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Double Bind
By gail johnson
The Georgia Straight
Publish Date: 2-Dec-2004

Is Opposition To Residential Treatment Facilities Jeopardizing People With The Combination Of Mental Illness And Addiction?

It was the voices, George says, that told him to follow the jogger. The Vancouver resident explains that, high on crystal meth, he didn't want to go after the lone male runner, but that the voices--the sounds he had been hearing incessantly for months, as if a radio were on in his head--continued urging him: "Follow the jogger; follow the jogger." George would even stop himself in his tracks, only to start tailing the man again and again.

"I guess he started getting nervous, because he went into a Shoppers Drug Mart," George tells the Georgia Straight. "I followed him in there, and the voices said, 'Do something funny.' So I gave the guy a huge bear hug. I guess he didn't appreciate that very much. The cops came and I got charged for assault."

George hadn't always heard voices--certainly not when marijuana, cocaine, and heroin were his drugs of choice--but after nearly a year on methamphetamines, the commands started. He says he felt increasingly tense, fearful, paranoid, anxious, and depressed. He's been off the substance for months, but he's still dealing with what's known as dual diagnosis: the cruel combination of addiction and mental illness. He sees a psychiatrist and takes part in group recovery programs at Berman House, a refuge where he now lives.

A three-storey heritage home with stained-glass windows surrounded by tall, old trees not far from Commercial Drive, Berman House is a 24-hour supervised residence for men recuperating from chemical dependency and mental disorders. Although it took him years to find the right help--the 32-year-old was 13 when he started using--George is one of the lucky ones: Berman House has just six beds. A similar dual-diagnosis facility, though larger and coed, is being proposed for Fraser Street and 39th Avenue. The project, which has recently been the source of tumultuous debate among the neighbourhood's residents and business owners, will be discussed Tuesday (December 7) at a special meeting of Vancouver city council. Even if it does get approved, the complex will provide only 30 spots for people with dual diagnosis, also known as concurrent disorders.

Yet thousands of men and women suffer from the complex condition. Health Canada states that one in five people has or will develop a mental illness in his or her lifetime. According to B.C. Partners for Mental Health and Addictions Information--whose members include the B.C. Schizophrenia Society, the Centre for Addictions Research of B.C., and the Mood Disorders Association of B.C.--at least 50 percent of those with mental illness abuse drugs or alcohol, compared with 15 percent of the general population. Forty-seven percent of people with schizophrenia report problem drug use, as do 56 percent of people with manic depression. And more than a third of people with an anxiety disorder also have a substance-use disorder. Many of those affected, along with their relatives, friends, and caregivers, say there are dangerous gaps in services.

The problem stems from the fact that those with an addiction to drugs or alcohol and who also have an illness like schizophrenia, posttraumatic stress disorder, or depression are stuck in a Catch-22. Many mental-health programs will only take in people who are abstinent; meanwhile, users might not be accepted into drug-treatment programs unless they've addressed their mental disorder first.

"Those with mental illness are at higher risk of developing a substance dependence, and clearly those with substance dependence are at higher risk of developing mental illness. Which came first in a lot of cases is irrelevant," says Dr. Ian Martin, who works out of Three Bridges, a community-health clinic in downtown Vancouver. "Some users with attention deficit hyperactive disorder use drugs to self-medicate. To diagnose a mental illness in the context of drug use is quite frustrating."

Many of Martin's patients are hooked on crystal meth, but it isn't the only drug that can induce psychotic symptoms. Cocaine can lead to irrational thinking and hallucinations as well, explains Dr. Gabor Maté, who works out of the Downtown Eastside's Portland Hotel Society. "They'll think they have parasites and bugs on their skin and will scratch themselves raw," he says. "Drug use totally complicates and obscures whatever mental illness the person has."

With their mental demons and drug cravings fuelling one another, users often end up in and out of hospitals, living on the streets, or both.

Take one of local psychiatrist Dr. Bill MacEwan's patients. MacEwan, who specializes in drug-induced psychosis and who started the Fraser Health Authority's Early Psychosis Program (, treats one woman with schizophrenia, hepatitis C, and HIV--and who's also addicted to crystal meth. The drug can make people aggressive and paranoid in the extreme; schizophrenia itself can cause distorted, delusional thinking. Having wound up in a psychotic state many times, she's been to the emergency ward at St. Paul's Hospital on more than 60 occasions in the past year--the type of patient staff refer to as a "frequent flier". Typically, she's given antipsychotic medication then discharged as soon as she's "stable" or has come down off her high. But without any follow-up or ongoing care, she goes back to the streets where she lives and uses drugs to cope and eventually comes back through the hospital's revolving door.

"Every time she goes in there, she gets punted out," MacEwan says in an interview over coffee. "She's back on the streets where she's assaulted or raped. How do we deal with this? There's no place for these people to go. In emerg...they have so many people coming through the door. I see it all the time: people get taken in, then they punt them out. It's just not good enough. People deserve better. People fall between the cracks."

