the most intensive community integration program in the United States. Located in Boston and New York City, Ellenhorn aims to serve clients who are typically perceived by mental health professionals as appropriate for hospital care, outside the hospital, in their own communities. Dr. Ellenhorn’s book, which addresses parasuicidality, psychiatric hospital recidivism and techniques for diverting hospital use, was published by Springer Publishing in 2007.