A Family Guide to Concurrent Disorders

(2007) was produced by Caroline P. O’Grady, RN, MN, PhD. And W.J. Wayne Skinner, MSW, RSW for the Centre for Addiction and Mental Health (CAMH)

It defines the concept of concurrent disorders, looks at the impact on families, explores the treatment system, and talks about the journey to recovery.

The guide is designed to help families find the information they need to support their family member:

• Information about substance use and mental health problems—and above all, to know that families do not cause the problems
• A common language with treatment providers—to make it easier to collaborate
• Strategies to cope with issues associated with concurrent disorders
• Strategies to look after themselves and reduce the impact of their relatives’ problems on their own lives.

The guide is divided into four parts:

• Part I: What are concurrent disorders? provides an overview of concurrent disorders, an introduction to treatment options and information about substance use and mental health problems and how they interact.
• Part II: The impact on families focuses on the impact of concurrent disorders on family life. It includes information on experiencing, understanding and coping with the effects of stigma and on self-care strategies for family members.
• Part III: Treatment explores treatment and support for people affected by concurrent disorders. It includes strategies for navigating the mental health and substance use treatment systems and information about psychosocial and medication treatment options, recognizing and planning for relapses, and anticipating and coping with crisis situations.
• Part IV: Recovery talks about the journey to recovery.

The term concurrent disorders “describe a situation where someone has both a substance-use problem and a mental health problem at some point in their lifetime”, either in the past or in the present.The authors point out, “The results of the Epidemiologic Catchment Area Study (Regier et al., 1990) indicate that a person who has a mental health disorder is almost three times more likely to have a substance use disorder at some time in his or her life than is a person who does not have a mental health disorder. A person who has a substance (other than alcohol) use disorder is about 4.5 times more likely to have a mental health disorder at some point in his or her life than a person who does not have a substance use disorder.”

The impacts are not only on the individual themselves, but can cause confusion and frustration for the affected individual’s family.Chapter 4 of the guide looks at impact on families and Chapter 5 talks about coping strategies.

Chapter 4 address the feelings of families who discover that a relative has both a mental health disorder and a substance use disorder.Family members’ lives often change dramatically after a family member develops con- current disorders. Many of these changes create stress. The chapter discusses:

• Behaviour changes in the person with concurrent disorders
• Relationship changes amongst family members
• Increased responsibility for caregiving and the impact on the caregivers.

The authors point out, “The person with concurrent disorders will often feel that family members are invading his or her personal life. Resentment about being overprotected may lead to anger, rebellion and acting out. These behaviours may increase the risk that the mental health problems will worsen or that the person will end up in unsafe situations. The cycle of the family’s preoccupation and the loved one’s reaction then repeats itself. This costs everyone in terms of time, physical and emotional energy, and quality of life.”

Family members, particularly parents, may experience similar emotional patterns to those of grief and the death of a loved one, including emotional pain, a sense of loss, grief, sadness and anger.Siblings may experience fears that they are themselves vulnerable, and feelings of anger as parents time and energy is drawn towards care of the individual in crisis.They can also experience fear of their sibling’s behaviour and guilt “that they have a better life than their brother or sister.”

The guide suggests that parents can help their other children by:

• Assuring children that behaviours such as aggression are symptoms of the illness and shouldn’t be taken personally
• Sharing feelings and encouraging children to talk about how they feel and how their brother’s or sister’s problems are affecting them
• Explaining that family members often feel uncomfortable, embarrassed or ashamed of their relative’s behaviours, symptoms and diagnosis
• If appropriate, discussing the issue of stigma and why it happens, as well as effective ways to deal with it (see Chapter 6 for more information about stigma)
• Helping siblings learn about substance use and mental health problems and how these interact with and affect each other
• Spending time alone with siblings, talking and doing enjoyable activities
• Helping children build a new relationship with their brother or sister and creating unique ways of being with their sibling.

They also point out that people with concurrent disorders often have trouble maintaining stable and decent housing, which can create further challenges for families.Families can feel overwhelmed and isolated by the circumstances in which they find themselves.The authors warn that, “before you can begin to take care of yourself and play a positive role in your loved one’s recovery, you need to think honestly about the different ways that your life has been changed.”They give a reference to My Therapy Netfor strategies in dealing with compassion fatigue.

They suggest keeping a personal impact log, recording impacts on physical and emotional health, social life and spiritual life.The log is designed to help you think about the effects of your loved one’s mental illness and substance use problems on your own physical, emotional, social and spiritual health. It will help you break the overall impact on your life into smaller, more manageable areas of concern.

They also include a tool called Preoccupation and Impact, designed with questions to help think through how much having a family member with concurrent disorders is affecting your life. A third tool is The Family Concurrent Disorders Index of Concerns Quiz, designed to pinpoint areas of concern as a first step to think about how to resolve them.It can also help to identify personal areas of concern over which you have little control.

Chapter 5 looks at Self-Care, including resilience, short-term self-care strategies, long-term self-care goals, and building a self-care plan.The chapter includes a variety of tools, starting with a resiliency assessment.

