Sheldon Zimberg – författare

Patients who have both a psychiatric disorder and a substance abuse problem cause most clinicians to throw up their hands in despair. The clinical problems that these "dual diagnosis" patients present are enor­ mously complex. Diagnostically, how is one to tell if disorders of mood and thinking, for instance, are signs of a mental illness or consequences of substance abuse? How is one to obtain important historic information when the patient may be unable or unwilling to provide it and there are no readily available collateral sources of information? In any case, why bother? Treatments for dually diagnosed patients are ineffective; patients won't stay in treatment; recidivism occurs at a very high rate. To make matters even more difficult, traditional health care reim­ bursement mechanisms do not provide for the multimodality clinical programs and special services needed by the patient who is both mentally ill and a substance abuser. So the clinician needs an effective bureaucratic strategy as well as a treatment strategy. For the most part, clinicians have handled the problem by ignoring it.

Sodetal attitudes toward alcoholism are characterized by several types of denial, with disastrous personal and sodal consequences. Refusal to admit the extent of alcoholism as a major national health problem leads to a public policy which allocates relatively few resources to research, prevention, treatment, or rehabilitation. On an individual basis, the combination of sodally approved drinking and the stigma assigned to the chronic alcoholic results in individuals blinding themselves to the existence of the problem in family, friend, and self until it has reached such an advanced or obvious degree that denial is no longer possible. There is the third kind of denial, exemplified by therapeutic de­ spair, which proclaims thatgaps in knowledge of the cause of alco­ holism are so great and failures to treat alcoholics successfully so dra­ matic that there is no assurance that efforts will lead to a positive outcome. This denial is perhaps the most troublesome because it re­ flects an attitude of therapeutic helplessness. It discourages families from seeking help, and it reinfOlces the tendency of physidans and other human-services workers to overlook the presence of alcoholism as they treat its physical, sodal, and economic consequences. Denial frequently surrounds those who treat alcoholics with an aura of hope­ lessness, which itself is a negative therapeutic force.

Sodetal attitudes toward alcoholism are characterized by several types of denial, with disastrous personal and sodal consequences. Refusal to admit the extent of alcoholism as a major national health problem leads to a public policy which allocates relatively few resources to research, prevention, treatment, or rehabilitation. On an individual basis, the combination of sodally approved drinking and the stigma assigned to the chronic alcoholic results in individuals blinding themselves to the existence of the problem in family, friend, and self until it has reached such an advanced or obvious degree that denial is no longer possible. There is the third kind of denial, exemplified by therapeutic de­ spair, which proclaims thatgaps in knowledge of the cause of alco­ holism are so great and failures to treat alcoholics successfully so dra­ matic that there is no assurance that efforts will lead to a positive outcome. This denial is perhaps the most troublesome because it re­ flects an attitude of therapeutic helplessness. It discourages families from seeking help, and it reinfOlces the tendency of physidans and other human-services workers to overlook the presence of alcoholism as they treat its physical, sodal, and economic consequences. Denial frequently surrounds those who treat alcoholics with an aura of hope­ lessness, which itself is a negative therapeutic force.

Patients who have both a psychiatric disorder and a substance abuse problem cause most clinicians to throw up their hands in despair. The clinical problems that these "dual diagnosis" patients present are enor­ mously complex. Diagnostically, how is one to tell if disorders of mood and thinking, for instance, are signs of a mental illness or consequences of substance abuse? How is one to obtain important historic information when the patient may be unable or unwilling to provide it and there are no readily available collateral sources of information? In any case, why bother? Treatments for dually diagnosed patients are ineffective; patients won''t stay in treatment; recidivism occurs at a very high rate. To make matters even more difficult, traditional health care reim­ bursement mechanisms do not provide for the multimodality clinical programs and special services needed by the patient who is both mentally ill and a substance abuser. So the clinician needs an effective bureaucratic strategy as well as a treatment strategy. For the most part, clinicians have handled the problem by ignoring it.