Triple Diagnosis: AIDS, Addiction, and a Psychiatric Disorder

To be eligible to reside at PSI, the patients must have AIDS and substance addiction. Frequently, however, there is a third diagnosis of a psychiatric disorder as well. I remember learning in my psychiatry class in school about the co-morbidity of drug dependence and mental illness; people suffering from drug addiction are over 2 times more likely to have an anxiety disorder and over 4 times more likely to have a mood disorder such as depression. Having a disease with such social stigma such as AIDS contributes to a higher incidence of psychiatric disease as well. So needless to say, the psychiatric nurse practitioner and mental health counselors here are kept very busy.

In my short time at PSI this summer, I have seen many different psychiatric symptoms that are likely indicative of an underlying disorder. To name a few:

• Suicidal ideation. When I asked one of the patients how she was doing that day, she replied, "Still breathing, unfortunately." Concerned, I asked, "Do you really mean that?" She told me that she did.
• Grandiose delusions. One patient adamantly believes that HIV does not exist. He insists that it was invented by the Surgeon General to make money off of antiretroviral drugs sold by the pharmaceutical companies.
• Paranoid traits. One patient here always thinks the world is out to get her. She often refuses to reply to the journal questions in my class, asking, "Why are you trying to pick my brain?". More than once, she has referred to herself and other patients as "guinea pigs" that doctors are using to test out antiretroviral medication.
• Antisocial traits. One patient used to belong to a machete-wielding gang in Puerto Rico, and has done hard time in jail for having dismembered body parts in his car. Despite this, he has no remorse.
• Symptoms of Conduct Disorder. I had the privilege of observing the Anger Management group, in which several patients described the extreme satisfaction they get out of physical aggression towards others.

This may be a chicken and the egg type of situation - which came first, the psychiatric illness, the drug addiction, or AIDS? The Lancet had a great review article last month, detailing the intricacies in treating patients with this triple diagnosis. The article (justifiably) calls for more funding and research in this area to be able to successfully treat these patients who so desperately need the help of the medical community.

Can You Predict Who Will Relapse?

I like to think of myself as a pretty optimistic and idealistic person, though some might just call me naive or gullible. I tend to believe what people tell me, and assume that they have good intentions. This is certainly true for the patients at PSI, although some people on the staff are quick to remind me that many of them used to be big-time drug dealers and criminals, and have retained the tendency to lie and cheat. Now that I have been at PSI for almost the entire summer, I have gotten to see how strong of a grip addiction has on some of the patients here. As they say, addiction is a life-long illness. Even if you are clean, when you're an addict, there is always the temptation to use again and fall back into old habits.

The patients at PSI live at the facility for about a year, during which time they are working toward their recovery. Once they graduate from the program, unfortunately, some patients eventually find their way back to their old lives and addictions. From talking to several staff members at PSI, they believe all of the patients here have at least some chance of relapsing. The vocational educator was describing how it is nearly impossible to predict who that will be. Some of the people who she thought were best equipped to succeed in the community ended up relapsing almost immediately after they left the program. Conversely, people in the program who seemed unstable often ended up doing very well on their own.

One of the students in my Health Literacy class - one of my very best, in fact - was kicked out of PSI for using and attempting to sell drugs inside the facility. I was absolutely shocked when this happened, since she was so intelligent, engaged, and a lovely person all around. Literally the day before she was discovered, I had asked my students to respond to the journal question, "When you graduate from PSI, what could happen that would make you want to use drugs again? What can you do to avoid those triggers?" Her response: "There is nothing that could happen that would make me want to use again." What I didn't know at the time was that she had already been sneaking around inside PSI using and trying to sell, and blatantly lying to me in her journal response. I just couldn't understand how she could have me and other staff members fooled like this. She's the last person I would have guessed would relapse while still at PSI.

There is one staff member, the GED educator, who seems to have it figured out. He has been working at PSI for years, and says there is one quality that is a great predictor of who will relapse: arrogance. In fact, he goes so far as to say he has never met a patient who was arrogant that didn't relapse. That's a strong statement. Maybe it has something to do with admitting that you have a problem that is out of your control. Once you surrender to your addiction, acknowledge it is bigger than you, and admit you need others' help, you're more likely to gain that control back. What are your thoughts? Do you agree?

