When families learn that a relative has both a mental health disorder
and a substance use disorder, they often feel shocked and scared.
Mental health disorders on their own can overwhelm families. Families
who once had a safe and comfortable daily routine may find themselves
on an emotional roller coaster.

There are many studies that document the stress families experience
when they have a relative with a mental illness. However, few studies
have looked at the added impact when that family member with mental
illness also has substance abuse problems. One study by researchers in
the United States showed what many of these families already know too
well: that substance abuse contributes to family conflict and wears
away social support (Kashner et al., 1991).

Family members’ lives often change dramatically after a family member
develops concurrent disorders. Many of these changes create stress.
This article discusses:

• behaviour changes in the person with concurrent disorders
• relationship changes between family members
• increased responsibility for caregiving
• the impact on the caregivers.

Before we discuss these experiences further, it’s important to
recognize that some positive changes can and do happen. While family
members must acknowledge and cope with the challenges they face, these
challenges represent only one aspect of the caregiver experience. Many
family members describe a renewed sense of closeness with their loved
one and an appreciation for the truly important things in life, such
as connecting emotionally with another human being, having hope,
overcoming extreme hardships and experiencing the journey of recovery
along with their loved one. Many family members find a positive way to
think about difficult circumstances—for example, seeing caregiving in
terms of hope and personal growth, as an experience that has
positively transformed them.

Mental health problems can bring frightening changes in how people
experience reality. These changes can affect their relationships and
ability to function. Behaviour changes include paranoia and
hallucinations, feelings of anger, drastic mood changes or
overwhelming anxiety. People with mental health problems may:

• begin to lose trust in close family members
• find it hard to make even simple decisions, to complete plans or to set goals
• stop participating in activities that they once enjoyed
• cut themselves off from the outside world
• find it hard to express their feelings and thoughts
• retreat into their own inner world
• become hostile, even with their families.

You have lots of your own feelings about it, and then lots of feelings
for your loved one. How is this going to affect their life? What’s
going to happen to them? There are so many things that just come
pouring in. And you have concerns for their siblings, for your other
children . . . it can affect so many people.
Substance use problems can interfere with a person’s ability to follow
family routines and meet their responsibilities. They may:

• spend more time getting and using substances, and less time or more time in their usual activities
• have financial problems (the cost of using substances can become quite high; in some cases, substance use can lead to job loss, which can create further money problems)
• act out physically.

The family member with concurrent disorders

The person with concurrent disorders will often feel that family
members are invading his or her personal life. Resentment about being
overprotected may lead to anger, rebellion and acting out. These
behaviours may increase the risk that the mental health problems will
worsen or that the person will end up in unsafe situations. The cycle
of the family’s preoccupation and the loved one’s reaction then
repeats itself. This costs everyone in terms of time, physical and
emotional energy, and quality of life.

Parents

Parents of children with mental health disorders often feel a great
sense of loss and sadness when they see the changes in their child.
Family members may have to change their expectations for their loved
one regarding education, career paths, marriage and children. This can
involve emotional pain, a sense of loss, grief, sadness and anger. The
grieving process is similar to the one experienced by those who have
had a loved one die, or who must adjust to a serious chronic physical
illness in a loved one.
The whole family—we had so many other problems to face, you know? I
remember feeling grief and frustration and a sense of tremendous loss,
for my daughter and for her potential.

Siblings

Siblings may worry about developing mental health problems, substance
problems or both. They may worry about the stress and strain that
their parents are enduring, and may take on the burden of trying to
make up for what their parents have lost in their other child. At the
same time, brothers or sisters sometimes resent the time that parents
spend with their sibling. They may become angry to the point of acting
out or distancing themselves from family and friends.

I remember being teased as a child because I was so serious, so
sombre—and people told me that I acted like a middle-aged woman, a lot
older than I actually was. It was impossible to explain to other
people—like, you go to school after not sleeping all night, and after
the police were at your house because of your sister’s psychotic
episode, and no one thought of dinner or anything like that because
she overdosed and your parents had to go to the emergency room with
her, and then you go to school the next day and it’s like, all the
expectations are still on you. But you don’t tell anybody anything,
you just carry on as usual. You can’t talk to anybody about it. Nobody
will understand . . . .

Siblings may also experience anger, hostility or verbal or physical
aggression from their brother or sister. These behaviours can evoke
shock, dismay, fear and a sense of abandonment and rejection.
Sometimes, children may feel like they have lost their best friend.
They may feel guilty that they have a better life than their brother
or sister.

Helping children cope

Parents can help their other children by:
• assuring children that behaviours such as aggression are symptoms of
the illness and shouldn’t be taken personally
• sharing feelings and encouraging children to talk about how they
feel and how their brother’s or sister’s problems are affecting them
• explaining that family members often feel uncomfortable, embarrassed
or ashamed of their relative’s behaviours, symptoms and diagnosis
• if appropriate, discussing the issue of stigma and why it happens,
as well as effective ways to deal with it (see Chapter 6 for more
information about stigma)
• helping siblings learn about substance use and mental health
problems and how these interact with and affect each other
• spending time alone with siblings, talking and doing enjoyable activities
• helping children build a new relationship with their brother or
sister and creating unique ways of being with their sibling.

Caring for basic needs

Family members may begin to take on much more responsibility for their
relative. In more severe cases, the relative may be unable to care for
basic needs such as keeping up with personal hygiene, eating meals or
even getting out of bed. If the caregiver is also the family’s only
source of income, being unable to leave the family member alone can
lead to huge financial consequences for the family and more emotional
strain for the caregiver.

