Written by: Hanna LeBaron, LCSW, Clinical Director
Should substance abuse and mental health patients be treated separately? Many professionals in substance abuse and mental health field have learned to separate recovering people based on their adaptation or maladaptive coping skills due to historical ways of treating substance abuse and mental health disorders. This separation of substance abuse patients and mental health patients is neither needed nor the most effective way of treating recovering people.
Separating the substance abuse and mental health patients can help group members to quickly relate with the other patients in therapy groups and makes facilitating the groups seemingly easier for the helping professionals, but is it really necessary?
As humans, we try to survive difficult situations the best of our ability and sometimes the actual coping becomes a problem. Coping skills are normal part of the human experience and some of them can cause big problems for a whole nation, such as tobacco smoking. Many people use tobacco smoking as a coping skill for stress. Coping skills are a natural part of everyday life and some of the everyday coping skills aren’t working for us anymore or become problematic. However, all of them worked for us at some point.
Using drugs and alcohol as a coping mechanism is obviously unhealthy and often dangerous. Eating a lot of sugar or fast food can become a health hazard as well. When substance abusing people come to treatment with array of unhealthy habits, we understand that these coping mechanisms were used to try to survive the unbearable stresses of life at some point. We look at our clients as survivors, brave and resilient. Most of the time, they are highly intelligent and adaptive to their difficult and often abusive environments.
Substance abuse is a difficult issue to treat when it has reached the point of obsessive and compulsive using. The substance abusing person has become addicted and has hard time abstaining from substances that are now threatening their very life. The substance abuse is actually the secondary problem to the “unbearable stress”, but a lot of times has to be addressed first as it is impossible to treat the mental health issues or underlying issues if the person is under the influence. Sometimes the long term effects of substance abuse cause issues with learning and the brain needs time for healing before therapeutic interventions can be started.
However, we must remember that substance abuse was a coping skill that once worked in helping the person to deal with other problems in their life. It is surprising that sometimes treatment centers and insurance companies only address the problematic substance use when the substance use is most times only the adaptation or the maladaptive coping skill.
If the substance abusing person doesn’t address the underlying issues after being able to remain sober for a period of time, they will most likely relapse back into the old coping mechanisms that have often times been used for years before coming to treatment. The underlying issues should be the focus of the treatment, and the maladaptive coping skills are actually a secondary issue.
The treatment center clients have many different maladaptive coping styles. Teaching the clients about defense mechanisms such as distraction, catastrophizing, terminal uniqueness, denial, acting out, dissociation, intellectualization, rationalization, suicidal ideation and so on is vital part in increasing the awareness of how someone can truly change. Most clients deal with maladaptive coping such as: substance use, codependency, eating disorders, cutting, sexual acting out, suicide attempts and so on. They need to learn why they are acting such way, how they can change it and what they can do instead.
Even though many of these coping skills work in reducing personal suffering and do not always cause irreversible harm, sometimes they can become problematic and even dangerous – causing death. Some more severe adaptations such as current suicidal ideation with a definite plan of action and certain levels of eating disorders need hospitalization and specialized care.
Many clients that use above maladaptive coping need residential treatment as the adaptive behavior has become dangerous and self-abusive. This behavior is visible to others, scary and many times it is the very reason why clients and their family members usually seek help. Once the clients are stabilized and safe, they are able to dive into processing the real underlying issues, why the coping skills were developed in the first place.
The maladaptive coping skills do not disappear immediately upon recognizing the consequences of acting out. Clients act out in treatment centers and learn new coping skills together with the staff and the therapeutic group. The treatment centers treating clients with maladaptive coping styles must be equipped with trained staff and be able to tolerate acting out. The staff knows how to help clients through situations with compassion and without shaming. Clients are offered many learning experiences in the therapeutic community as they have corrective experiences when staff reacts differently to them than what they are used to. This is why many times staying in a residential treatment center is more effective than short stays in the hospital or detox centers.
Most underlying issues found in clients who come to treatment are: trauma (physical and emotional), organic mental health issues, physical illnesses, societal problems – mostly nurture and nature issues. Even though the trauma stories are horrendous in the treatment communities, the clients feel that the worst trauma they have dealt with usually is: toxic parenting, emotional neglect and abuse, abandonment, and being bullied in school and home.
Clients suffer from historical and structural trauma as well which they don’t usually even know about or understand without psychoeducation. The underlying issues are more common amongst the clients than the maladaptive coping. People often share similar traumatic backgrounds but the way they deal with it is unique and different.
Mixing clients with different styles of maladaptive coping helps with focusing more on the underlying issues. Clients tend to identify themselves based on their maladaptive coping skills rather than who they really are which is not helpful in the long-term recovery.
It is not useful to relate with maladaptive coping skills in treatment center as it can lead to “war storying” and talking about the “good old using days” or who has done the most dangerous self-abusive behaviors, which can be triggering and too powerful for the client. “War storying” doesn’t help the recovering brain, on the contrary, it causes relapses and makes healing slower.
Clients tend to feel comfortable quicker and easier at first when therapeutic community has others who have struggled with the same maladaptive coping skills, but as they learn to trust and understand that the group is non-shaming and pro-recovery for all, there is no difference whether your maladaptive coping skill is using heroin or suicidal ideation. The experience from true dual-diagnosis groups suggests that mixing clients is the best practise when focusing on the underlying issues.
Substance Abuse and Mental Health
Mixing clients with primary substance abuse diagnoses and mental health diagnoses help clients understand that they need to work on their underlying issues and they have to learn new healthy coping skills. Mixing mental health and substance abuse clients seems to help clients learn to relate with different kinds of people and increase overall empathy and understanding for all people.
Recovery is not inclusive for one type of recovering person, but for all who are changing their lives for better and healing from their past. Clients in the residential treatment centers need to focus on all aspects of their health, changing maladaptive coping and learning new skills.
Whether the client is suffering from addictions, mental health issues, trauma or behavioral problems – the issues are in the brain. A residential treatment center for substance abuse, addictions, trauma and mental health is really a center for brain health. The treatments and activities are geared towards changing the brain and teaching the client how to care for it.
There is nothing scary or magical about treating the brain. The brain is a vital organ that sometimes doesn’t function correctly and due to life experiences, behaviors, substances or environmental issues, it has wired itself in a way that is not adaptive for the person or the current environment anymore.
Treating mental health and substance abuse clients together is possible and needed due to the similarities in the underlying issues. When mental health and substance using clients are mixed, they are more focused on working on their underlying issues and less likely to identify themselves due to their acting out behaviors. The majority of substance abuse clients have mental health diagnoses and trauma anyway.
When the focus is on recovery, it doesn’t really matter how the underlying issues manifested themselves or how the client was trying to cope with it. What matters is treating the brain and the underlying issues, learning new coping skills and getting healthy.