Getting a Job as an Addict

As I described in an earlier post, the vocational educator at PSI invited me to help facilitate the "transition groups" she leads. These groups are designed for the patients who are getting ready to graduate from the treatment program and need to learn practical skills to help them succeed once they reenter society. This week, the transition group focused on filling out a job application and preparing for a job interview. As if the job market weren't tough enough already, many of the patients here face additional obstacles to finding employment. First of all, they have all been unemployed for at least the year they have lived at PSI. Many have not graduated from high school or earned a GED. Some have been fired from previous jobs for performance issues or drug problems. The majority have been incarcerated at some point in their lives, and some have serious charges, like felonies, on their criminal record.

During the group, the vocational educator gave the residents advice for how to address negative aspects of their background on the job application and in the interview. Here are some of my favorite tips:

• Do not offer any information that was not specifically asked about. For example, if a job application asks if you have been convicted of a felony in the last 5 years, but your felony was 7 years ago, it is perfectly acceptable to answer 'no' and leave it at that.
• Whenever you can, try to make the reason you were terminated from your previous job sound as neutral as possible. For example, if several people were let go at the same time as you, you can state the company was downsizing. If you moved to a different state after you were fired, you can say that you relocated. If you did not get along with your supervisor, you can say you were let go for political reasons. You can stretch the truth, but whatever reason you give must have some truth to it in case your new employer checks up on you.
• If asked directly about negative information by an interviewer, you should acknowledge it, briefly describe it, and then move on to talking about something positive. For example, "Yes, I was laid off from my previous job because of a drug problem. At that time, my addiction caused me to be late or absent frequently. However, I have been clean and sober for two years now, and I have a reference from my treatment program that states my attendance and punctuality have been perfect."

I am impressed by this advice. I think they are all great strategies to help the patients present themselves in the best possible light. At the same time, I am trying to view this situation from an employer's perspective. If I had two equal job candidates, except one was an addict with a criminal record, and the other was neither of these things, I think I would be inclined to pick the latter. If you didn't take the time to get to know the patients - how they are truly reformed, and very kind, hard-working individuals - I can see how you might be disinclined to hire them. The patients here are going to have to work incredibly hard to show future employers how dedicated they are, perhaps by first interning or volunteering at the company where they want to work. Hopefully their employers will see the potential that I see in them, and these patients will be able to support themselves and lead sober, healthy lives.

Relapse Prevention

Last week I had the privilege of observing a "transition group" that prepares the residents of PSI for various issues they'll face once they are living on their own in the community. This series of six classes is led by the vocational educator, who kindly asked me to help with the group. The topic for the first meeting was "Avoiding Triggers in the Workplace."

All of the residents of PSI are addicts. Even though to live at PSI they can not be currently using drugs, they still struggle with addiction and carry that diagnosis for the rest of their lives. I was completely unaware of the difficulties that addicts face in a place as seemingly innocent as at their job. As a group, we discussed what could happen at work to make someone want to use again, as well as what solutions to those problems could be. Some of the common workplace triggers to use include:

• Pay day. When an addict is handed a check, it can be hard to resist cashing it in to buy drugs. To avoid this, you can immediately hand their check over to a trusted friend, or set up direct deposit to distance yourself a little from the money.
• Having too much free time or too little supervision on the job. Being bored at work and having no one there to watch you can lead to temptations to use on the job. To avoid this, you can ask your supervisor for extra tasks to pick up, or attend meetings that you aren't necessarily required to be at.
• Working long hours or having too much supervision on the job. This can lead to stress and pressure to perform, which can lead to a desire to use. To avoid this, you can politely turn down tasks your supervisor asks of you, or kindly tell your supervisor you would like the opportunity to work more independently.
• Office holiday parties. There will be lots of alcohol and possibly drugs around, and co-workers may even unknowingly pressure an addict to drink. To avoid this, you can show your face to the VIPs at work, and then tell co-workers you have other plans and can't stay at the party.

I was fascinated by our discussion. It is so important for people to be sensitive to these issues, and I feel very privileged to have had the opportunity for the residents to teach me about the struggles they face.