Our son not only has schizophrenia, but he uses drugs, he’s been
involved with gangs—and with the police. Half the time we’re not sure
if he’s taking his medication—he gets mad if we keep after him to do
simple things, like have a shower . . . we’re so stressed as it is.
We’re trying to find out things, how we can resolve some of these
problems. Sometimes I think I can’t deal with it all.

People with concurrent disorders often have trouble maintaining stable
and decent housing. They may:

• spend their money on substances rather than rent, which can lead to eviction
• become involved in criminal activity such as robbing, property theft, prostitution or the sale of drugs to raise the large amounts of cash needed to buy the substances they use, which can result in loss of supportive housing and sometimes homelessness
• open their home to others involved in problem substance use, then be unable to maintain that home, forget to feed and bathe themselves, pay heat and light bills, and face eviction.

These consequences create even more challenges for the families.

 

Co-ordinating treatment

Some mental health programs refuse to treat people with concurrent
disorders, or only treat the mental health problem. Similarly, some
addiction treatment programs and facilities may not address the mental
health problem. Families may have to take responsibility for
co-ordinating treatment between two or more service providers, as well
as caring for their relative.

Having a loved one who is suffering from both a mental illness and a
substance use disorder can represent a significant disruption in the
lives of families and can have an enormous impact on overall family
functioning and sense of well-being.

People need to be able to call somebody when their loved one is in the
hospital because of a mental illness or a drug problem. They need to
be able to touch base and get information from someone. It’s hard for
people who don’t know the system—like, what channels have to be
maneuvered—or who to call when you have specific questions. There are
so many roadblocks.

Family members may be concerned about leaving their relative alone
because they are worried that he or she will take harmful drugs,
forget to take medications, take part in dangerous or criminal
behaviour to get illegal drugs, or harm him- or herself during a
serious episode of illness. If family members are constantly watching
for symptoms and dealing with the impact of the illness, they may feel
overwhelmed.

You become extremely protective of [family members who are ill]. It
takes incredible emotional energy.

Some family members may find it almost impossible to soothe their own
anxieties, and distract themselves from the strain of coping with
their relative. They may feel unable or even guilty to take time for
themselves, to relax, care for their own emotional and physical
health, and rebuild their own coping resources. Sometimes, family
members even feel guilty if they experience resentment or anger. They
should admit if they are extremely tired, worn out, angry or bitter.
Denying these emotions can lead to exhaustion, depression, isolation
and hopelessness.

They may feel isolated from others who were once very good friends.
They might feel that they don’t have the time to maintain friendships,
or they may be embarrassed or ashamed about the concurrent disorders.
Think about your own situation and how your life has been affected.
Remember that all family members experience difficult circumstances
and negative feelings. It is very common for family members to feel
guilty when they are asked to think about how this has affected their
own lives. However, before you can begin to take care of yourself and
play a positive role in your loved one’s recovery, you need to think
honestly about the different ways that your life has been changed.

Caregiver burden and compassion fatigue: A note about language
The term caregiver burden is used in professional literature to
describe the emotional, social and psychological toll on the family
that comes from caring for someone with a substance use and/or mental
health problem. Many caregivers, while they like others to recognize
how difficult it is to care for a family member with concurrent
disorders, don’t like the term “caregiver burden.” They feel it
ignores the positive side of looking after the needs of someone
important to them and negates the fact that, in spite of the stress,
they love the person and would go to the ends of the earth to help and
protect them. It also dehumanizes their loved one, and reduces him or
her to a “burden,” which the caregiver hopes will not always be the
case.

The stress and feelings of powerlessness that are such a large part of
caring for a family member with concurrent disorders may be better
described as compassion fatigue. We use compassion fatigue here to
describe the overwhelming physical, emotional, social and spiritual
exhaustion that can strike family members affected by concurrent
disorders. It is a much more user-friendly term for describing the
results of ongoing coping with extreme adversity.

Self-care

You and your family members should never underestimate the benefits of
taking care of yourselves. Taking good care of yourself gives you more
physical and emotional energy to deal with the challenges you face,
and that will benefit your family member with the illness. Family
members will each find their own way to care for themselves. Being
able to soothe, relax and calm yourself involves:

• knowing what kinds of thoughts and behaviours make you feel better or worse
• coming up with a self-care plan that helps you to prevent or overcome the negative feelings.

This plan involves following a structured routine each day, engaging
in a particular activity, spending time with a good friend, or
focusing on a way of thinking—anything that may comfort you and give
you a sense of well-being and stability.

“The strongest oak of the forest is not the one that is protected from
the storm and hidden from the sun. It is the one that stands in the
open, where it is compelled to struggle for its existence against the
winds and rains and the scorching sun.”
—Napoleon Hill (1883–1970)

 

What is resilience?

Resilience is frequently described as the capacity to thrive and
fulfill one’s potential despite (or perhaps because of) stressful
circumstances. All of us are resilient in one way or another, but some
people seem to be more so. They are inclined to see challenges as
learning opportunities that can lead to healthy emotional growth and
development.

Factors that are characteristic of resilient people include:

• a sense of closeness and connectedness to others
• strong, dependable support from at least one significant other in their lives
• attention to their own personal health and well-being
• high self-esteem
• a strong sense of personal identity
• a realistic and balanced awareness of their strengths and limitations
• the ability to be assertive and emotionally tough when necessary,
• but also sensitive and compassionate
• a playful, lighthearted approach to life
• a sense of direction and purpose in life
• the ability to turn difficult experiences into valuable learning opportunities
• the capacity to pick themselves up, shake themselves off and keep moving forward after traumatic and upsetting situations
• the ability to adapt to and live comfortably with uncertainty and unpredictability
• the ability to laugh at themselves. Resilient people do not “sweat the small stuff.”

