Article by Robert A. Battisti, Clinical Psychologist, Postdoctoral Research Fellow Clinical Research Unit, The Brain & Mind Research Institute

Self-Harm and Psychiatric Comorbidity with a Substance Use Disorder
It is my strong belief (both personally and from a theoretical perspective) that you cannot effectively treat a substance use or mental health problem when the other is not also addressed. This is particularly true in those instances where a substance use disorder meets the criteria for a dependency. This implies some level of functional impairment as a result of the substance use and, almost always, the substance use is tied to emotional regulation and/or habitual patterns of use. This tends to result in an intertwining of the substance use disorder with the other mental health concern, making successful (without relapse) treatment for either highly problematic.

Introducing the context of suicidality and/or self-harm with a dual diagnosis of substance use plus another mental health concern can result in a non-stereotypical presentation. As an individual may be using one or more substances to manage their mood, they can be effectively self-medicating and able to get along with some semblance of a normal life. Their self-harm/suicidality may therefore not manifest while they are regularly using (although substance use in of itself could be considered a self-harming behaviour). In most cases of drugs of abuse though, psychiatric symptoms worsen with continued use, and the substance becomes further enmeshed with the individual’s mental illness and day-to-day functioning.

Within the health system, substance use is not classified as suicidal behaviour, even if the individual is at high risk for overdosing (whether this is due to inexperience of use, accidental overdose, or a chaotic personality type). As it is considered a choice, scheduling is not an option as this would be considered to impact upon an individual’s personal freedom. Only in those cases where an individual is suicidal with intent via overdosing is scheduling an option in the context of substance use.

As substance use, in particular dependency, tends to not be short-term, a forward-looking perspective needs to be considered for any treatment approach with treatments that respond to more acute concerns, eg. via a detox facility, not actually addressing the underlying problem but sometimes necessary to keep a person alive long enough to address it. What this essentially means though is that if substance use is a coping mechanism, simply getting a person to stop using is going to leave them with no coping mechanisms (or at least none that feel available to them).

What to look out for
When performing routine assessment for any mental health difficulty, such as low mood or anxiety, querying the use of substances within this context is important. A series of questions may include:

• Do you drink alcohol, use cannabis, amphetamines [or other substances]?
• If yes: Do you ever find that when low mood/anxiety gets too much that you want to use this substance?
• How frequently does this occur?
• Does it work? For how long?
• How would you cope if you didn’t use?
• Do the feelings ever get to the point where you’ve thought about harming or even killing yourself?
• Are the feelings worse when you don’t use?

What about after you use?
There are, of course, lots of other ways of examining this, but asking specific questions about the frequency of substance use and its function as a coping mechanism is important for accurate diagnosis. It can also tell you whether an individual is likely to worsen if they take a cold turkey approach to their substance use difficulty.

What to do
Identifying that a substance use difficulty may be intertwined with psychiatric comorbidity and self-harming/suicidal behaviour in of itself can be quite insight producing for a client. Of most importance though is to take a non-judgemental and empathetic approach to the substance use behaviours. Individuals that use substances are often on their guard to be judged as they may be used to labels such as junkies or smackheads and therefore being overly directive about reducing/ceasing substance use can entirely backfire. Substance use disorders are psychiatric disorders like any other kind of Axis I disorder, and therefore need to be treated as such.

Particularly when the substance use is a coping mechanism for powerful emotions, the exploration of other coping options is important. This can involve both medical and non-medical approaches, but is essentially about helping a person believe that there are other, safer, ways for managing the way they feel without hurting themselves.

These options are always going to feel more difficult than the established substance use coping strategies at first, but stressing that they improve with practice (much like driving) is important. For substances that have lower mortality, such as alcohol, cannabis, cigarettes and some amphetamines, gradually reducing use tends to be much more effective in the long-term. This is more problematic for opiates or other substances with higher risks of mortality where, for the safety of the client, the focus often needs to be on abstinence but with regular monitoring and active use of alternative coping strategies (often pharmaceutical at first).

Engaging other services, such as psychologists, occupational therapists, detox facilities and longer-term rehab facilities, can greatly improve long-term treatment out- comes. Collaborative work tends to be most effective as it essentially targets the problem from multiple angles. Services such as headspace are particularly useful for younger individuals (aged 12-25 years) as costs are either low or not present and there are good mechanisms in place for accessing other services.

General Practice ATAPS Self-Harm stream is quite unique as a service pathway as well as it has the flexibility for a client to see a suitably qualified mental health professional very regularly with phone consultations also encouraged. It does not limit intensive out-patient treatment, as can be the case under the Medicare Better Access to Mental Health scheme, and encourages interactions between the mental health service provider and the referring GP.

About Robert A. Battisti
I have been working as a clinical psychologist in private practice since the start of 2008. Prior to that I had a background in human learning theory, drug and alcohol research, and neuroimaging. To date, I have kept strong links with neuroscience and, in particular, psychiatric comorbidity where there is a substance use disorder alongside some other mental health concern. I have also worked within this field for the Brain and Mind Research Institute at the University of Sydney, and the National Drug and Alcohol Research Centre at the University of New South Wales.