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Resilience
A Systems Failure
Treatment facilities often fail to address co-occurring disorders.
Posted July 31, 2019 Reviewed by Abigail Fagan
On January 3, 2014, my daughter died of a heroin overdose in a step-down unit at a residential rehab facility. Her name was Giana Natali and she was a few weeks from her 34th birthday.
She had begun using opioids about six years earlier and turned to heroin 14 months before her death. She began using a synthetic opioid to relieve pain from body-building, and later she was prescribed opioids for a back injury that occurred in her work as a veterinary nurse. Initially, however, her opioid use relieved something else ultimately more significant: major depression and anxiety that had been diagnosed more than a decade earlier while she was in treatment for severe anorexia.
Research confirms that comorbidity of anorexia and other mental health disorders is common and that a pre-existing mental health diagnosis, including eating disorders, is a significant risk factor for developing a substance use disorder.
What is difficult to understand, then, is the widely documented failure of substance use treatment to adequately address these co-occurring disorders in an integrated and effective fashion. Unfortunately, this is not just the failure of our rehab and mental health facilities but a more difficult structural challenge resulting from the separation of the systems that treat mental illness and substance use, with people working in each system who are not trained to treat the other issue.
While in the early 20th-century severe addiction was sometimes addressed in mental health settings, with the rise of AA and an emphasis on addiction as a “moral failing,” substance use treatment separated from mental health care. This was formalized by the federal government with the establishment of institutes and funding streams that separated the two. Obstruction by state government exists as well; in some states, there is no licensing category for a facility that provides both addiction and mental health treatment.
After two years of treatment for her eating disorder, Giana returned to college in 2001. She was still medicated for depression and anxiety and under the care of a psychiatrist, but she was positive and hopeful about the future. She graduated, went to work, and then returned to school for two years and gained her veterinary technology degree in 2009.
When she first entered substance use treatment in 2012, her documented depression and anxiety were not treated as co-occurring disorders but as symptoms of her substance use. Often this tendency—not treating co-occurring disorders—is based on the belief that addiction must be treated first, assuming that the person must stop the substance use before mental health treatment will be effective.
Confusion can occur because depression and anxiety are common responses to prolonged addiction, and the thinking goes that you can’t make an accurate diagnosis until the person is abstinent. In Giana’s case, there was ample history of mental health diagnoses and treatment to conclude that these were not symptoms of her addiction but of co-occurring disorders. From the treatment notes, it’s unclear whether Giana ever saw a psychiatrist or a psychologist at either of her first two residential treatment stays, but in the second her medication was changed by an attending physician without consultation with her outside psychiatrist.
Even though many rehabs advertise treatment of co-occurring disorders and reassure patients and families that there will be a connection with existing therapists and doctors, in my family’s experience this doesn’t happen in a systematic way. In August of 2013, Giana entered a well-known treatment center that touted its treatment of co-occurring disorders on its website. She spent four months there. Her primary addiction counselor, who had a Bachelor of Arts degree in an unrelated discipline, did communicate with Giana’s outside psychiatrist every few weeks with updates.
However, the mental health treatment Giana received was minimal. Despite Giana entering this rehab with a significant mental illness history and a connection to a psychiatrist, the psychologist who did Giana’s initial assessment only recommended that the facility psychiatrist evaluate Giana’s anti-depressant medication and stated that Giana might “benefit from periodic follow-up with the unit psychologist to monitor her depression and anxiety.”
That monitoring—not actually treatment—consisted of four individual sessions over four months. In her initial assessment, this psychologist noted that “Giana is a relapse patient and may not have fully grasped the 12-Step concepts including Step One” and recommended that she be “immersed in 12-Step relapse extended-care programmatics.”
In addition, the psychologist noted that part of her problem was that she didn’t have a connection to her Higher Power and recommended spirituality counseling. Giana spent more time with the spiritual counselor than she did in therapy. Giana was seen periodically by the psychiatrist for medication checks, although she was never given addiction medication to deal with the cravings that she complained of continually.
What did happen at this facility, as at many, were groups. The issue of groups versus individual therapy comes up frequently in discussions about rehab. Obviously, groups are more cost-effective. But are they therapeutically effective for people with severe addiction and a mental health diagnosis? At most rehabs, patients with a substance use disorder only and those with co-occurring disorders are put in the same groups and treated identically. At the rehab under discussion, Giana attended a separate group for opioid use disorder patients once a week. She was also assigned to an eating disorder group that met erratically. The other seven or eight groups to which she was assigned met at varying intervals with no distinction by type or severity of substance use or by mental health diagnosis.
Well-known addiction experts such as A. Thomas McLellan, Ph.D., and Dr. Mark Willingbring have repeatedly questioned the efficacy of groups, especially since people with some mental health disorders don’t function well in them, and advocated for more individual work in treatment settings. Giana’s depression often expressed itself in silence and inaccessibility, which ironically is mentioned in the notes from every rehab she attended. The groups were not an effective treatment modality for her.
During the four months in this program, Giana’s depression worsened and we strenuously questioned their decision that she was ready for discharge to a step-down facility so she could gain more independence. The psychiatrist at the new program immediately changed her anti-depressant medication. The therapist there noted Giana’s extreme depression and stated that the plan was for her to act on her treatment goals and wait for the new medication to take effect.
Recognizing her fragility, both Giana and I tried to reach the psychiatrist, but he had gone on vacation just after changing her medication. Deeply depressed, adjusting to a new anti-depressant, unprotected by addiction medication such as Vivitrol, and alone in her step-down unit most of the time, Giana overdosed and died three weeks after arriving at this program.
