Large numbers of people with mental illness also abuse drugs and alcohol. Accurate figures are hard to obtain. My estimates, which approximate those in the literature, are 40% of outpatients, 70% of emergency room and inpatients, 80% of homeless and 90% of incarcerated mentally ill people abuse substances. These figures have two implications: 1) More money is spent on mentally ill people that abuse substances than those that don't, and 2) They primarily use expensive services.

Clearly services are needed that address both problems simultaneously. Trying to separate out primary mental illness with secondary substance abuse from primary substance abuse with secondary mental illness, in order to assign responsibility to separate bureaucracies, is in general impossible, especially since many people are lying to get what they want. Furthermore, clinically this division makes no sense. Their needs (benefits with money management, supportive housing, medication, substance abuse treatment, rehabilitation, etc.) are identical. Dividing these services, and populations, is harmful and should be stopped. The division is an artificial bureaucratic one and can be eliminated bureaucratically with jointly funded and staffed programs.

Substance abusing mentally ill people have several common features:

1) They lie and say they're not abusing substances. This is in general effective. A recent study at Harbor General's psychiatric emergency room showed that 70% of people whose charts contained no mention of even a suspicion of substance abuse tested positive for drugs or alcohol. The fragmentation of our system makes this deception much easier. The bureaucratic division actually encourages this lying as do policies excluding people "under the influence."

2) They say their substance abuse isn't causing any significant problems. This is sometimes a lie and sometimes they're fooling themselves. It is far more popular to blame their mental illness or the treatment system for their problems, but it's almost never true. In my experience with mentally ill people, substance abuse is the most common cause of not getting benefits, of eviction and homelessness, of hunger, of incarceration, of losing jobs, of destroying relationships and families, of medical and psychiatric emergencies and of death. It is exceedingly rare not to have significant negative consequences from substance abuse.

3) They say they don't want to stop their substance abuse. A very small fraction identify decreased substance abuse as a goal and even fewer are willing to go to treatment.

Our treatment system, where it exists, is designed for people who say they abuse substances, that it's causing problems and that they want to stop, despite the fact that the vast majority don't meet these criteria. This selection is generally justified by saying that very few of the rest will attain sobriety and therefore it's a waste of limited resources to serve them all. Plenty of data would seem to confirm this pessimism. In actuality, we are spending considerable resources on these people even while we're trying to exclude them. All this approach does is eliminate them from any continuous, coordinated, reasonably priced, proactive treatment. In addition, this line of reasoning contains two generally unchallenged assumptions: Firstly, that there are no legitimate goals besides sobriety, and secondly that there are no ways to organize services to help people attain those desirable criteria.

A pervasive counterargument usually surfaces at this point: Having these people suffer as much as possible, and experience as many negative consequences as possible, is, in fact, the best way to get them into treatment. They need to "bottom out." Although so pervasive, I see very little evidence this is true. It is not the amount of loss that correlates with "bottoming out," but the meaning people attach to these losses. Data from substance abuse programs routinely show that people with families, with jobs, with money, with social networks, etc., are most likely to attain and maintain sobriety. They have more resources to help them. They have more left to lose, and more reasons to stay clean and sober. They have "higher bottoms." I would advocate for a treatment that "raises bottoms" instead of one that maximizes suffering. "Enabling" needs to be avoided by allowing "natural consequences" of substance abuse to occur and by dealing with problems directly without taking responsibility for solving them away from the person or "rescuing." If people have control of their lives, and the opportunities to both succeed and fail, they will more likely take responsibility for their failures and for making changes. There is an added inhumanity to this "bottoming out" approach. The vast majority will never attain sobriety. They are suffering for no apparent purpose. Unfortunately anger and frustration, fueled both by society's general moral negativity towards people who abuse substances and by the annoying, destructive things people who abuse substances often do, often distort the process of working with these people. I think it has also distorted our whole thinking about treatment approaches.

Within the context of these premises, we have developed a 4 stage treatment system that includes all substance abusing, mentally ill people. This treatment system fits together almost seamlessly with our psychosocial recovery program for mental illness.

Clearly this approach needs a great deal of work. There is no theoretical and value consensus surrounding my underlying premises. I purposely presented them starkly to highlight the discussion that is needed. The system organization needed to provide these services in a continuous, integrated, responsible manner exists only sparsely. And the technology, although promising, needs refinement and yields only modest results at present. Nonetheless, I feel this approach to be worthwhile enough to urge the substantial changes its implementation would require.

Stage 1: Engagement

Target group: people lying about their substance abuse.

Substance abuse treatment goal: to engage the person in a discussion of their substance abuse.