Developing resilience

Ask yourself:

• How resilient am I?
• In what specific ways am I very resilient?
• In what ways am I less resilient and how can I change this?

Developing a plan of self-care involves thinking about ways to care
for yourself on days when you might feel particularly stressed or worn
down. Short-term goals focus on the fast and relatively easy ways that
you can soothe yourself and replenish your energy. We call these
strategies “the quick wins.”

Putting the brakes on

Family members identified these short-term strategies that helped them
ease their anxiety for a moment so they could face their situation
with renewed energy:
• Have your morning coffee.
• Talk to someone you trust.
• Hug your pet.
• Take a deep breath.
• Take a timeout.
• Take a long, hot shower.
• Apply your favourite body lotion.
• Watch your favourite TV show.
• Sit in your backyard after dinner.
• Go for a long walk.
• Become more aware of nature.
• Go to a movie.
• Go shopping and treat yourself to something new.
• Give yourself permission to feel upset and frustrated, and
permission to overcome these feelings.
• Structure your day to ensure it includes leisure time.
• Think about things that make you feel happy or soothed or comforted
and make a note of them so you can remember to add those things to
your list of self-care quick wins.

These short-term strategies will be unique to each family member. List
the quick wins that might be most helpful for you, and add to your
list when something comes up that you find pleasant or re-energizing,
such as visiting a flower market.

Strength and forgiveness

Another self-care strategy involves recognizing and having
appreciation for your own personal strengths. This can take a great
deal of practice. We can be very hard on ourselves. We can also start
to focus on what we think we are doing wrong, instead of right,
particularly where it concerns family members who are ill. In fact, it
can be much harder to suffer the illness of someone you love than to
suffer the illness yourself.
It is essential to keep a sense of yourself as a person independent of
your relationship to your relative with the illness. Acknowledging
your strengths and giving yourself permission to be human may involve
learning to think in new ways about your circumstances. For example,
acknowledging positive aspects about yourself—such as intelligence, a
good sense of humour, perseverance, motivation, physical abilities—is
particularly important when you are stressed. You can practise this
type of thinking every time you become overwhelmed with guilt or
hopelessness.

Positive self-talk

One way to learn to think about your situation in new ways is by using
self-talk. For example, tell yourself, “I am doing the very best I
can. I’m only human. I am a caring and loving mother.” Letting
yourself experience all of your feelings is extremely important when
you are coping with difficult circumstances.
Challenges
There are many challenges in having a relative with concurrent
disorders. Try to identify and prioritize these challenges. You may
decide that some cannot be dealt with quickly or easily. Others can be
addressed immediately and even resolved. It can be difficult for
family members when a loved one:
• refuses to take psychiatric medication
• feels severely depressed and suicidal
• lacks motivation and will not get out of bed
• doesn’t think it’s necessary to go to appointments and groups to
solve problems
• uses alcohol or other drugs in your home
• doesn’t see the alcohol or other drug use as a problem and, in fact,
may tell you that those substances improve the symptoms of the mental
health problem
• will not respond to your suggestions or offers for help
• becomes angry, verbally abusive or aggressive toward you and other
family members.
It can also be difficult when:
• you or another family member become physically ill and are unable to
attend to your relative
• you feel overwhelmed, anxious or depressed yourself, and it begins
to affect your ability to care for your loved one
• you are afraid to leave your loved one at home alone, and yet you
need to go to work
• another family member develops a mental health or substance problem
(or both).

Making a list of your options and possible solutions can help you
develop an action plan. Some challenges may require help from other
people, such as other family members, friends or health care
professionals. You may decide to see a health professional who can
help you with your own needs and concerns. You may join a family
support group after this one, or even while this one is running. You
can make a list of especially close and supportive relatives and
friends for help in a crisis. Maybe you can hand over some
responsibilities that can be carried out by others, so you can lighten
your load in general (e.g., ask for help in car pools, have another
family member shop for groceries, simplify the home cleaning schedule,
teach everyone the miracle of the microwave!).
Sometimes you need to change the way you think about the problem.
Perhaps you need to deal with it differently. For example, you might
decide to set limits and clear boundaries with your loved one, so that
you do not feel helpless, angry and manipulated. Setting limits also
helps your relative because your expectations for his or her behaviour
are clearly stated (see Chapter 10: Limit-setting). Then you must
always follow through with the consequences, whatever you decide they
will be. Feeling in control is an important part of a long-term
self-care strategy.

Understanding problematic thought patterns

Trying to cope with emotions is challenging for many people at the
best of times. When faced with severe and persistent stress, you can
find it even harder to deal with anger, grief, loneliness, sadness,
shame and guilt.
Remember that feelings are intertwined with thoughts, beliefs and
behaviours. For example, if caregivers believe that they caused a
family member’s co-occurring mental health and substance use problems,
then they are more likely to feel responsible for their family
member’s relapses. Such beliefs may then lead to feelings of sadness,
guilt and remorse. If caregivers are not able to cope with these
emotions constructively, they could avoid seeking help for their
family members or for themselves. This may have serious repercussions
for their family members and for their own health and well-being. All
the self-care morning coffees in the world will not help if you let
problematic thinking rule your thoughts.

In Feeling Good, David Burns discusses how errors in thoughts and
beliefs may lead to negative emotions. Awareness of the types of
problematic thinking often helps caregivers to recognize these types
of thinking in themselves. They are then in a better position to work
on strategies for changing problematic thoughts and beliefs.

