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A young woman comes for services to a county contract agency. She is seen for intake by a psychiatrist and a therapist. Asked about the meds she's been prescribed she recites a lengthy list. Her history is one of polysubstance abuse and, although she has been "clean" of non-prescription substances for many years, she is currently misusing her prescribed medications. She is also the
child of an alcohol abuser. The warning flags are up.

Her case is assigned to a therapist who focuses on her alcohol/chemical abuse issues and her secondary diagnosis of "Borderline Personality." There are subtle and not so subtle power struggles between the two. The doctor is manipulated to prescribe what the client wants and she "acts out." Her negative attention seeking is well rewarded and she is in and out of the hospital several times. How can the cycle be interrupted?

She begins to attend a self-help Group where she is educated regarding her illness and the meds and how they interface. She is accorded respect, her negative behaviors are ignored and her positive efforts are rewarded. Life goes on and she is able to leave the agency. She forms a therapeutic alliance, which supports her efforts and develops a working relationship with a physician. The "Borderline" qualities recede. Her relationships generally improve.

The above scenario may sound too good to be true, but my point is that nothing is static. Change is the natural order of things, even in issues of mental health and substance abuse, especially when therapists and physicians do not resist cooperating and dare to become more innovative and open to new learning side by side with their clients.

I have been a mental health professional for over 20 years. When I began, I was working with substance abusers and found I often could not understand why a "relapse" occurred, especially when the client was "doing everything right," honestly doing a program (AA or one of the other groups).

During this period, I made a concerted effort to learn as much as possible about what I was dealing with, i.e. etiology of brain disorders, progression and effects physically, mentally and emotionally. I never made a referral to a group or meeting, which I had not myself attended. To me, that seemed common sense in order to make better matches. But I was to find out that that was a rarity and considered by many to be a waste of time and effort.

Another truism for me was the need to include family and/or significant others as soon as possible and as much as possible. Time and again they proved to have valuable insights and were invaluable to facilitate solutions. I found myself getting good at repairing bridges between loved ones, relationships that had been damaged by the abuse inherent in a life of CD (chemical dependency).

After several years on the CD service I had an opportunity to increase my income by returning to "straight" mental health work again where I was appalled to realize how abysmally ignorant most of my peers were about chemical dependency. What they hadn't learned in an academic setting they discounted totally. I, on the other hand, had found that most of what I knew to do that worked for my clients was what they and their families had taught me as we struggled together within their circumstance.

Probably what disturbed me the most was the number of times I heard otherwise competent therapists decry the need for medications, which interestingly is a bias they seem too often to share, despite more and more evidence of the biochemical basis for both conditions, substance abuse and mental illness.

One of the most valuable sources of my own evolution as a helping person was my eleven-year involvement with a self-help group in Van Nuys, California called "Ups and Downs," a mutual support group for persons with affective, or mood, disorders. While the literature seems to say that about 33.3% of persons with these diagnoses also tend to have substance abuse problems, my own observations indicate the percentage to be much greater. I believe that most persons afflicted with persistent mental illness have at some time "self medicated" with substances licit or illicit, depending on availability, desperately looking for something that works!

When one realizes how difficult life can be for such a person, is it any surprise that he or she would seek a respite, however brief, or return to this relief time and again until one problem becomes two or more?

Most times it is really difficult, if not impossible to say which came first: the mental illness or the substance abuse. After the fact, does it really matter? In terms of treatment, they must both be addressed! True, a totally accurate diagnosis may not be made when a person is "loaded and/or episodic." Still, insisting on six months "clean and sober" before diagnosis and treatment is, to me, ridiculous. Better to make a presumptive diagnosis, treat both conditions and repeat your psycho-social assessment later.

Respect is the key to successful treatment; respect between professionals whose disciplines have unique roles to play and especially respect for the persons whose needs bring them together. To say that persons who are both mentally ill and substance abusers are generally hypersensitive to criticism and rejection is, I believe a basic truism. Their fractured lives have made them expert manipulators, "cons" in defense of their feelings and circumstances.

With an absence of professional jargon, a generous amount of patience and encouragement, a firm insistence that responsibility and rights go hand in hand and an involvement of family and/or significant others on "the treatment team," I have participated in success after success. No sure things and no cures, but certainly the opportunity for a more fulfilling life. It has been rewarding to be a part of that process. A rocky road, to be sure; one that often brings me into conflict with traditional therapeutic approaches that emphasize boundaries and non-directiveness. But I have seen successes and knowing they are possible seems to sustain me through failures and frustrations.