The authors include a list of short-term strategies, or ‘quick wins’ that families have found useful to renew their energy and face their challenges:

• Have your morning coffee.
• Talk to someone you trust.
• Hug your pet.
• Take a deep breath.
• Take a timeout.
• Take a long, hot shower.
• Apply your favourite body lotion.
• Watch your favourite TV show.
• Sit in your backyard after dinner.
• Go for a long walk.
• Become more aware of nature.
• Go to a movie.
• Go shopping and treat yourself to something new.
• Give yourself permission to feel upset and frustrated, and permission to overcome these feelings.
• Structure your day to ensure it includes leisure time.
• Think about things that make you feel happy or soothed or comforted and make a note of them so you can remember to add those things to your list of self-care quick wins.

They note that these short-term strategies will be unique to each family member. “List the quick wins that might be most helpful for you, and add to your list when something comes up that you find pleasant or re-energizing, such as visiting a flower market.”

They stress the value of positive self-talk and the need for regular reminder that there is no need to be perfect, and that it is important to allow yourself to experience all of your feelings within the situation.Another tool helps to identify role models as guides to help you find your own path through the challenging circumstances in which you find yourself.

The next tool helps identify ways of behaving that you would like to either stop, start or continue.

The authors then go on to look at long-term strategies.They explore some of the behaviour patterns that can be most difficult to deal with and look at personal difficulties which might occur (e.g. having you or another family member experience a period of significant ill health).They suggest that making a list of options and possible solutions can help in developing an action plan.“Some challenges may require help from other people, such as other family members, friends or health care professionals. You may decide to see a health professional who can help you with your own needs and concerns. You may join a family support group after this one, or even while this one is running. You can make a list of especially close and supportive relatives and friends for help in a crisis. Maybe you can hand over some responsibilities that can be carried out by others, so you can lighten your load in general (e.g., ask for help in car pools, have another family member shop for groceries, simplify the home cleaning schedule, teach everyone the miracle of the microwave!). “

They look at how to understand problematic thought patterns, and reference Dr. David Burns classic cognitive therapy book, Feeling Good, which is written in accessible language for non-specialists to use as a resource.They explore a variety of thinking ‘traps’, including:

• Overgeneralization
• Magnification
• Minimization
• Disqualifying the Positive
• All-or-Nothing Thinking
• Jumping to Conclusions
• Mind Reading
• Should, Must and Ought Beliefs
• Personalizing and Blaming

They suggest a variety of strategies that may help you to deal more effectively with difficult feelings including:

• Repeating positive affirmations over and over to yourself such as, “I am doing the best that I can and I am a good and decent person.”
• Being aware of yourself and any problematic thoughts you might be having about situations, events and other people that might be resulting in negative feelings
• Being aware of how you handle stress and what kinds of stressful situations leave you feeling most vulnerable
• Developing effective ways of coping with a family member who has concurrent disorders (e.g., finding out how to navigate the treatment system and get help)
• Setting limits and clear boundaries
• Talking openly and honestly about how you feel, and examining those feelings, either with someone you trust or within a peer or professionally led support group
• Talking to other families about effective ways to deal with stress and difficult emotions
• Developing and following your own personalized self-care plan.

They give strategies for building social support networks, and suggest that being open about your situation can often draw support from the least likely places and people.They reinforce the value of becoming informed, and recommend searching out and connecting with specialist and support organizations in your community.They stress that you have a right to ask questions and receive support, education and information from medical professionals for all members of the family impacted by the situation. They also stress the importance of building a self-care plan in order to build your resilience and reduce your vulnerability, and include a tool to begin to develop your plan.

There is an extensive exploration of stigma, including internal feelings of fear and shame, and external attitudes from within society and the media, and the resultant danger of isolation.The authors note that strategies to survive stigma are unique to each family, but may include:

• Turning to other families in similar situations for support
• Keeping the problems private — as a family matter
• Sharing their stories with the public
• Challenging negative attitudes (including a list of advocacy tips)
• Looking at the situation from a different perspective.

In Chapter 7, the guide looks at treatment options, and makes a strong case for integrated treatment.They suggest the following questions to ask a treatment agency:

• What is your treatment philosophy and method?
• Do you refer clients to other agencies for some substance use and/or mental health services? If so, who is responsible for overall co-ordination of services?
• What percentage of your clients has co-occurring substance use and mental health problems?
• What is your policy about using medication as a treatment option?
• Does the program support a full range of needs (e.g., social and medical)?
• What role do family members play in their relatives’ treatment?
• Do you offer services and referrals for family members?

If your relative has agreed to having you involved, they suggest some questions to ask about his or her treatment plan:

• What is the provisional diagnosis?
• What are the possible causes of my relative’s problems?
• What is the proposed treatment?
• What are the benefits and risks of the treatment?
• Are other treatments available?
• What are the options if this treatment doesn’t work?

