FROM: Kristine W.
1. According to Inaba and Cohen, clients have traditionally been â€œmore reluctant to seek help from the MH system than from SA treatment programs.â€ (Inaba & Cohen, 2011, p. 10.10). Inaba and Cohenâ€™s third point: â€œClients are more reluctant to seek help from the MH system than from SA treatment programsâ€ is very confusing. The text goes on to say that there is a stigma attached to mental illness and that clients and their families hope that if they treat the addiction the mental health problem will resolve itself. However the third line says, â€œThere is a persistent stigma and a negative stereotype attached to being a female addict or alcoholic, so many women seek mental health treatment as a way to address their chemical dependency problem.â€ (Inaba & Cohen, p. 10.10) The authors seem to be completely contradicting themselves - unless they are unconsciously talking about the â€œclientsâ€ of the first sentence as strictly men.
2. "When using street drugs, patients feel a false sense of control over which drugs they ingest, inject, or otherwise self-administer. The same patients, when receiving medication from a doctor, often express the feeling that they are not in control of their lives." (inaba and Cohen, 2011, p. 10.25)
This statement deserves close scrutiny. One may pose the question: â€œIs the feeling of having control when choosing to self-medicate with street drugs completely â€˜false?â€™â€ Perhaps, from the clientâ€™s perspective, there is some veracity in such a sentiment. When clients seek, test and initiate sustained use of a particular street drug, they are making an attempt to take some form of control over their condition. One of the biggest indicators of stress is the feeling of loss of control. Drug use is a response to that stress. The entire medical system, from the authoritarian stance of some physicians, to the false, reductionist assumption that medications are the primary way in which clients can control mental health issues, to the inhumane and irrational convention of insurance industry number crunchers making medical decisions wrenches the locus of control out of the clientâ€™s hands.
â€œThe biggest problem with psychiatric medications (with any prescription medication) is compliance with the physicianâ€™s instructions.â€ (Inaba and Cohen, p. 10.31) In this dysfunctional and misguided system, is it really that surprising that clients are non-compliant (a problematic, patronizing concept in and of itself)? Yes, street drugs are scary and unregulated, but from a clientâ€™s perspective, it is understandable that they would prefer them to being stripped of their power, their choice, and their dignity.
Thanks very much for the observation regarding our bookâ€™s depiction of differences between mental health and substance abuse item #3 on page 10.10. You are quite correct that it is confusing in the book due to editing it down to fit appropriately and not overwhelm readers. The observations noted in this section was solely based upon my 40 year experience with a very ethnically diverse population at the Haight Ashbury Clinics in San Francisco and as you point out also has to do with variances between men and women in that population. Women in that population as well as the general US population during the era of the 1960 â€“ 1990 were less likely to be in addiction treatment then men. I believe that a double standard existed where male alcoholism/addiction was almost expected and therefore somewhat more acceptable within this population whereas females alcoholics/addicts were stigmatized to be almost inhumane to be obsessed with drugs â€“ having no â€œwill powerâ€ to control their use compromising their projected â€œsacred imageâ€ as mothers and family nurturers that societal roles expected them to be. Thus, even now about 66% to 75% of those treated for addiction are men. Women often came into addiction treatment first only seeking problems for emotional issues or were referred from mental health services when their addiction issues were discovered. Having depression or stress seems to be much less stigmatized to them as compared looking at themselves as an addict or having that label put upon them. Men, especially men of color look at major mental health issues as totally disabling and unmanageable so they were avoiding having to look at those issue as much as possible preferring to being an crack addict or cocaine addict rather than someone who was, in their minds, â€œcrazyâ€. Also, they saw those who had experienced the â€œmiracleâ€ of recovery and had great hope that it would occur with them. They and their families had a negative view of men with major mental health disorders only gaining limited functionality and lifestyles on chronic neuropsychiatric medications. Now my work in Oregon is with a less culturally diverse population and there are a more equal requests for addiction treatment between men and women. Also, men are more accepting of mental health disorders here and know that they have less hope of maintaining their recovery unless they get their mental health issues stabilized. Hope this is less confusing to you but I may need to speak with you directly about this since you bring forth a very complex yet significant discussion that was greatly truncated in the book.
Your second point regarding our comments on page 10.25 are even more insightful and begs a tremendous discussion that needs to be addressed in-depth probably in another book that is more direct to the topic of co-occurring disorder treatment and also one that worries less about the political interpretations that can be inferred. We are in actual very strong agreement with you on this as the end of that paragraphs shows that our book comments are directed to the mental health provider not towards the person taking street drugs to self-medicate: â€œThus many are more apt to rely on street drugs rather than on prescribed psychiatric medications for relief of their emotional problems.â€ Much too often clinicians inappropriately write off substance abuses as merely malingering, manipulative or worse, medication seeking rather than looking at their mental health treatment issues. Thus we end there with: â€œIt is up to the physician to work with the patient regarding any and all issues raised by the use of prescription medicationsâ€ We indeed should have added, ....and street drugs.) What is troubling is that current neurotropic medications are still basically â€œshotgunsâ€ at best! Specific individual genetic and epigenetic expressions result in a medication having great benefits to some but almost an equally detrimental effect to others. Thus we have several different classes of antidepressant that work on different parts and even different neurotransmitters in the brain. The same antidepressant that finally relieves major symptoms in some may actually cause schizophrenia or worse depression in others. Though science is now working on pharmacogenomics to address these variances, we need current practitioners to listen to and work closely with their patients to find a therapy (with or without medications) that can be most advantageous for the specific patient. I believe that close physician â€“ client interactions happens less with those with co-occurring addictive disorders because of the current stigma of addictions in the psychiatric field. The Mental Health Parity and Addiction Equity Act of 2008 was supposed to start eroding stigma for these conditions but it has yet to be implemented anywhere.
Your final point regarding comments we made on page 10.31 is another way of looking at the consequences that result when practitioners are unwilling or not interested in working closely with co-occurring disorders. Both clinician and client need to understand that there are a wide range and availability of mental health therapies and medications that can effectively minimize the impact of such conditions on those affected. Clients need to follow closely what resources the clinician is providing and provide immediate feedback on their efficacy. Clinicians need to listen closely to all feedback and keep altering the treatment resources until a good match is found. It truly is wonderful when such a match is made.
Self medication can often lead to temporary illusions of relief from mental health problems but long-term continuing deterioration. There are now 15 University medical residencies in addiction medicine that have started in 2011 that will help to implement the 2008 Addiction Equity Act. So, clients may have better resources to deal the the issues you so expertly identified at some time but not anytime soon Iâ€™m afraid. Thanks so much for your insights and comments. I will have to more closely review the wording of these issues on the next edition of our book and fight with my editors to make them more understandable. Speaking of which, sometimes my editor like to post questions and responses I provide on our web-site â€œask Darrylâ€ segment. If such is the case with your comments and questions, is ok for us to post them on the site to help others. We can take out your name and anything that identifies who asked the questions if you would like us to but we wonâ€™t post any of it unless you give us your approval via replying to this email.
Thank you Dr. Inaba for such a thorough explanation! I wasnâ€™t expecting a response. I learned so much from your text and I am humbled and appreciative that you are open to suggestions from students. I never expected a reply. I would be happy to have my questions/comments posted on your site and you are welcome to use my name. Thank you again.