The adolescent mentally ill chemical abuser: Special considerations in dual diagnosis

Summary

Chemical abuse in adolescence, in this object relations perspective, is predisposed by disintegration anxiety and by characteristic fears associated with status transitions. Severe manifestations of these anxieties and fears can also appear in the abuse of chemical substances and in psychiatric disorders. Because adolescence is a time of powerful external dependency (itself a function of incomplete psychological growth), the disease process associated with either chemical dependency or mental illness can be accelerated by the dynamics of the period. These dynamics are frequently controlled by sensitive dependence on such external sources as peer groups and by what are sometimes described in terms of the homeostasis processes of dysfunctional families. Dysfunctional families play into these dynamics in numerous ways — one way, for example, is by creating family crisis at the prospect of their adolescent children's growth and separation, which serve to convert their offspring into “problems” that then will serve the “family system” integratively. In general, such family “systems” discourage psychological growth by sustaining “enmeshment” of caregiving figures with their offspring. By contrast, external (nonfamily) adolescent milieus provide the adolescent with leverage against such dynamics as well as support in the face of isolation or repudiation. But since such external milieus are driven by conformist pressures, feed on separation‐individuation anxieties, and enclose rebellious and delinquent activities, they often encourage experimentation with retreatist and disinhibiting substances. In turn, abuse of these substances both telescopes the disease process connected with any underlying psychiatric problems and then superimposes on the signals of these illnesses additional chemically induced but transient symptoms.