He says he's had some patients tell him they don't even make it past the hospital's security guards. Granted, users can be unpredictable and difficult to deal with. "But to say, 'We can't do anything,' that's bullshit. The way people with mental-health issues are treated in our two major hospitals is disgusting. The dismaying part is that this is just going to get worse years down the road." (Dr. Grant Innes, the head of emergency medicine at St. Paul's, did not respond to the Straight's repeated requests to the hospital's communications department for an interview.)

Olivia Lambert, the client-services coordinator at Covenant House, a downtown centre that provides food, shelter, and counselling to at-risk 16- to 24-year-olds, sees the effects of dual diagnosis every day. "The vast majority of people have major drug-misuse problems, and many kids present with mental-health issues; the two exacerbate each other," Lambert says. "Throw in poverty and it's a bleak picture. Sometimes, if they have a serious psychiatric illness, they're not able to make it to a treatment centre. They're not ready to get clean, so they're not eligible for any other help. That's a roadblock. There needs to be more flexibility, so say if somebody misses an appointment because they're under the influence, they won't be banned from a program altogether. Outreach workers are great--they go out and find people and bring them in--but they can only do so much. So they're left out in the cold. How do they get help?"

Lambert says the situation has only gotten worse by ongoing cuts to social services and the closing of beds at Riverview Hospital. Cathy Stewart, a nurse at Riverview, says that downsizing caused the hospital to lose 15 residential beds specifically for patients with dual diagnosis. With three decades of experience in the health field behind her, including 15 years specializing in substance abuse, she's now acting as the addictions-counselling nurse for the whole facility, which treats hundreds of people with severe conditions like schizophrenia and bipolar disorder.

"Mental health has long been the poor cousin of the health-care dollar," Stewart says in a phone interview. "We've known for some time--about 15 years--that we need to be treating both illnesses together. One of the major things I've discovered with co-occurrence that hasn't happened is education. Nurses are slugging it out in the trenches and doing the best they can," she says, adding that through no fault of their own, many health professionals don't know how to deal with the effects of chemical dependency. Like Martin, Stewart regularly gives talks at St. Paul's Hospital to help staff handle such cases.

Addressing both illnesses simultaneously is the focus of the Vancouver Coastal Health Authority's Dual Diagnosis program (604-255-9843), which provides group sessions on early recovery, relapse prevention, anger management, family support, and self-esteem, among other subjects, to adults, seniors, and youth. The fact that it gets 75 new referrals every month speaks to the problem's prevalence.

AT 43, ROB HAS BEEN clean for a year. He credits his newfound stability to the help he's received at Berman House, where he's lived for the past 12 months. He says his recovery was a long time coming.

He started drinking heavily 17 years ago and also suffers from severe depression, anxiety, and borderline personality disorder. For a while, he managed to maintain corporate jobs, like that of a publicist and as an executive director of a local health organization. "Whatever else was going on in my life, I'd use alcohol to self-medicate, and that bumped up the process of addiction," he says in Berman House's living room, where the next-door neighbour's cat is sitting at his ankles. "By all outward appearances, I was high-functioning. But it was progressive: I'd relapse, and the alcohol would get more destructive. I ended up sleeping under the Burrard Street Bridge drinking mouthwash."

Rob, who clearly has a sense of humour, says he could write a Michelin Guide to Vancouver's recovery and drug-treatment centres. He questions the theory that people can only get better if they're willing: "I doubt that anybody who goes into recovery wants to be in back alleys again.... You need the right kind of support. In the past year, I found the right support and guidance."

According to psychiatric nurse Nancy McLean, Berman's manager of care, part of what distinguishes the dual-diagnosis housing from many other services is the luxury of time. Men like Rob and George can stay for as long as a year. Most drug-treatment programs, by contrast, typically last 28 days.

"In a month, you can barely address post­acute withdrawal," McLean says. "Twenty-eight days don't give you enough of a chance to get your life in order....We don't want them to come here then go back to an SRO [single-room occupancy hotel room]."

At Berman House, "senior" residents act as mentors to those just coming in. And because everyone understands dual diagnosis, residents can talk about their experiences freely. As George puts it, no one thinks he's crazy when he brings up the voices that sometimes still invade his mind.

The home is named after David Berman, who worked with the Strathcona mental-health team for seven years. He founded the dual-diagnosis program in 1989, two years before he died. The home has a warm, welcoming feel, but there are strict rules in place: residents must be alcohol- and drug-free and willing to participate in random urine tests. "Once they get here, there's zero tolerance," McLean says. "If one person is using, it endangers everybody."

Men must also comply with taking their psychiatric medications, which are administered by staff. Besides being willing and able to live in a group situation--there are two single bedrooms and two shared ones, along with shared bathrooms--they take part in household chores and develop independence in "activities of daily living", like maintaining personal hygiene, making their beds, and doing laundry. Ultimately, they're working toward "contributing to the community in a meaningful way", Berman's mental-health worker, Dan Simms, says.