Overgeneralization
This is a common distortion in thinking that leads people to conclude
that things are worse than they really are. It occurs when a person
exaggerates and therefore inaccurately appraises an event or
situation. For example, a family member may think, “I failed to
convince my daughter that she needs to take her medication, and she
ended up being taken to emergency by the police. Since I failed to
help her, that must mean I’m a failure as a person.” Mental filter
bias is a type of overgeneralization in which a person focuses only on
the negative aspects of an experience and downplays or ignores the
positive aspects.
Magnification
Magnification, or catastrophizing, occurs when a negative event is
blown out of proportion. For example, the father of a teenage son with
concurrent depression and alcohol abuse thinks “Our neighbours looked
at my wife and me in a funny way this morning and didn’t even say
hello. That must mean they think we’re to blame for our son’s illness
and they want nothing to do with us because they think we’re bad
parents.” This brief encounter is interpreted as something
catastrophic.
Minimization
Minimization occurs when people downplay the meaning and importance of
a positive event. “It’s great that I was hired for this job after
almost 25 people applied for it. It pays more than any job I’ve ever
had before and my new boss said he is looking forward to hearing more
about my ideas. I’ll get to talk about these ideas in the executive
board room meetings . . . but all I can think about now is the
increase in taxes I’ll have to pay with the higher salary and all the
extra meetings I’ll have to go to. Besides, I probably won’t last long
anyway. Once my boss sees that I’m actually underqualified, I’ll be
fired and then I won’t be able to pay any of my bills. And I really
only got the job because my cousin worked here for years and put in a
good word for me.”

Disqualifying the positive
Disqualifying the positive occurs when people do pay attention to
positive information but then later find a reason to discount it.
“It’s great to have a friend like Barb call me all the time to talk,
but she only calls me because her best friend got a new job now and is
busy during the day. She really doesn’t even like me.”

All-or-nothing thinking
All-or-nothing, or black-and-white, thinking occurs when a person’s
evaluation of an experience lies at one extreme or the other. For
example, a person does not get a job that he or she really wanted.
Instead of thinking, “Up until now, I’ve been hired for most of the
jobs that I’ve ever applied for, so if I keep looking, a great job is
bound to turn up,” the person thinks, “I was just turned down for the
best job I’ve ever applied for. I’ll never have an opportunity like
that again—I’m a total failure.”

Jumping to conclusions
This occurs when people jump to (usually negative) conclusions that
are not justified by the facts that they have about the situation. “It
looks like this is going to be a good day to relax and watch
television, but I just know that the minute I sit down, another family
crisis will start up.”

Mind reading
Mind reading occurs when people assume, without any evidence, that
someone is thinking something negative about them. They react based on
this conclusion, which is often false. “Why should I bother trying to
talk to my co-workers down the hall? They all hate me and think that I
should be replaced by somebody who actually knows what they’re doing.”

Should, must and ought beliefs
These thoughts and beliefs are often found in people who set
unrealistic, often impossible demands on themselves. When they fail to
meet these demands, they either punish themselves for their perceived
failures or sink into low self-esteem and depression. “I should be a
better father”; “I ought to try harder to stop my husband from
drinking”; “I should be better looking. I’ll never get ahead in this
life being this ugly!”

Some people with perfectionistic tendencies may also hold others to
unrealistically high standards. “My mother should learn a lot more
about how to deal with my brother. She should kick him out of the
house if he refuses to take his medication and clean himself up. And I
can’t understand why she doesn’t demand that he go to a drug treatment
centre. She lets him just sit around the house thinking about whether
or not he’s ready to get help. If he were my son instead of my
brother, I’d have him whipped into shape in no time. Nobody in this
family can do anything right.”

Personalizing and blaming
This happens when a person takes responsibility for something that in
reality they had very little control over. “I wasn’t paying enough
attention to my son. If I hadn’t been so busy working and doing other
things, I would have known that he was planning to hurt himself and I
could have stopped him. It’s because of my negligence that he’s back
in the hospital.”

Similarly, a person might unfairly assign responsibility to someone
else. “You would think my adult children would have noticed how
stressed out I’ve been trying to take care of their father and work
and manage the whole household at the same time. They can be so
selfish and self-centred. If they had been more helpful, I could have
paid more attention to my husband and he’d be off the drugs by now.
It’s really their fault that the whole situation is so out of
control.”

Dealing with difficult emotions

Strategies that may help you to deal more effectively with difficult
feelings include:

• repeating positive affirmations over and over to yourself such as, “I am doing the best that I can and I am a good and decent person.”
• being aware of yourself and any problematic thoughts you might be having about situations, events and other people that might be resulting in negative feelings
• being aware of how you handle stress and what kinds of stressful situations leave you feeling most vulnerable
• developing effective ways of coping with a family member who has concurrent disorders (e.g., finding out how to navigate the treatment system and get help setting limits and clear boundaries
• talking openly and honestly about how you feel, and examining those feelings, either with someone you trust or within a peer or professionally led support group
• talking to other families about effective ways to deal with stress and difficult emotions
• developing and following your own personalized self-care plan.

If you practise these strategies on a regular basis, you can cut down
the frequency and intensity of distressing thoughts. They can help
prevent negative moods from occurring in the first place, and also
help prevent them from getting a lot worse.
In order for many of these strategies to work, it is better if you are
calm and thinking logically and rationally. In a stressful situation,
if you find that you are already experiencing intensely negative
feelings, it might be better to first try calming and soothing
yourself before you try to work on any problematic thoughts and
beliefs.