Quality of life goals:

1) obtaining and retaining benefits to live on

2) obtaining and retaining housing

3) obtaining food and clothing

4) minimizing psychiatric symptomology

5) minimizing medical problems

System goals:

1) avoiding homelessness

2) minimizing psychiatric emergency room and hospital treatment

3) minimizing medical treatment

4) diverting incarcerated people to substance abuse treatment

5) deal with quality of life issues directly to minimize "system abuse"

Treatment Approach:

Form a long standing, "no fail," relationship with the person in a variety of out of office settings. Tolerate ongoing substance abuse, without becoming angry or punitive but confront as often as possible the denial of the substance abuse, and the "natural consequences" of it in a variety of out of office settings. Help achieve the quality of life goals, involuntarily if necessary. Undermine the secrecy around the substance abuse as much as possible. Try to understand as much as possible the role of substance abuse in the person's life. Try to educate about the reality of substance abuse. Work with others in the person's social network and family to increase confrontation.

Services Needed:

1) mobile, continuous case management with emergency response

2) benefit assistance, money management, payee program

3) supportive housing

4) psychiatric medication, medication management

5) drug testing

6) liaison with medical treatment

7) liaison with the court system

8) substance abuse education

Stage 2: Persuasion

Target group: people who admit to substance abuse but deny it's causing problems.

Substance Abuse treatment goal: to persuade people that their substance abuse is causing problems in their lives.

Quality of Life goals:

1) Stage 1 goals continue

2) increase material possessions, quality of housing, social network, employment, education and whatever other positive "rehabilitation" goals the person can be encouraged to pursue.

System goals:

same as Stage 1

Treatment Approach:

Continue the established relationship through multiple cycles of helping the person get things they want and then lose them to substance abuse. Do not protect from the natural losses, but always confront that substance abuse caused the loss, and help to rebuild. Try to avoid getting frustrated and punitive through these cycles. Try to avoid the program losing things as the person loses things. This up-and-down process is a more effective persuasion / learning process than unrelenting suffering and hopelessness. Coach other skills besides substance abuse that are useful in living successfully.

Services Needed:

1) same as Stage 1

2) supportive socialization

3) supportive education

4) supportive employment

5) successful living groups

6) money management training

7) medication management training

8) symptom management training

Stage 3: Active Treatment

Target group: Those who say their substance abuse is problematic and are willing to consider, at least temporarily, sobriety as an alternative.

Substance Abuse treatment goals:

1) to attain significant periods of sobriety

2) to convince people that it is preferable to be clean and sober

3) to teach them how to maintain sobriety.

Quality of Life goals:

This is not a real focus during this stage. In fact, many people may give up a significant amount temporarily to attain sobriety.

System goal:

1) minimize treatment costs using residential programs instead of inpatient programs.

Treatment Approach:

Maintain enough support system to help the person become and stay sober. Often, temporarily, some isolation is necessary from their substance abusing network. As much as possible, build that support system back into their environment as they return to the community. Teach skills needed to live sober (e.g. "work a program"). The intensity of the program should be able to be increased as the person allows and should be continued in the community. Some people may succeed without entering a program but they will need to leave their old substance abuse network. The case manager should not be the primary substance abuse treater in this stage, to allow their relationship to continue even if the person drops out of a given program. The case manager does help coordinate treatment and support and is an active part of the ongoing support system.

Services needed:

1) same as Stage 1

2) "pre - AA groups"

3) AA/NA groups

4) residential substance abuse programs

5) sober living residences

6) other social support for sobriety.

Stage 4: Relapse Prevention

Target group: people who have attained significant periods of sobriety and desire ongoing sobriety and have at least some understanding of what that would require.

Substance Abuse treatment goals:

1) to maintain sobriety as long as possible

2) to limit the length and destructiveness of relapses

3) to develop a sober identity and lifestyle

4) to become active promoters of sobriety in others.

Quality of Life goals:

1) return to Stage 2 goals, this time expecting to maintain gains instead of losing them to substance abuse

2) to attain increasing freedom and responsibility

3) to reintegrate into the community

4) to achieve rehabilitative goals as desired by the person.

System goals:

1) to retain the participation of sober people to enrich the overall treatment environment.

Treatment Approach:

The vast majority of people in active treatment are able to attain significant periods of sobriety. The vast majority will later relapse. The support system needs to be maintained as strong and as long as needed. Assist in not catastrophizing relapses and limiting their length and damage including returning to active treatment if needed. Encourage the relationship to change from dependent to adult-to-adult without terminating it. Need to be available, but not restricting.

Services Needed:

Same as previous stages.