The Dual Diagnosis Problem in Foster Care

 

During my 10 years as a foster youth advocate, and my five years as an attorney representing children and parents in the foster care/dependency system, I became very familiar with the mental health double whammy of a dual diagnosis (also known as “co-occurring disorders”). The National Institute of Health (NIH) gives this very basic definition of dual diagnosis:

“A person with dual diagnosis has both a mental disorder and an alcohol or drug problem.”

Based on my 15 years of professional experience with the foster care system, I feel comfortable saying that a very large percentage of parents who are involved in that system suffer from both mental illness and drug/alcohol addiction, or, in other words, are dually diagnosed.

The Problem

When social services removes children from their parents’ care and places the children into foster homes, the parents are given a case plan that outlines what the parents must do to successfully reunify—in other words, what the parents must do to get the children back in the parents’ care. For a mentally ill parent, the case plan will include a mental health evaluation, the recommendations of which the parents must follow. This typically includes counseling and appropriate medication. For a drug or alcohol addicted parent, the parent must complete drug/alcohol treatment, and prove sobriety by passing a certain number of drug tests. So we have two directives: 1) get help for your mental illness (i.e. medication) and 2) get sober.

In the case of the dually diagnosed parent, a special problem presents itself: psychiatrists will not provide psychotropic medication to a person who has drugs in his or her system. Since many mentally ill people turn to drugs and alcohol to self-medicate their illness, the requirement that a parent be completely substance free before psychotropic medications are prescribed is almost impossible to fulfill, thus creating a system of certain failure.

As the NIH explains:

“Sometimes the mental problem occurs first. This can lead people to use alcohol or drugs that make them feel better temporarily. [self-medication] Sometimes the substance abuse occurs first. Over time, that can lead to emotional and mental problems.”

“Someone with a dual diagnosis must treat both conditions. For the treatment to be effective, the person needs to stop using alcohol or drugs. Treatments may include behavioral therapy, medicines, and support groups.”

A Hypothetical

Consider a mother who has her children removed from her home because of her rampant drug use. After beginning her case plan, which includes a mental health evaluation, it comes to light that the mother had previously been diagnosed as bi-polar, and the current evaluator agrees. The mother is ordered by the judge to comply with the recommendations of a mental health professional. The mental health professional suggests that the mother be placed on lithium to treat her bi-polar disorder. That same mental health professional, however, refuses to provide the mother with a prescription until she has at least 30-days of sobriety, as proved by random drug testing. Because the mother is self-medicating her bi-polar disorder, she cannot stay off drugs for the required amount of time. Because she is not off drugs, she cannot get the lithium, therefore she cannot get off the drugs. As is apparent: this is a Catch 22.

Difficulties in Treatment and Reduced Odds of Reunification

There are some residential drug treatment programs that can help a person obtain sobriety for long enough to receive psychotropic medication; however, the beds in these program fill up quickly, and many will not take a patient with a dual diagnosis. The residential programs that are specifically designed for those with a dual diagnosis are few and far between, and of course, funding and space are always short.

Compounding this problem is a general culture of stigmatization, especially where dual diagnosis is in play, as well as an assumption that the parent will fail. Not all judges, attorneys, and social workers buy in to this line of thinking, but I would argue that the overall culture of the foster care system is one of misunderstanding and stigmatizing the mentally ill (including mentally ill children, but that’s a topic for another post).

For instance, one thing that often bothered me about the reports social workers write to summarize their interactions with parents is the common use of the word “admit” in connection to mental illness. Example: “Mother admits she suffers from depression.” Or, “Father admits he takes Prozac for his depression.” Or, “Mother admits to often being overcome by anxiety.” One “admits” to stealing or lying. One does not “admit” to feeling depressed or anxious, or to taking necessary medication to bring a very real illness under control. When mental illness is couched in terms of a crime, it is viewed as a crime.

In such a culture, the odds of a parent successfully reunifying with his or her children is drastically reduced, if not completely obliterated.

The Solution

According to the Substance Abuse and Mental Health Services Administration, only a small proportion of those with dual diagnosis actually receive treatment for both disorders. In 2011, it was estimated that only 12.4 percent of American adults with dual diagnosis were receiving both mental health and addictions treatment. This is in part because those with dual diagnoses may not be able to receive mental health services if they admit to a substance abuse problem, and vice versa. (Id.)

The following is an excerpt from Wikipedia, discussing treatment of dual diagnosis patients:

“There are multiple approaches to treating concurrent disorders. Partial treatment involves treating only the disorder that is considered primary. Sequential treatment involves treating the primary disorder first, and then treating the secondary disorder after the primary disorder has been stabilized. Parallel treatment involves the client receiving mental health services from one provider, and addictions services from another.

Integrated treatment involves a seamless blending of interventions into a single coherent treatment package developed with a consistent philosophy and approach among care providers. With this approach, both disorders are considered primary. Integrated treatment can improve accessibility, service individualization, engagement in treatment, treatment compliance, mental health symptoms, and overall outcomes. The Substance Abuse and Mental Health Services Administration in the United States describes integrated treatment as being in the best interests or clients, programs, funders, and systems. Green suggested that treatment should be integrated, and a collaborative process between the treatment team and the patient. Furthermore, recovery should to be viewed as a marathon rather than a sprint, and methods and outcome goals should be explicit.”

As you can see, there is no easy answer. The suggestions above take time, money, health insurance, and advocacy, none of which (most) parents in the foster care system have. These treatment options also require a streamlined and interconnected system, which is certainly lacking in the bureaucracy of social services. Given the short timeframe parents have in which to reunify with their children, the fact that treatment for a dual diagnosis should be a “marathon rather than a sprint,” is especially troubling.

I am not a doctor, psychiatrist, counselor, or social worker. I am an attorney, writer, mom, and wife. Unfortunately, the latter set of credentials does not qualify me to come up with a perfect solution, or even an imperfect one. I understand a doctor’s belief that mental illness cannot be treated while drugs are either masking symptoms or creating symptoms that wouldn’t otherwise exist. But perhaps greater reunification periods could be given to parents with dual diagnosis. Perhaps doctors could cross their fingers and hold their breath and hope that the medication prescribed works well enough for the parent to get sober, then doctor, parent, and therapist can see what symptoms are left, and what new ones appear.

Whatever the alternative, it can’t be worse than what these parents face now.

Author’s note: While I may some day turn this into a legal, scholarly article complete with footnotes, statistics, solutions, and multi-syllabic words, please take it for what it is today: a blog post. It is not meant to address every problem with mental health treatment within the foster care system, but it is meant to get people thinking.

CC Photo by Leland Francisco

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Elise Hilton
Jamie, as an adoptive mother of five kids with varying degrees of mental illness, and having spent an enormous time with mental health professionals, this article is spot-on. We need to do SO much education in our country regarding mental illness. Thanks for leading the way.
10 months ago · ( 0 )
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Jamie Calloway-Hanauer
Thanks, Elise! And thanks for being such an amazing and giving mother. Your kids are lucky to have you.
10 months ago · ( 0 )

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