Building social support

Family members often give up their own activities, and can become
isolated from their friends and colleagues when caring for a family
member with concurrent disorders. Social support is crucial to help
you achieve and maintain emotional and even physical health.
Friends and colleagues
Some people find it helpful to have a large social network to draw on.
Others prefer to have only a few supportive and understanding friends.
Participating in a group activity you enjoy, such as a walking club, a
sports team, a reading club or church group can help you retain your
social network. Old friends and colleagues you’ve grown apart from may
appreciate hearing from you. Being open about your situation will
often bring support from the least likely places and people.

Self-help organizations
Many family members join family self-help / mutual aid support
organizations such as the Schizophrenia Society of Ontario (SSO), the
Mood Disorders Association of Ontario (MDAO) or the Family Association
for Mental Health Everywhere (FAME). While these groups provide
support, education and advocacy for family members of people with a
mental illness, many of the participants have loved ones with both a
mental health problem and a substance use problem.
Some of the groups are structured with educational programs or guest
speakers from the mental health care system. Other groups are more
informal and may involve small group discussions and peer support from
other family members struggling with similar issues. Some families
also choose to attend self-help groups for family members of people
with alcohol or other drug problems. These groups include Al-Anon (for
family members of people with alcohol problems), Alateen (for young
adults who have siblings with substance use problems) and Nar-Anon
(for families of people with substance use problems).

Becoming informed
Information is power. Many family members seek both formal and
informal opportunities to learn about concurrent mental health and
substance use problems. They find it helpful to learn as much as they
can about their loved one’s particular mental health and substance use
problems, including the causes, signs, symptoms and possible
treatments.

Believing in yourself and your rights
You have a right to ask questions and to receive attention and respect
from health care professionals. Some people with concurrent disorders
want their family members to be very involved in their treatment plan,
even if they’re in hospital. Others may prefer not to involve their
families and may want to keep their personal information confidential.
Whether or not you are actively involved in the professional care of

• your family member, you have a right to:
• your own support from health care professionals
• education about mental health and substance use problems
• information about the latest research and most effective treatment options
• respect and validation.

For people with concurrent disorders to achieve and maintain recovery,
they need to:

• be treated as unique and important
• be treated as human being with goals and dreams
• have the freedom to make choices and decisions about their lives
• be treated with dignity and respect
• accept that their unique journey through life has taken a different path
• recognize that recovery is the potential to become free of symptomsby following an individualized treatment plan
• acknowledge that relapse is a common and expected part of recovery, but does not mean that they have “failed” or that previous gains are lost—rather, it is a chance to learn and to move forward again
• have hope about their future
• have meaningful relationships with others who care and do not stigmatize
• have a routine and structure to their day marked by meaningful activities that may or may not include work (paid or volunteer)
• have a reliable and steady source of income
• live in stable, clean and comfortable housing, whether it is and independent living situation or supportive housing
• accept that recovery may require a structured community day treatment program or other links to professional mental health and addiction systems of care
• recognize that pets may be important
• recognize that spirituality or religious beliefs and practices may be important.

It seems to me that people reject the sick when there’s little hope
that they’ll get better. Why invest time and energy if a person will
very likely remain ill for the rest of their lives? But it’s not true
of most people with concurrent disorders, provided they are caught
early enough and receive good care. My son is working now, he has a
girlfriend . . . and it certainly didn’t look like he would have any
kind of a normal life five years ago when he was diagnosed with
schizophrenia and drug abuse. So I tend to believe there’s a lot of
hope out there.

The role of hope
I think as family members we have an opportunity to offer a lot of
hope to other families going through the same thing. The general
public seems to think that once a doctor tells you your family member
has a mental illness or a problem with drugs and alcohol, it’s
over—like, there’s no hope; their lives are destroyed and yours too.
But it’s so different now, so many people recover from concurrent
disorders. And look at the research, the new medications and
treatments—there have been so many advances. I know so many parents
whose kids have gone back to university or have jobs—I mean, they’re
doing well. Mental illness and substance abuse doesn’t have to mean
that the person’s life is over. So I think we need to give some hope
to people.

There is great hope for people who have concurrent disorders. Over the
past 10 years, many improvements have occurred, including:
• improved medications
• improved understanding of treatment needs
• increased opportunities for learning from others.

A diagnosis of both a mental health and substance use disorder does
not mean that a person will inevitably decline and be unable to
function. On the other hand, recovery does not necessarily mean that a
person’s previous abilities and situation will be completely restored
or that they won’t need medications or other treatment.
The overarching message of “recovery” is that hope and a meaningful
life are possible. Hope is recognized as one of the most important
determinants of recovery.

Patricia Deegan of the U.S. National Empowerment Council says:
For those of us who have been diagnosed with mental illness . . . hope
is not just a nice sounding euphemism. It is a matter of life and
death . . . We have known a very cold winter in which all hope seemed
to be crushed out of us. It came like a thief in the night and robbed
us of our youth, our dreams, our aspirations and our futures. It came
upon us like a terrifying nightmare that we could not awaken from.
—Deegan, 1993

Inspirational quotes
If you have ever spoken with someone who has benefited from a 12-step
program such as Alcoholics Anonymous or Al-Anon, you may have heard
about the “recovery slogans” that thousands of people have said were
important contributors to their recovery journeys.
Many family members affected by mental health and/or substance use
problems have also found similar kinds of slogans (sayings and quotes)
to be inspirational, motivating and enormously beneficial.
What is it about these little sayings or quotes that make them so
powerfully memorable and effective that they can help people actually
change how they think, feel and behave? They can be thought of as
“bits of wisdom written in shorthand.” Many of them, in a mere one or
two lines, can shift a person’s entire perspective on particular
aspects of life.

