By Tom Graham, MA, LLP, CSW

John was upset. He had just learned his health insurance would not pay for him to be in treatment for depression and alcohol abuse at the same time. John had been seeing a therapist for six months for depression and last month he was told to seek help for alcohol abuse as an outcome of his recent conviction for DUI (Driving Under the Influence). John's story is not unusual.

Traditionally, substance abuse and mental health difficulties have been viewed as separate problems. Services to treat these conditions have been isolated from each other and often, as in John's case, in conflict with each other. People seeking help have found that substance abuse programs often screen out individuals with significant mental health concerns and conversely, individuals seeking help for mental health problems are often screened out because of an existing substance abuse problem. As John found out, some health insurance companies have policies and practices that effectively discourage people from getting the help they need when they need it.

Unfortunately, in the world of behavioral health care services, it has been rare to have mental health and substance abuse problems treated in a coordinated manner. John had been candid with the therapist he saw for depression about his increased use of alcohol but his increased drinking pattern was not identified as a problem in his treatment plan. Conversely, many individuals in treatment for substance abuse are shocked to learn their counselor does not want to talk about their difficulties with mood. Often they feel the substance abuse counselor is unconcerned about their mood difficulties, viewing these complaints as signs of avoidance or denial of their substance abuse problem.

Reasons for the separate and often antagonistic approaches in the treatment of these problems are varied. For years, clinicians have been trained to be an expert in one field or the other. Each field has had proponents that have justified their view, often at the expense of the other. This has resulted in barriers for people in getting the help they need when they need it.

Goals of treatment have traditionally been different for these disorders as well. Mental health treatment has focused on the reduction of symptoms. These treatment environments have concentrated on providing support, most often typified by a therapeutic relationship with a psychologist or social worker. A psychiatrist (medical doctor with advanced psychiatric training) will often prescribe medication for the resolution of a disorder. The individual receiving medication may or may not be involved in other psychotherapy or counseling for the difficulty.

Goals of substance abuse treatment programs are typically abstinence from alcohol and/or other drugs. Treatment models have been more confrontational and group-based in an effort to break through what is viewed as the individual's denial process. Separate philosophies and training of professionals in the fields of mental health and substance abuse have also influenced the development of today's behavioral health care insurance policies and practices. It is encouraging however that this has begun to change and there is now more of an emphasis on providing care in an integrated manner. Clearly this is a benefit to the person who is struggling to cope with both a substance abuse and mental health problem.

For some time now our culture has had clear evidence that untreated problems, whether they are of a substance abuse or mental health nature, only get worse. When mental health and substance abuse difficulties are present in the same person at the same time they are said to be coexisting or co-occurring. Persons with coexisting disorders are often referred to as dual diagnosis patients.

Studies support the existence of co-occurring mental health and substance abuse problems, indicating 30%-50% of either group have significant difficulties with the other. These percentages have tremendous implications for what is needed to help people get better. Programs that acknowledge the prevalence of coexisting disorders have emerged in recent years. Some providers have been trained to be competent psychiatrists, psychologists and social workers for patients who present with dual diagnosis difficulties.

Successful programs and providers are those that emphasize the similarities between co-occurring disorders as opposed to their differences. These similarities are essential to keep in mind when working with patients with co-occurring disorders.

There is no one cause for either disorder. Many factors influence the development of a mental health problem as well as a substance abuse problem. Both disorders can impact every facet of a person's life. Each can be progressive. No cure is evident for either disorder, rather reducing or eliminating symptoms and learning how to change one's life to reduce the risks of relapse events is treatment success. Denial or minimizing are common characteristics of either disorder that serve to dissuade an individual from seeking help and often prevent a person from fully benefiting from help received. Loss of control is a primary aspect of both disorders. In substance abuse, it is the loss of control of one or more substances. In mental health, it could be the inability to control feelings of depression or anxiety. Both substance abuse and mental health disorders affect not just the person but have tremendous impact on family members, friends, and society at large.

To provide proper care for individuals with coexisting mental health and substance abuse disorders, Pine Rest Christian Mental Health Services provides dual diagnosis treatment services throughout its continuum of care. This begins with the recognition that both mental health and substance abuse needs must be fully assessed in order to develop a meaningful treatment plan with the patient. When individuals are suffering from an acute phase of either disorder, inpatient hospitalization is usually favored. The individual is admitted to Pine Rest for stabilization of a mental health crisis or to the Recovery Center at Spectrum Health - Kent Community Campus for stabilization of a substance abuse crisis. Pine Rest and the Recovery Center at Spectrum Health- Kent Community Campus are working closely together to integrate treatment services and provide a broad continuum of care.

Once an individual has been stabilized and additional assessment has occurred, other levels of care are recommended depending on the needs determined from assessment activities. Options for care are Partial Hospitalization or day treatment, Intensive Outpatient Treatment (IOP) consisting of several weekly group-based sessions, and traditional individual outpatient care scheduled to fit the needs of the patient. Programming designed to address coexisting mental health and substance abuse disorders is present throughout these levels of care. For individual outpatient care, specialists who have expertise in the treatment of co-occurring disorders are available in most Pine Rest outpatient clinic settings. See sidebar on page 14 for specific location information.

There is much work to be done to continue the integration of care for those with coexisting mental health and substance abuse difficulties. Many communities across the nation are attempting to remove barriers to help for those in need. Pine Rest Christian Mental Health Services and its colleague in this effort, the Recovery Center at Spectrum Health - Kent Community Campus, place the highest priority on serving the needs of persons with co-occurring problems. Pine Rest takes pride in being in the forefront of this important mission for Western Michigan and looks forward to continued expansion of quality services for people who are in need of help.