They provide a treatment-tracking log, which can prove useful in conversations with professionals, and look at the stages of change: pre-contemplation, contemplation, preparation, action and maintenance.They include a Readiness for change ruler tool for families to help think about how ready you are to change certain beliefs and actions associated with having a loved one with concurrent disorders.They also give tips for evaluating peer-support groups and questions to ask about a self-help group.Finally, they include a list of questions to ask about a transition or discharge plan.

They include information about medications that may be prescribed, medication management and the risks of medication abuse or dependence, drug interactions, and stopping medication.They also have a section on relapse and relapse prevention for both substance use problems and mental health problems, including risk factors and relapse prevention strategies.As well, they include a section on crises and emergencies, and how to create both and emergency and a crisis plan.

The final chapter looks at recovery, which is individual to each person, and the role of hope in recovery, and give a list of elements that may feature in recovery for both the individual and their family. They include a Recovery Attitudes Questionnaire tool to help identify your own beliefs and attitudes about recovery, and make the point, “Recovery is a process and experience that we all share. People face the challenge of recovery when they experience the crises of life, such as the death of a loved one, divorce, physical disabilities and serious mental illnesses. Successful recovery does not change the fact that the experience has occurred, that the effects are still present, and that one’s life has changed forever. Rather, successful recovery means that the person has changed, and that the meaning of these events to the person has also changed. They are no longer the primary focus of the person’s life (Anthony, 1993). “

The guide ends with a list of resources including websites, online publications, books and booklets.A more recent guide to resources is also available through Kelty Mental Heath.Some of the resources listed in their Concurrent Disorders resource list that may be of particular relevance for the PHAC programs include the following:

• BC Mental Health & Substance Use Services bcmhsus.caProvides general information about mental health and substance use, as well as resources, programs and services related to mental health and substance use across BC
• Centre for Addiction and Mental Health camh.net | Click on “Health Information”, then “C”.Provides a list of information and related links on concurrent disorders for youth, parents and health professionals.
• Centre for Addictions Research of BC carbc.ca Covers a comprehensive range of articles and information about a variety of topics related to substance use for communities, families and teachers.
• Here to Help heretohelp.bc.ca Offers multilingual information, personal stories and fact sheets on substance use and mental health.
• mindcheck.ca mindcheck.ca A youth and young adult-focused interactive website with quizzes, self-help tools, website links, and assistance in connecting to local professional resources across BC.
• Substance Abuse & Mental Health Services Administration (SAMHSA) samhsa.gov Provides an extensive list and information on drugs, alcohol and concurrent disorders.
• A Family Guide to Concurrent Disorders camh.ca/en/hospital/health_information/a_z_mental_health_and_addiction_information/concurrent _disorders/Documents/partnering_families_famguide.pdf Free, downloadable resource for families who have children with concurrent disorders.
• Concurrent Substance Use and Mental Health Disorders: An Information Guide camh.net | Click on “Health Information” -> “C” -> “Resources”Prepared by the Kelty Mental Health Resource Centre | Last updated: January 2016 Tel: 604-875-2084 Toll-Free: 1-800-665-1822 Email: keltycentre@cw.bc.ca keltymentalhealth.ca Concurrent Disorders This guide is for people with concurrent disorders, their families, and anyone who wants basic information about concurrent disorders, their treatment, and their management.
• You and Substance Use Workbook: Stuff to Think About... and Ways to Make Changes heretohelp.bc.ca/sites/default/files/you-and-substance-use-stuff-to-think-about-and-ways-to-make- changes.pdf This resource guides you through the process of understanding more about the role of alcohol or other drugs in your life.
• Alcohol and Drug Information & Referral Service Tel: 604-660-9382 | Toll Free: 1-800-663-1441 Worried about drug or alcohol use? Whether it's for yourself or someone you care about, you can call the Alcohol and Drug Information and Referral Service for information, options and support.
• Kelty Mental Health Resource Centre Tel: 604-875-2084 | Toll-Free: 1-800-665-1822 keltymentalhealth.ca | keltycentre@cw.bc.ca | youtube.com/user/KeltyMentalHealth Offers information, resources, help with system navigation, and peer support to children, youth and families across BC dealing with mental health and substance use challenges. The Centre also provides resources and peer support to individuals of any age struggling with an eating disorder.
• BC Children’s Hospital Provincial Youth Concurrent Disorders Program Tel: 604-875-2345 | bcmhsus.ca/programs-and-services/provincial-youth-concurrent-disorders- program Outpatient clinic that provides consultation, comprehensive psychiatric assessments and limited treatment for youth with mental health and substance use concerns ages 12-24 from the province of British Columbia.
• Dual Recovery Anonymous draonline.org An independent, non-professional, twelve step, self-help membership organization for people with a dual diagnosis.

The BC Mental Health and Substance Use Services (BCHSUS) site has a particularly easy to follow FAQs responding to questions families and individuals may have about how to deal with issues of substance use and mental health, with pathways to follow to access help.

A Family Guide to Concurrent Disorders Kelty Mental Health - Concurrent Disorders