For example, consider the following quote:
“I haven’t failed. I’ve identified 10,000 ways this doesn’t work.”
—Thomas Edison

Thinking about a quote such as this (and even better, discussing it
with people who care—what the quote means, how it gives you a new way
to look at things in your life, how thinking this new way would be
really useful and helpful for you) can help you focus on the positive
aspects of a situation.

Quotes, slogans and sayings can help people change their attitudes and
behaviours so they are less affected by the opinions and actions of
others. In these ways and in so many others, these little pearls of
wisdom are guides to peace that can have a powerfully beneficial
effect on a person’s emotional health. As such, they can help to build
resilience and reduce a person’s vulnerability to developing
compassion fatigue. We have summarized some of our thoughts on a few
of the quotes, just to get you started.
You can’t direct the wind, but you can adjust the sails.

This quote is about learning to accept the things we can’t control and
to try to change those things we do have some control over, such as
our own actions and behaviours, and sometimes even our thoughts, moods
and perceptions. Learning this valuable lesson in life may very well
be one of the keys to serenity and contentment.

We’re responsible for the effort, not the outcome.

Do not let what you cannot do interfere with what you can do.

These two quotes centre on one important theme: It is much more
helpful and realistic to concentrate your efforts on what you actually
do have control over, rather than expend time and energy trying to
make a change in something over which you have no control. For
example, it is helpful to support family members in their struggle to
stop or reduce the use of substances, as long as you understand and
accept the fact that only they are ultimately responsible for their
own recovery.

This too shall pass.

When you find yourself in the middle of a crisis or caught in the grip
of distressing feelings or situations, it can feel like the experience
will never end and that you won’t be able to survive it. Sometimes the
only way to get through extremely stressful and adverse situations in
life is to keep in mind one simple truth: Nothing lasts forever.

Act as if . . .
For some people, trying to change their thoughts and feelings before
they change their behaviours may not get them very far in their
recovery. Waiting until you feel more motivated and less anxious
before trying out new recovery behaviours can lead to a worsening of
both the substance use and the mental health problems. More motivation
and reduced anxiety won’t happen if you stick to the same behaviours
every day that allow the lack of motivation and anxiety to flourish.
Sometimes, people have to take action in spite of feeling depression,
anxiety, worry, shame, anger and exhaustion, and in spite of
struggling with problematic thoughts and beliefs. So it might be
helpful to live by one rule . . . act as if you are feeling great and
thinking rationally. In other words, no matter what else is going on
inside your own head or outside in the world, follow through on your
commitments and your recovery plan (e.g., go to AA meetings, keep
appointments with your therapist, eat three nutritious meals every
day, get eight hours sleep every night). You will have to force
yourself at first, but if you can act as if things are better, you’ll
actually help that come true.

The role of family
Not only should family members be included in discussions about
recovery—they can actually share the road to recovery.
Many elements considered important for your loved one’s recovery may
overlap with your own journey of recovery. Some of these might
include:

• having hope about your own and your relative’s future
• being educated about your loved one’s mental illness and substance use disorder and understanding how these problems interact
• having supportive relationships with others in the family and community who are caring and do not judge or stigmatize
• feeling a sense of connection to people who are important to you
• being considered a knowledgeable, engaged and respected part of your loved one’s health care team, and being kept informed by health care professionals
• accepting that your loved one’s journey through life has taken a new course
• understanding that if relapses occur it does not mean that you relative has “failed” or lost previous gains
• viewing relapses as a chance to help your family member get back on his or her path to recovery
• feeling a sense of control and personal mastery over your own life
• learning to let go of the all-encompassing preoccupation with your ill loved one and allowing yourself to have a life of your own, with meaningful and relaxing time to yourself to engage in activities that are pleasurable, stress-relieving and fulfilling, and learning to do so without anxiety or guilt
• recognizing that strong spiritual, philosophical or religious beliefs or practices may help you sustain yourself through difficult times.

When people meet my son now, everybody is just so flabbergasted. And I
think he offers such hope to sufferers and families . . . and people
tend to want to talk to you about it. And we try. We try to help
families whenever we can. And I think we give them a lot of hope. We
get a number of families calling us over the course of a year. And
either a social worker or doctor or somebody from the family support
group—they’ve used our family as an example and say, “their son is
doing so well”—and then families say, “Can we come over and visit
you?” and they come over and talk to my son. So we try to help. We try
to give hope to other families.