Some residents pick up cooking or gardening; others go to nearby community-centre gyms. The men work with a mental-health team and must participate in wellness and recovery groups in-house plus those offered by the VCHA's Dual Diagnosis program. Some go to Alcoholics Anonymous or Narcotics Anonymous. They learn vocational and communication skills, and several do volunteer work. Plus, they take part in adventure therapy, doing activities like hiking, camping, and rock climbing. As recreation therapist Tanis Bentley explains, such outings "replace drug use with healthy thrill-seeking".

Building all those varied skills serves to gradually integrate the men back into society. Once they're ready to leave, staff at Berman House connect them with community resources and help them find housing.

"To have that safety net coming out of a recovery house is crucial," Rob says. "This program was a godsend. There is a critical shortage of that kind of housing. In my observation, there are a lot of services for crisis, but I don't see a lot of services for people in the middle stages of recovery. It's so easy to fall back....Anyone is a drink away from the street again; that's me."

THE PROPOSED dual-diagnosis, apartment-style housing in the Kensington­Cedar Cottage area could be a safe haven to others like George and Rob. Vancouver Coastal Health and Triage Emergency Services and Care Society are the main partners in the project at 5616 Fraser Street, along with B.C. Housing, the federal government's Supporting Community Partnership Initiative, and the City of Vancouver. The drug- and alcohol-free Triage Special Needs Residential Facility would have 30 studio units--a number that has dropped from the initial plan of 39--and 24-hour staffing, and applicants would be able to stay for as long as 18 months. People would only be accepted if they are psychiatrically stable, have been free of alcohol and drugs for at least two months, are receiving ongoing treatment with mental-health teams, and have no history of violence or sexual offences. After the upcoming council meetings, the fate of the project will go to the city's development-permit board, which is expected to make a decision early in the new year.

The housing was the subject of heated debate at a community meeting in October that more than 1,000 people attended. Some expressed concerns over the project being close to two schools, John Oliver secondary and Sir Alexander McKenzie elementary. Coun. Anne Roberts says that part of what's needed is more education about the Four Pillars, a multipronged approach to Vancouver's drug problem that's based on treatment, prevention, harm reduction, and enforcement.

"It's good that people are communicating their concerns about the community, but some of this is based on an unfounded fear," says Roberts, who lives near the proposed building and who adds that a neighbourhood-advisory committee--which she encourages parents to join--would be set up.

"We need to engage in a general education program throughout the whole city to develop a general understanding of what it's going to take to implement the Four Pillars," she says. "People have been so focused on the safe-injection site, and I don't think people have really thought about supported housing. We need to look at...the role of supported housing, how people get off drugs, and what kind of supported housing works....We can't just have stopgap measures like shelters."

Background information on the proposed supported housing (available on-line at the City of Vancouver's Web site, outlines and addresses residents' concerns, chief among them a potential increase in crime.

"It has been VCH's experience that these types of buildings actually act as a deterrent to street crime, as on-site staffing, awake at night, provides additional safeguards for the community," the document states.

"Similar facilities report that crime declines in the vicinity of the facility because of the 24/7 surveillance provided."

The report also includes a map showing Vancouver's 30 licensed residential mental-health homes, which range in size from six to 18 units and are located as far west as Alma Street and 4th Avenue and as far southeast as Kerr Street and 54th Avenue.

A lack of NIMBY concerns clearly exists in the Downtown Eastside, where local businessman David Ash was recently lauded as a hero after he purchased the Vivian, a renovated rooming house that will take in 24 mentally ill and addicted women.

ALISON CREDITS Berman House for saving her son's life. The West Side mother says the youngest of her three boys started using drugs when he was 14, after his father died. Over the years he has attended many 28-day treatment programs in Vancouver, Victoria, and Kelowna and spent five weeks on UBC Hospital's psychiatry ward, only to end up back on the Downtown Eastside, sometimes suicidal. Her son had been using crystal meth and ended up hearing voices. He has since been diagnosed with schizophrenia. Unbeknownst to Alison until last year, the disease runs in her late husband's family. Now 25, he's been clean for two years.

"I got a phone call from him on Christmas Eve 2002," Alison says in a phone interview. "He said he looked around where he was staying. He was in a room with smelly, old guys and the one in the next bed was masturbating. He had a realization. He said, 'I don't want to be here anymore.' "

The family eventually heard about Berman House through Parents Forever, a support group for parents of addicted kids (604-524-4230), but there was a three-month waiting list when Alison's son inquired. However, he got in right away after two other applicants couldn't be located by staff. He stayed at Berman until last July, takes medication for schizophrenia, continues to work with a mental-health team, and volunteers as a cook. He wants to be a chef.

"It was perfect for him," Alison says. "He got individual attention and was part of a family.

"I feel very strongly that we should have an awful lot more dual-diagnosis beds in the city," she adds. "If he hadn't gone to Berman House, he wouldn't be alive today."

It's possible the same could be said for George and Rob. If the Fraser Street project goes ahead, others like them might also have a place to call home--and the chance to finally conquer their double demons head-on.
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