I work on an Acute Inpatient Mental Health unit. We provide mental health treatment, not drug and alcohol treatment yet we keep getting folks who are addicted to illegal or prescription drugs. Individuals who are violent and psychotic from using bath salts get dragged to the ER by police and then are dumped on us. Addicts trying to escape going to jail come to the unit claiming that they are depressed and suicidal. People with “chronic pain" whose doctors won’t give them anymore pain meds or who have used up their script early suddenly claim that they feel hopeless or depressed and “can’t take it anymore.” They know that when they’re admitted they will be given more pain meds. Once these people get on the floor, they spend the whole time arguing and drug seeking. If they come to groups, they blame everyone else for their problems and don’t take responsibility for anything. They act like teenagers.
The attitudes expressed above reflect the feelings unit staff can have about individuals we serve who abuse substances. Inpatient mental health providers may have less compassion when they perceive that someone’s mental health issues are the result of a choice to abuse substances. This perception causes staff to react to patients’ expressions of anxiety, irritability and/or pain with, at best, annoyance and, at worst, hostility. Therapeutic detachment is internally justified through the belief that the mental health system has nothing to offer patients until they stop using drugs. It seems as though the current treatment paradigm supports this view.
Mental health issues and substance abuse issues often intertwine. I don’t think anyone working in the field will disagree. Unfortunately, this professional consensus is not translating well into the provision of treatment, particularly the provision of more restrictive levels of care. In general, people who are looking for treatment must choose between a drug and alcohol model or a mental health model and ne’er the twain shall meet. The movement toward a co-occurring treatment option has begun but has been slow to truly define itself. It’s important for me point out that my exposure to the drug and alcohol model has been limited.
Therapeutic detachment in unit staff is reflected in the grouping of all individuals with addictions into one category. First, motivations are believed to be self-serving; for example, escaping the consequences related to drug use or attempting to obtain medications that will prevent the experience of withdrawal. But similar motivations could also be said to apply to some of our non-addicted folks. We see individuals who recurrently consider suicide to escape the pain of relationship, legal, financial or work related problems. In addition, some folks express that they came to the unit to “get a med adjustment” because their current meds “aren’t working.” Med seeking? Second, individuals with addictions often resist participating in groups and can present as sarcastic or argumentative. Again, this behavior is not exclusive to individuals with addictions. Many individuals are ambivalent about treatment, particularly regarding participation in groups. Resistance is not unique to people with addictions.
Finally, it is believed that “they” are just going to go out and use again. While recidivism is, in fact, high among people who are addicted to substances, it is not uncommon for patients to return to unhealthy coping patterns upon discharge. We see many folks return to the unit without having followed through on outpatient treatment or whose self-destructive thoughts return shortly after discharge. Does this mean inpatient treatment is useless?
As with all cases of therapeutic detachment, it is important gain insight into the cause of the detachment. The reaction often relates to a lack of education, experience, and ability to relate to the processes involved in addiction. In some instances, staff have family members with addictions and project these negative attitudes onto patients. I confess again that my own deficiencies in these areas can affect my confidence in providing services. I am not an addict. I smoke, but that’s different (wink, wink).
Individuals with addiction differ with regard to how their use began. It may have been related to social anxiety, depression, low-self esteem or hallucinations. It’s possible that family patterns of substance use normalized addictive behavior. For some folks, use began as attempts at pain management. Or maybe, the person tried the substance and simply found the experience enjoyable.
While factors that lead to use differ, the biological effects of substances are the same. Patterns of tolerance, dependence and withdrawal are similar within each class of substance. In addition, the consequences of substance dependence and abuse tend to be similar. The addiction often leads to interpersonal, vocational, legal, physical, financial, and emotional problems.
On an inpatient unit, we can offer the best services by addressing both of these areas of concern. An education group on the physical effects of substance use is a critical factor in providing treatment. I believe people feel a greater sense of power over their lives when they can make some sense of their experiences. Understanding the symptoms of withdrawal and that these symptoms will wane over time may help the person ready for abstinence to hold on when it seems like too much. This has to be done with a non-judgmental approach. A psychiatric nurse trained in addictions would be the best choice as a facilitator for this kind of group. For patients who are not yet ready, the knowledge plants a seed which may be used later.
Inpatient therapists can also offer individual and group therapies which address psychosocial factors common to everyone on the unit. There are many ways to escape emotional pain. Most people who come to our unit have found that their current means of escape is no longer effective. Those means may involve isolation, aggressive anger, sexual promiscuity, creating a world outside of reality, or abusing substances. Viewing individuals with addictions in this way allows us, as mental health professionals, to understand that treatment is not either/or but must include both a solid mental health and addictions approach.
I would greatly appreciate input from those who work in a co-occurring setting. The clients I have known who have been in co-occurring rehabs give mixed responses. A very dear friend of mine with chronic and persistent mental health issues was taken off all medications, including psychiatric, upon arrival to a rehab that specialized in co-occurring disorders. The reason they gave was that “a drug is a drug.” Reportedly, his insurance (Medicare) stopped paying after two and a half weeks. They discharged him suddenly with no follow up plan.
When I picked him up, he was in a full blown manic state with psychotic features. He had lost over 20lbs. I chose to stay with him at his home for a week before encouraging his admittance into the nearby psychiatric unit. I believed that safe, familiar surroundings might help his paranoia and assist in reorientation. During this week he slept less than six hours. While being home seemed to help his paranoia some, his mania continued to be severe. He agreed to go to the psychiatric hospital (where he was very familiar with the staff and setting). He ended up being placed on 400mg of Seroquel (as well as other medication) twice a day before he was able to sleep. He left on more medication than he had ever been on. I have known him ten years and have never seen him like that before or since. I could not believe what happened, and still can’t. By the way, he is still clean after 5 years. I’m so proud of him.
Jill Presnell is a Counselor in Northeastern Pennsylvania as well as an advocate for the provision of recovery oriented mental health services.