A family journey of recovery

My dad was treated for alcohol problems when he was 64 years old. By
then I was seriously questioning the effects of my Dad’s illness on me
as wife and mother. I was concerned about the genetic, familial
predisposition to addiction and mental illness and how it might impact
on my children.
My mother and I sought out Al-Anon where we discovered that we were
not alone in our search for direction regarding shame-based thinking
and powerlessness over a loved one’s addiction. We heard about the
necessity of practising self-esteem and maintaining boundaries.
However, many times while dealing with my adolescent and teenaged
children, I found myself caught in a trap where my inability to say
‘No!’ made me question my parenting skills. As a child I avoided
confrontation, hid anger and disappointment, and ran from conflict.
This behaviour afforded me quietude but an inability to verbalize my
emotions.
Our eldest son struggled with alcohol dependency between the ages of
19 and 23. We strongly encouraged and supported him through treatment
at an inpatient facility (he stayed only three weeks). Although
haunted by angry emotional outbursts in his early 20s, he succeeded in
maintaining sobriety, facing his demons with honesty, courage and
faith. My husband and I supported him financially, when necessary, and
always communicated our love to him and our confidence in him as a
special person. I was determined that I would shield my other children
from exploring any form of addictive drug. I kept reading about
substance abuse. I also took a course in assertiveness training that
gave me confidence to believe in myself, stand firm in my beliefs and
voice my feelings.
Our seventh child, a gregarious, bright, talented, honest, well-loved
person, sank into depression at the age of 18. Over the next few years
he struggled to avoid taking medication while seeking professional
psychological help, attempting university studies as well as actively
seeking out human relationships that most often failed him. He was
plagued with suicidal thoughts, inability to cope with studies, and
was unable to manage occupational work hours, all the while attempting
to ‘keep face.’ He and I kept in close touch and we often had
‘emergency meetings over coffee’ when he felt that he couldn’t carry
on. But he would pluck up his courage and try again.
At age 21, after a suicidal episode, he was admitted to hospital with
a diagnosis of depression with suicidal tendencies. He began
antidepressant therapy that relieved his anxiety and increased his
energy output so that he could continue university while living at
home. Soon stress mounted; he found home too confining and he went to
live downtown with friends in an environment where he felt
comfortable. Once again he discontinued his studies. I was anxious
when he left home but I knew that he must walk his own journey. His
brothers and sisters kept in touch with him and he faithfully called
his dad and me. My husband, through all this, often remarked to me how
he admired his son’s courage in facing these hard moments in his life.
And my son often said to me, in moments of desperation, ‘Mom, no
matter what happens to me, promise me that you will never blame
yourself. You have been the best mother. I take responsibility for my
life and how I am living it.’ My prayer for him continued to be:
‘Lord, you love this child of yours even better than I can. I know you
will take care of him.’
Two years later he succumbed to the temptation of street drugs in the
hope of regaining lost energy and experiencing a more manageable life.
Cocaine, crystal meth and marijuana, his drugs of choice, were at
first exciting but within a few months, his life careened to a
debilitating crash. His brothers, sisters and a cousin encouraged him
to return home. They all knew he was desperate and could not manage on
his own. Humiliation, guilt and his loss of independence were his
major concerns. We are told to have self-reliance but that is tricky
when one has no self to rely on.
My husband and I and our niece, a close friend of our son, attended an
introduction to addiction and recovery program that helped us face the
challenge before us. Our son always supported our need to learn coping
skills and we shared insights with him and the other family members
who were eager to share in the recovery process of their beloved
brother. We learned that lapses can be opportunities for growth. We
must concentrate on love rather than fear and judgment.

At this time our son has been ‘clean’ for one year since the
completion of a six-week inpatient treatment and follow-up program for
concurrent disorders. He continues antidepressant medication under
supportive medical care and has a full-time job. He also has a
meaningful relationship and hopes to return to university this year.
He is socially active and very grateful for each day.
Recovery (finding self and gaining control) is an ongoing life
challenge. At some time on our journey, we all face grief,
disappointment and loss. Each day brings its own challenges. Regaining
control can only be accomplished when the pain from lost dreams is
faced honestly in a safe, understanding setting. With concurrent
mental health and addiction issues, the challenge is two-fold.

We were greatly helped by the open communication we shared with our
son. He tried so hard to be affable and grateful even at the worst of
times. He would stay talking and listening as long as he could and
then retreat into the silences of his despair. At this time of his
greatest need, we tried to be for him the beacon in the lighthouse.
One important factor in my recovery is self-care. Each day I ask
myself, ‘What do I need today and how can I accomplish this?’ I have
learned that, in recovery, I must not only be conscious of my own
needs but I must verbalize them and take action to achieve them.

Comments
1. People who are in recovery need the support of others.
Feeling a sense of connection to people, such as other family members,
friends and professionals, is very important to re-create a sense of
belonging and closeness. We humans are social beings. We are most
content and fulfilled when engaged in meaningful relationships with
others. Support from people who are non-judgmental, compassionate and
who accept concurrent disorders as legitimate illnesses from which a
person can recover is crucial to the recovery of both consumers and
their families.
2. Recovering from mental illness is possible no matter what you think
may cause it.
Concurrent disorders are generally a result of a complex mix of
hereditary, genetic, biological, psychological and social factors.
However, people can sometimes hold mistaken beliefs about the causes
of these disorders. This journey of recovery may take different paths
and look very different from person to person, but yes, it is a
definite possibility regardless of one’s beliefs about the causes.
3. A good understanding of one’s mental illness helps in recovery.
The experience of mental illness is often filled with fear and
anxiety, grief and loss, altered expectations and dramatic changes in
one’s perception of oneself as a human being. These feelings increase
when a substance use disorder is also involved. For many people with
concurrent disorders and their families, becoming educated about
concurrent disorders is essential for gaining a sense of control over
these conditions and for recovery. It’s important to learn about the
signs, symptoms and effects of mental health and substance use
disorders, possible causes, treatment methods, and the possibility for
recovery.
4. To recover requires faith.
“Faith” holds many meanings. Some people may think that believing in a
higher being or following a particular religion is necessary for
recovery. However, for many people, “faith” may simply mean believing
in yourself, having hope for a better future and believing in the
people around you who care about you and want to help you.
5. Recovery can occur even if symptoms are present.
Recovery from concurrent disorders doesn’t necessarily mean that
people will never again experience symptoms, go through hard times or
relapse. Recovery implies learning from these experiences and having
the courage to move forward in spite of them. Many people reach their
goals and realize their dreams even if they have setbacks along the
way.
6. People in recovery sometimes have setbacks.
As discussed above, people with concurrent disorders will likely have
setbacks from time to time. This is not a sign of failure, but an
opportunity to learn about potential triggers and sources of stress,
and perhaps new and more effective ways to manage difficult aspects of
life.
7. People differ in the way they recover from a mental illness.
“Recovery” means different things to different people. Some may
recognize the importance of psychiatric medication for their recovery,
while others may need more intensive ongoing support from health care
professionals. Some people want to return to work, while others find
work too stressful and become involved in self-help groups or other
community support activities. Some people hold on to strong spiritual
beliefs, while others find that simply enjoying the company of a pet
or close friend sustains them. No two people recover in the same way.
8. Recovering from mental illness can occur without help from mental
health professionals.
Many people in recovery from concurrent disorders will have contact
with health care professionals at some point. Finding and working with
compassionate and understanding health care professionals who respect
clients’ unique needs and goals is often very important to beginning
the journey of recovery and to maintaining the gains that one makes.
This contact with professionals may be intensive and continuous, as
some clients may be part of supportive outpatient programs or have the
ongoing help of a community case manager. Some clients may see a
physician only once in a while, to obtain prescriptions for
psychiatric medications. The type of contact may also change over
time. As people become stronger and more comfortable in managing their
illnesses and their daily lives, they may have less involvement with
professionals and eventually may wish to stop seeing them, except in
cases of relapse or more difficult times.

