He's also a loving husband and father to two gorgeous girls. Whenever he isn't spending time with his family, or working, you'll find him on his bicycle...or running...or camping...or raising awareness of mental health issues. Last year he even rode his bike to Queensland. Most importantly, Mark is just a really great guy. We thank him for writing for us on the important topic of the difficulties carers face when looking after loved ones with mental illness and substance dependence issues.
David Bowie’s classic song makes a nice title for this reflection on the heroic role of carers in people with mental illness and substance dependence issues. I have worked for over 20 years in the mental health and drug and alcohol field, more commonly referred to as Dual Diagnosis. Some say "what a tough job that must be" but I don’t agree. I choose this job because of the rewards and challenges it offers me.
I make the point about choice because as a health worker, that is my decision. But for a carer, it's often not a choice and unlike the David Bowie title they are heroes but not for ‘one day’ - it’s an endless role in many cases.
Carers are heroes because of the way in which they put themselves out there, every day, to help their loved one or family member in whatever way they feel best. Often there is ridicule, judgement and risk of social exclusion experienced by those caring. Sadly, people like to judge those with a family member having substance use issues or mental health as though in some way they, as a parent or partner, in some way contributed to the current situation. I for one can’t recall a single time a carer ever said to me that they would choose this role, or worse, deliberately set out to create the sickness within the family member.
It is true, addiction and addictive behaviour can result in some challenging behaviours in their loved one. Violence and psychosis can happen, but even more tragic can be the loss of a loved one through accidental over dose or in some cases, suicide. In order to cope with this, I firmly hold to the adage that people do the best they can, with the resources they have at their disposal. I ask myself, who am I to place judgements on those carers who are making the effort to help?
To an outsider, supplying money to someone with an addiction is often seen as crazy or “enabling”. Remember, this person is doing the best they can with the resources they have. If you don’t know of another way of helping then the attitude will often be one of "this will do for now." It tears at the heart of carers knowing that the money might be going to drugs, but it tears greater at their heart the fear that if they don’t help, their loved one might end up dead or in jail.
Families do the best they can with the resources they have at the time. What carers might not know is there is a lot of support and information out there. There are evidenced based interventions that can be applied, however, to deliver other strategies takes alot of support and encouragement for a family member to begin to make the changes they need.
I would urge any family member or loved one struggling to deal with someone with a dual diagnosis to arm themselves with as much information as they can. There are funded services out there to assist, but also voluntary groups that are formed by people in similar situations to provide peer support.
I will never forget the power of peer support of carers. I remember very clearly one time at a carer’s conference where the speaker was billed as being an expert in aggression and psychosis and had worked for the Forensicare service (for the criminally insane). The poor gentleman started off his talk around what families and parents should do to manage someone with mental illness, aggression and substance use.
Pretty quickly the group started to challenge a lot of his information as not relevant to their real world experience. One mother talked about her son attacking her for money and how she felt helpless and defenceless. Another mother stood up and answered her question around practical things she did to protect herself from her son when intoxicated. Simple things like a lock on the bedroom door, mobile phone always on hand, escape plans. Another guy stood up and offered some of his suggestions.
Pretty quickly the guest speaker became irrelevant as the group started talking amongst themselves and solving their own real world issues with shared knowledge and wisdom. I felt sorry for the speaker as he didn’t get to finish his talk, but I think the whole group would agree they got some valuable information from the session, albeit from each other.
Nonetheless there is worth in listening to some of the clinical knowledge and wisdom and incorporating it to the carer's real world. One model I found really helpful for understanding the discord between carers and loved ones was recognising the stage of change a person is at and recognising where you as a carer, or health professional, are at as well.
Prochaska and Diclimentes developed a model for behaviour change called the “Stages of Change” which recognised that any person trying to make change to an addictive behaviour (in their case, looking at smoking) would often need to go through several distinct phases. These phases are known as precontemplation, contemplation, preparation/determination, action and maintenance. What this model also recognised is that change is not a linear process meaning that people can swing between the stages and that lapses and relapse is considered a part of the process.
To make sense of this model, think of a behaviour of yours that you have tried to change, such as exercise, dieting, or getting off work on time. For most of us, change is not easy. The first and often most difficult step is to determine that change is even needed or wanted. Then, working through the ambivalence of wanting change and not wanting change until finally a decision is made that you “will” make a change. This leads to a process of making a plan about the change and sticking to it. Sounds simple enough but for many of us it's very easy to lose that motivation and slip back into the behaviour we know best and sometimes actually feel more comfortable doing.
The reason I raised the Stages of Change Model is because that is exactly what families and carers go through when dealing with someone with an addiction. Initially families might “turn a blind eye” to the substance use or even be complicit in the use of the substance, such as buying alcohol for parties etc. (what we call precontemplation phase). The family then might start to get concerned for their loved one regarding the impact of the substance use on their health, both physical and mental, or the impact on work/study, perhaps even issues with the legal system (this is the contemplation phase). Then comes the time when the family might say enough is enough and demand the loved one to stop using (they are now in determination phase) but don’t really have a plan of how to go about implementing it. It's at this point when families might revert back to old behaviours of just demanding the person to change their behaviour or become argumentative, or give in and just give the person money to buy drugs etc.
What is not recognised by the carers and family sometimes is that the loved one is also going through their own stages of change at the same time. What often happens is a disconnect between the stage of change of the family and that of the loved one. The result can often be a lot of frustration and angst. What is helpful is to come along side each other and understand which stage a person is at and then think about the best response commensurate to that stage. For example, a family who are sick of the substance use want a house free of drug use. The loved one is still very keen to use substance use despite this impact. A family meeting could determine that each are on different paths. What might a middle ground outcome look like in this case?
One suggestion would be its okay for you to continue using, just not in the house. If that were the agreed goal, then some planning can commence on how do we make that happen but also importantly make it as safe as possible (harm reduction principles). Obviously what is implicit in this approach is that the family and loved one come together and communicate openly without argument or high emotion but remain purposeful to finding the middle ground. Clearly not everyone will be happy with the plan but it’s the start of a journey towards more sustainable changes in the family.
To this end I was greatly impressed by the model of single session family consultation which enabled bringing a family together to focus on a common goal and work through the issues and barriers. Whilst not all problems can find solutions easily, it certainly helps promote better communication and look for solutions.
Obviously, there is so much more to say on the topic of people who selflessly provide care to others. This is only a quick snapshot of some thoughts. Family work is vital in the journey of recovery. I'm hopeful that one day we will see a service system that genuinely engages and works with the best support system that consumers of mental health and drug and alcohol services have - their family/loved ones.