Chapter 6: Substance Use and Mental Illness

I first noticed signs of a mood disorder shortly after I turned 16. One month everything was awesome, life was grand. Then the next month I couldn’t even crawl out of bed for work or school. I remember hearing “Manic Depression” by Jimi Hendrix and thinking: That’s what I have!

I grew up with a stepdad who was physically and verbally abusive, used drugs (sometimes) and alcohol (almost always). When he was sober, my stepdad was a great guy. Sometimes I even wanted think of him as my dad–especially given that my biological father abandoned us. But in that environment, talking about my feelings wasn’t safe, and so, I bottled them up.

You can only pack so many feelings into your brain’s inner-bottle before something gives. In my mid-20s, when I found myself tossing and turning every night, butterflies kicking around in my stomach, and bad thoughts racing through my mind, I finally went looking for help.

I told my doctor what was going on: My anxiety was so bad I had physical symptoms. I hated being around people. It was impossible to form an emotional bond with anyone, even my kids. Sometime I couldn’t sleep, others I could work all night, non-stop.

She sent me home with a box of antidepressants, a sample dropped off, no doubt, by the latest pharmaceutical rep.

I tried the pills for a few weeks with no luck. I went back complaining that my symptoms were getting worse. So she wrote me a prescription for another antidepressant. This yielded the same result. After a few times of that, I gave up on doctors.

Within a few months of my last visit, I was injecting heroin every day.

When Self-Medication is the Only Medication You Can Find

Despite the “Drug War” myths I’d heard growing up, I wasn’t “hooked” on heroin instantly (and, in fact, most people who try drugs–even heroin–never become addicted). I did, however, notice an immediate effect on my mental condition. It was like someone twisted the top off that bottle and a decade’s worth of worries floated away. Heroin felt like medicine.

I was able to function for two years as a software engineer using heroin every day. The stereotypes you hear about drug users aren’t always true.

Heroin almost completely eliminated the stress of a 70-hour, 24/7 on-call work week. Later, when I began bartending and waiting tables, I relied on the excuse that being on drugs made me “more fun to be around” and better at my job (which was true to an extent, until my habit spun back out of control).

Eventually life caught up with me. Heroin is expensive. Even with a well-paying job, I was unable to support a daily habit and pay the rent. I found myself in a self-perpetuating cycle that only reinforced my need for more drugs.

When I started seeking treatment, the only options I could find were twelve step programs. I attended meeting after meeting, and nothing clicked. If anything, being told that I used drugs because of character defects and that I was powerless seemed counterproductive. It crystallized what I already thought about myself by that point: I was a bad person doomed to be an “addict” for life.

Through countless AA and NA meetings, several trips to inpatient and outpatient treatment, a detox facility, a dozen different courtrooms, and two years in prison (where I was offered no substance abuse treatment), at no point-of-contact with any of these institutions was I offered, or was it suggested I might benefit from, mental health treatment.

It was only after I entered a methadone program and started attending SMART Recovery, a free,  evidence-based alternative to twelve step programs, that a facilitator suggested I might be self-medicating mental health issues.

The tools I learned in SMART made me feel like I could take back control of my life. Through SMART’s cognitive-behavioral therapy (CBT) and rational-emotive behavioral therapy (REBT), I learned several important skills:

  • Instead of giving in to urges or cravings to use, I could distract myself with positive activities
  • I could be on methadone or suboxone and still be in “recovery.” This was critical, because opiates did, and still do, feel like a critical part of my medical care
  • REBT taught me to dispute irrational thoughts–it wasn’t certain events that made me sad or depressed, but my thoughts about those events
  • That using once wasn’t a traumatic failure. I could slip and still keep moving forward. They differentiate between a slip, a lapse, and a relapse
  • That by changing the words I used to express thoughts about myself, my using, and my problems, I could move beyond being an “addict” to simply a person dealing with problems that I was now empowered to overcome

One of the most important things SMART taught me was unconditional self-acceptance (USA). This turned my self-esteem around and helped me survive until I was able to find effective mental health treatment. I still use these skills today, and they can be applied to more than just substance use disorders (SUD) or mental health issues.

I first noticed symptoms of mental illness in 1994. I started using heroin in 2004. It wasn’t until 2015 that I was properly diagnosed with bipolar disorder, general anxiety disorder, and post-traumatic stress disorder (PTSD).

It took me 20 years to even find my entry point to treatment for mental health issues which, had they been treated sooner, might have spared me that decade-long relationship with heroin.

The 2012 SAMHSA National Survey on Drug Use and Health indicates that 43.7 million (almost 19%) of adults live with some form of mental illness and that 20.7 million adults (almost 9%) have an SUD. About 8.4 million have both mental health disorders and SUDs. That means over 40% of Americans with SUDs also have mental health problems (and those are only the people who have been diagnosed).

According to the National Institute on Drug Abuse (NIDA), 40% of those with an SUD also have a mood disorder and about 30% have an anxiety disorder. They also estimate that genetics constitute 40-60% of a person’s risk for developing a SUD. So what about the rest?

Good News, It’s Not Your Brain — It’s Your Everything
For many years addiction was treated as a “brain disease.” This model presumed some people were “wired” to become addicted to drugs or alcohol, powerless victims with no ability to control their behavior. This was the standard belief in most of the drug and alcohol treatment community for over half a century.

But recent research (and in fact, some that dates back to the 1970s) paints a much more complicated picture. The brain does play a role in SUDs, but there’s more to a person than just their brain, and the same holds true for people who use drugs.

Data from NIDA and the CDC indicate there are a number of contributing factors to substance misuse, including emotional trauma, physical or sexual abuse, poverty, social pressure, and more. The “psychobiolsocial,” model provides a better explanation for why some people are at greater risk of developing an SUD than others.

Dr. Andrew Tatarsky, in his article “We Don’t Treat Brains, We Treat People,” describes a more comprehensive approach to managing SUDs. He writes that:

Accumulating data and clinical experience support a “psychobiosocial” model in which biology and behavior intersect with meaning and social context in complex ways that are unique to each person and give rise to the problematic and addictive behavior.”

Psychotherapy, which focuses on the patient’s mental, emotional, and physical well-being, is a critical component of treatment for people with SUDs and mental health disorders. Instead of focusing strictly on the brain, psychotherapy also addresses physical, social, and environmental causes. Tatarsky describes his approach as “a personalized treatment for substance misuse and addiction that goes beyond the one size fits all model of abstinence.

Connecting the Dots
As my experience demonstrates, finding effective treatment for mental health disorders or SUDs is not easy. While more effective treatments are becoming available, connecting patients to those treatments remains a problem.

From a policy level we must, at a minimum, provide better opportunities for mental health screening and treatment at every point of contact with the medical, drug treatment, and criminal justice systems. It shouldn’t take over 20 years for someone to find help, especially given my multiple encounters with all three.

We need funding for mental health programs and evidence-based treatment programs, but we also need an integrated approach to treatment for SUDs and mental health issues. We need more effective educational resources so that when people recognize symptoms, like those I first noticed as a teenager, they know where to turn and aren’t afraid to ask for help.

Life for those of us with co-occurring mental health issues and SUDs is especially dangerous, especially when it comes to suicide and encounters with police, not to mention overdose. There are effective treatment options out there, but without resources that make them accessible, most of us with co-occurring disorders might never find our way to a “normal” life.

More resources:

More from NAMI on Substance Use Disorders and Mental Health Conditions:

NAMI Dual Diagnosis Fact Sheet:

Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems, by Dr. Tatarsky

Practicing Harm Reduction Psychotherapy, Second Edition: An Alternative Approach to Addictions, by Pat Denning

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