Some people recover without the services of health care professionals.
They may have milder forms of mental illness and may be able to reduce
or control their problematic substance use so that these problems do
not significantly disrupt their lives. Some in this group find that
attending self-help groups and maintaining close and supportive
relationships with family and friends is enough for them to enjoy a
life of recovery.
9. All people with serious mental illnesses can strive for recovery.
Yes. Any person with mental health (and substance use disorders) can
work toward a life of recovery. Each person has the capacity for
hope, for a sense of acceptance and belonging, and for goals and
dreams.
10. People who recover from mental illness were not really mentally
ill in the first place.
The old belief in the chronic and hopeless nature of mental illness
and substance use problems has been challenged. The fact is that
people with concurrent disorders can enter a life of recovery that
involves emotional stability, good physical health, meaningful social
and work-related activities and close, supportive relationships. It is
no longer true that people with serious mental illnesses and substance
use problems are on a downward course to chronic disability. People
with very serious forms of mental illness and substance use disorders
can indeed recover.
11. The recovery process requires hope.
Hope involves believing in your ability to overcome difficulties and
looking to the future with optimism that recovery is possible. Having
hope is considered fundamental to achieving and maintaining a life of
recovery.
12. Recovery does not mean going back to the way things used to be.
Some people who are in recovery may be able to return to their former
activities, such as the same jobs, school, friends and social
interests. On the other hand, recovery does not necessarily mean going
back to exactly the same activities, beliefs and overall lives as in
the past. For many people, being in recovery often involves
establishing a new and different or altered set of goals and dreams—a
different job, a different school, new friends and social interests.
People may find that their priorities have changed dramatically from
the way they used to think.
13. Stigma associated with mental illness can slow the recovery process.
Stigma and discrimination can have devastating and destructive
consequences for those with concurrent disorders and their families.
Stigma and discrimination can definitely act as major obstacles to
recovery. Stigma can make people lose confidence in themselves,
undermine their attempts to reintegrate into the community and, in
some cases, can even lead to such despair that a relapse occurs. It
can also cause families to isolate themselves from others and feel
shame and embarrassment.
14. Recovering from the consequences of mental illness is sometimes
more difficult than recovering from the illness itself.
The consequences of mental illness or substance use can vary
dramatically. Some people may experience milder consequences, such as
short leaves from school or work, taking medications or being
hospitalized for a short time. Others may experience significant
effects that might include jeopardized family relationships, loss of
meaningful people in their lives, frequent and lengthy
hospitalizations, inability to work or attend school, involvement in
the legal system, medical problems, and so on. Once a person has
become emotionally, mentally and physically stable, the person may
have to deal with these consequences. This can cause more stress and
anxiety, and possibly lead to despair, a sense of failure and relapse.
This is why it is important to remember that recovery involves paying
attention to the whole person—all of his or her needs, all areas of
the person’s life that have been affected. These can all be included
in a comprehensive recovery plan.
15. The family may need to recover from the impact of a loved one’s
mental illness.
Ideally, this chapter will have helped you realize the importance of
recovery for your-self as well. We have discussed the effects of
concurrent disorders on family members, ranging from physical to
emotional, social, occupational, economic and spiritual. It is very
important for family members to allow themselves to recover their
sense of emotional stability, feelings of control, peace of mind and
an overall sense of well-being as they experience the effects of
concurrent disorders.
16. To recover requires courage.
Having the courage to move forward in life despite experiencing the
effects of both a substance use and a mental health problem is
fundamental to the idea of recovery. Every seemingly small step
forward, from getting out of bed in the morning, to getting through
the day without using drugs, taking the bus to a community support
program, calling up a friend, taking medications, going back to work,
etc., requires more courage than most of us could ever imagine trying
to muster.
Developing a self-care plan will help you think about the small steps
you can take in your own life to build your resilience and reduce your
vulnerability to compassion fatigue.
Imagine what your self-care plan might look like. This plan should
address all your needs:
• biological self-care (caring for your own physical health)
• psychological self-care (taking care of your emotional health)
• social self-care (taking care of your social needs and networks)
• spiritual self-care (drawing on sources of spiritual help that might
comfort and guide you)
• financial self-care.
This plan is called the biopsychosocial-spiritual self-care plan. Just
remember to be very specific in your self-care plan. For example, a
family member may choose to include something like the following in
his or her plan:
• I will work out at the local gym three times a week for 30 minutes each time.
• I will walk reasonable distances instead of taking my car.
• I will go to Pilates classes with my friend Sheila once every week.
• I will eat three fruits a day, and take a B6 multivitamin.
• I will prepare two meatless dinners a week.

source: CAMH