Blamed and Ashamed: The Treatment Experiences of Youth With Co-occurring Substance Abuse and Mental Health Disorders and Their Families

Bert Pepper, MD
TIE, Inc., 126 N. Main Street, New City, NY 10956

As a public health physician and psychiatrist who has described the development of people with co-occurring mental health and substance abuse disorders over the past twenty years, I was honored to participate in the session, Blamed and Ashamed, at the recent Federation’s Annual Conference. The presentation took place in Washington, D.C., on December 2, 2000. I am pleased to recap my remarks for the published report.

When I first read the draft report of this project I was astonished to find how closely the findings, produced by focus groups of adolescents with co-occurring disorders and their families, matched my own work. The material I have gathered from research and clinical experience dovetails perfectly with the findings and recommendations of the focus groups.

What is the big picture?

There are thousands of adolescents and young adults across the United States who, by their behavior, have earned tickets of admission to hospital emergency rooms, homeless shelters, substance abuse treatment programs, psychiatric hospitals, and jails. Many go back and forth in a confusing zigzag, never staying very long in any one place. Despite the best efforts of each agency, not one of them, working alone, can meet the complex needs of these young people. They live with a mixture of mental health problems, alcohol and other drug abuse problems, health problems, immaturities, broken relationships with families, disrupted schooling, and behavior that disturbs the community and is often technically criminal.

How many people are affected by co-occurring disorders?

The National Co-Morbidity Survey, headed by Dr. Ronald Kessler in the early 1990s, indicated that there are about 10 million adults who suffer from at least one mental health and at least one substance abuse disorder. Treatment is often unavailable. When it can be found, it is usually uncoordinated. We need to focus treatment so that it is integrated: humane, family-inclusive, and clinically effective. Treatment of either disorder alone does not work. Treatment integration is essential, because the commonest cause of mental health relapse in this population is continued use of alcohol and other drug abuse. AND, the commonest cause of relapse to the use of alcohol and other drug abuse is untreated mental health problems, such as panic-anxiety and depression.

Today, dealing with co-occurring disorders is an every day problem for families, schools, the mental health system, the substance abuse treatment system, the courts and the jails, But it is only recently that the interactive nature of these problems has begun to be recognized.

In the 1960s and 1970s the treating agencies denied that co-occurring mental health and alcohol and other drug abuse problems existed.
By the 1980s there was general acknowledgement that the problem of co-occurring disorders did, indeed, exist.
By the 1990s mental health agencies were referring the problem to substance abuse agencies, while substance abuse agencies were referring the problem to mental health agencies. Troubled youth and their families were getting a runaround.
In this new Millennium we are just beginning to see that providing effective, humane integrated treatment for these interacting disorders is a problem for our whole human service system, for our whole society. We have met the problem, and Pogo says it is all of us.

What are the problems today?

Agencies receive money from separate sources from mental health and substance abuse agencies, at the federal, state, and local levels. In many cases, conditions attached to the spending of these funds makes it difficult or impossible for treatment to be integrated for the individual with co-occurring mental health and alcohol and other drug abuse problems.
There are separate agencies for mental health and substance abuse at federal, state, and local levels. Their level of cooperation and collaboration has been poor, and is only now just beginning to improve.
The different professional jargons in mental health and in substance abuse make it difficult for treating clinicians to communicate with each other. This causes each agency to want to remain separate, and to avoid responsibility for the person with multiple problems.
Society stigmatizes people with mental health problems. It separately and differently stigmatizes people with alcohol abuse problems. And society’s stigmatization of people with problems with cocaine and marijuana are yet again different. When the person with co-occurring problems gets pushed into the criminal justice system because of ineffective treatment in the community, an additional stigma is tacked on. The person who has been marked as a criminal has a greater burden to bear, as s/he struggles to find an honorable place in society.
Mental health and substance abuse agencies want to do what they know how to do. Their staffs like to do what they were trained to do. Change is difficult.
As a result of many of the above factors, each agency is likely to reject change because, “We’ve always done it this way!” or,
“We’ve never done it that way.”

What are administrators doing?

In government bureaus and at the service agency level, officials responsible for public policy covering mental health and alcohol and other drug abuse services tend to put forward the following kinds of arguments:

"We know that what is being done now doesn’t work."
"But let’s not set up a new system for co-occurring disorders."
"That would be too costly."
"Don’t ask my agency to take on the task."
"That would further overburden us." and
"We are already doing all we can!"

Who gets hurt by current policies and procedures?

Troubled young children who, if their mental health needs are not met promptly and effectively, will probably selfmedicate with alcohol and other drugs.
The majority of emotionally troubled adolescents, because in addition to their mental health problem, they are likely to also have an alcohol and other drug abuse problem.
The majority of people with schizophrenia, who also have an alcohol and other drug abuse problem.
The majority of people with manic depression, 60% of whom have an alcohol and other drug abuse problem.
Perhaps 40% of people now in substance abuse treatment, who are at risk of substance abuse relapse because their mental health problems are not being addressed.

Who benefits from the current situation?

The prison-industrial complex, as money from government budgets for health, mental health, social services, and education gets sucked out of those budgets, to pay for the construction and staffing of more jails and more prisons.

What are the facts? What are the numbers?

The mental health treatment system has been radically downsized. In 1955 the nation had 559,000 public mental health hospital beds. By 2000 the nation had only 60,000 beds left.(Figure 1)
During the past forty years the population of the country has risen by 100,000,000 people.
The few remaining beds must serve many more people. That is why it is hard to get anyone into a hospital, and even harder to keep them there for more than a few days.
Even if a bed is available, restrictive managed care payments for hospital care makes it virtually impossible for hospitals to keep patients long enough to treat them.
We used to have too many beds and over-hospitalization: now we have too few beds and under-hospitalization.

What has happened to our jail and prison capacity?

In 1972 the total capacity of all U.S. incarceration facilities—federal, state, and local jails and prisons—was under 200,000.
In the year 2000 the capacity reached 2,000,000!
And, they are full:

Jails are like sports stadiums:
Build them and they will come!

The National Co-Morbidity Survey, and children:

As noted before, Dr. Kessler’s survey gives us our best national data regarding mental health and alcohol and other drug abuse disorders. The survey data suggests that:

Between 8 and 11 million persons in the United States have at least one mental health and at least one substance-related disorder today.
The mental disorder developed first in more than 85% of these people.
The median age of onset for the mental disorder was 11. That is, of these approximately 10 million people, 5 million developed their mental health problem at age 11 or older, and 5 million developed it at age 11 or younger!
The median age of onset for the substance abuse disorder, depending on geography, ethnicity, and gender, was somewhere between 17 and 21 years of age.

What are the implications of these disturbing numbers?

They tell us that co-occurring disorders usually begin in childhood. Whatever the reasons, millions of Americans develop mental health disorders during childhood. The fact that millions go on to develop an alcohol and other drug abuse disorder some years later—usually substance abuse—suggests that they are selfmedicating their depression, anxiety, confusion, disturbing conduct, and so on. Would providing adequate early treatment for these children be an effective means of substance abuse prevention? It seems likely that if we reached more children with mental health problems early we would do a good deal to reduce problems of alcohol and other drug abuse. Remember, only one in five children with a mental health disorder gets treated today.

Table of Contents | Previous | Next