Lives at Risk: Understanding and Treating Young People with Dual Disorders

Lives at Risk: Understanding and Treating Young People with Dual Disorders

Hillary Ryglewicz a Bert Pepper New York: Free Press, 1996

Reviewed by Dorinda N. Noble

MENTAL HEALTH PROFESSIONALS frequently see lives at risk: adolescents and young adults who are dabbling if not drowning in drugs and alcohol; those who exhibit signs of mental illness that make healthy relationships, all but impossible; those who are potential candidates for jail time if they're not already familiar with the inside of a cell. Such people are the subject of this well-written book which weaves together timely, thought-provoking information and ideas about a population with daunting problems: those people with dual diagnoses of mental illness and substance/alcohol abuse.

Ryglewicz and Pepper approach this topic with sensitivity and empathy, while acknowledging that this group of clients can present such perplexing, often obnoxious, and sometimes alarming behavior that it "sets a practitioner's teeth on edge." The authors have skillfully integrated insights about practice with such patients through various case examples, explaining the diagnostic categories of DSM-IV into which the cases fit and surveying current research that illuminates those diagnoses. The book provides an overviews of quirks of the service delivery systems serving the mentally ill and persons with addiction problems, and the larger societal factors that shape those systems. Given the scope of this material, coverage of each topic is necessarily telescoped - but it is provocative and engaging. The writing style is clear, eloquent, and uses effective imagery. The fact that the authors are intellectually disciplined is evident by their sometimes painstaking effort to clearly define any term that smacks of professional jargon or that might lead to unintended conclusions. While that communication ploy is at times repetitive and even ponderous, it reflects a laudatory commitment to clarity. That clarity, as well as the timely topic, makes this book an informative and interesting one to read, and a tempting textbook for students investigating mental health or substance abuse treatment.

The message of Lives at Risk is that the 30% of Americans between ages fourteen and fifty-four who suffer from both mental disorder and addiction (p. 5) are peculiarly difficult to treat because mental illness and addiction overlap and interact (p. 73). Through examples of schizophrenia exacerbated by substance abuse bipolar disorder with an accompanying diagnosis of alcohol dependence, borderline personality disorder aggravated by drugs, and drug addiction with a diagnosis of anti-social personality, the authors give an integrated picture of how the effects of drug and alcohol mesh with mental dysfunction.

The social, psychological, and biological co-mingling of effects between mental illness and substance/alcohol abuse blurs the distinction between chronic and acute condition, highlighting a need for a coherent, continuous range of services (p. 180). Yet, as the authors assert, the current treatment picture of people with dual diagnoses is fragmented, stigmatizing, and bewildering (p. 181). The move toward deinstitutionalization of persons suffering from mental illness has given way to transinstitutionalization between the mental health facility and today's largest mental hospital: the jail (p. 175). For many sufferers, the fiscal push to free up beds in both jails and hospitals has resulted in un-institutionalization - and no treatment at all (pp. 177-178).

All these puzzle pieces do not provide a pretty picture for the person suffering from dual diagnosis, or "double trouble." Barriers between psychiatric and substance abuse treatment systems are firm, long established, and supported by separate administrative and funding streams (pp. 73-74). Mental health programs tend to downplay substance abuse and assume that it will dissipate once the psychiatric symptoms are addressed, while substance abuse programs often see the person with marked psychiatric symptoms and prescribed medications as inappropriate for treatment (p. 94). Substance abuse programs identify abstinence as a goal, while mental health programs are mandated to treat the premotivated and preabstinent client and may thus be seen as "enabling" the client (p. 94). The authors maintain that the greater burden of responsibility rests with the mental health system, which is mandated to provide treatment and can offer initial treatment to develop motivation, followed by appropriate access to substance abuse treatment (p. 95). The book offers a thoughtful reflection on the circumstances of persons with dual diagnosis.

Dorinda N. Noble Louisiana State University, School of Social Work

Copyright Family Service America Jan/Feb 1999
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