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Abstract
People with mental disorders (MD) have high rates of substance use problems (SUP) that are
undertreated and understudied despite their adverse outcomes. The objective of this study is to
examine barriers and facilitators that influence help-seeking to addiction treatment from the
perspective of people with co-occurring MD and SUP. Forty-three individuals with MD and SUP
were selected from the sample (n=127) of a larger research project. This sub-group participated
in semi-structured interviews and completed questionnaires. Interview contents were
thematically analyzed using a trajectory approach. Based on participants addiction trajectories,
two mental health experiences were identified: the multiple disorders experience and the
anxiety disorder experience. The analysis highlighted how participants relate to barriers and
facilitators to addiction help-seeking at the individual level (denial/minimization of problematic
drug use, fear of being labelled an addict, influence of social networks, and knowledge of
addiction services) and health system level (waiting time, costs, relationships with health
providers, therapeutic approaches, and availability of psychological support). Interventions
should be sensitive to the different experiences of people with MD and SUP. Integrated addiction
services and a no wrong door approach are suggested.
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1. Introduction
Research findings suggest that individuals with mental disorders (MD) often have high
rates of substance use problems (SUP). For example, 56% of individuals with bipolar disorder
develop alcohol and/or drug dependence over their lifetime (Skinner, O'Grady, Bartha, & Parker,
2004), compared with around 15% in the general population (Kessler, Chiu, Demler, & Walters,
2005; Regier et al., 1990; Rush & Koegl, 2008). Prevalence of SUP is also significant in the
lifetime of people with other types of MD: close to 50% among individuals with a psychotic
disorder (Green, Drake, & Noordsy, 2007; Kessler et al., 2005; Mueser, 2013; Rush & Koegl
2008) and around 25% among those with major depression or anxiety disorders (Skinner et al.,
2004). Percentages of MD and SUP co-occurrence are even higher among people in clinical
settings, prisons and other institutional milieus (Chan, Dennis, & Funk, 2008; Little, 2001; Rush
et al., 2008; Urbanoski, Cairney, Adlaf, & Rush, 2007; Watkins et al., 2004; Wu, Ringwalt, &
Williams, 2003)
Despite their prevalence and negative consequences, SUP in people with MD are
frequently underdetected and therefore undertreated (Green et al., 2007; Mueser, Noordsy,
Drake, & Fox, 2003). For people with MD, SUP are associated with several adverse health
into higher service use and costs of care (Dickey & Azeni, 1996; Mueser, 2013; Rosenberg et al.,
2001; Rush & Koegl, 2008). Additional social consequences that contribute to diminishing their
quality of life have also been reported and include incarceration, criminalization, occupational
impairment, homelessness and victimization (Dixon, 1999; Rush & Koegl, 2008; Todd et al.,
2004). Several studies have shown that most individuals with co-occurring MD and SUP do not
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receive any treatment (Grant et al. 2004; Harris & Edlund 2005; Mojtabai, Chen, Kaufmann, &
Crum, 2014; Urbanoski et al., 2007; Urbanoski, Cairney, Bassani, & Rush, 2008; Watkins,
Burnam, Kung, & Paddock, 2001). Moreover, the few who access addiction services are often
transferred in and out of psychiatric care, and fall through the cracks between both systems
(Center for Substance Abuse Treatment, 2005; McKee, Harris, & Cormier, 2013).
Some research has been done on treatment-seeking behaviors among individuals with co-
occurring MD and SUP (Alegria, Carson, Goncalves, & Keefe, 2011; Harris et al., 2005;
Hatzenbuehler, Keyes, Narrow, Grant, & Hasin, 2008; Libby et al., 2007; Penn, Brooks, &
Worsham, 2002; Primm et al., 2000; Watkins et al., 2004). However, few studies have focused
on barriers and/or facilitators to addiction help-seeking (Bellack & DiClemente, 1999; Hartwell
et al., 2013; Mojtabai et al., 2014; Nidecker, Bennett, Gjonblaj-Marovic, & Rachbeisel, J., 2009;
Slayter, 2010; Treolar & Holt, 2008). Those studies examined addiction help-seeking in
vulnerable populations of people with co-occurring MD and SUP, including children and
adolescents (Alegria et al., 2011), ethnic/racial minorities (Alegria et al., 2011; Hatzenbuehler et
al., 2008; Libby et al., 2007), women (Penn et al., 2002) and ex-prisoners (Hartwell et al., 2013).
Some studies have focused on people with specific mental health problems such as severe mental
illness (DiClemente et al., 2008; Niedecker et al., 2009; Harris et al., 2005), depression and
anxiety (Treolar & Holt, 2008), and intellectual disabilities (Slayter, 2010). Economic, social,
systemic, therapeutic and attitudinal barriers and/or facilitators are the main factors cited in these
studies. However, only one study explored barriers and facilitators to addiction treatment from a
The objective of the current study is to describe and understand factors that influence
help-seeking to addiction treatment from the perspectives of people with of different experience
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of co-occurring MD and SUP. More specifically, it explores their points of view about the
barriers and facilitators that affect their ability to seek addiction treatment. Users' perspectives
are still underrepresented in the addiction literature (Neale, 1999; Treloar, Fraser, & Valentine,
2007). Moreover, the terms co-occurring disorders and dual diagnosis encompass large and
complex groups of people (Little, 2001) and could overshadow the specific characteristics of
service users.
2003), where individuals make their own interpretations based on their subjective experiences of
the world (Brunelle et al., 2015). More precisely, we used a descriptive phenomenological
approach (Giorgi, 1997). Although it pertains to real objects, this approach focuses on how
objects are perceived by an individual or what they mean for him or her rather than on their
essence or reality. At the end of the process, the researcher can state that actual experiences
gathered from the individual come from his or her own experience and not from objective
accounts of the reality (Giorgi, 1997). Accordingly, we took note of participants descriptions
of their experiences without forcing the meanings of their interpretations into our own categories.
We also chose the trajectory approach, frequently employed in the field of substance
abuse because it traces longitudinally the often chronic course of addictions and their evolution
(Hser, Hamilton, & Niv, 2009). This study defines trajectories as long-term patterns of stability
and change, both gradual and abrupt, in relation to transitions along the life span (Hser,
Longshore, & Anglin, 2007, p. 523). Addiction trajectories refer to lifetime course of
problematic substance use that are influenced by the interplay between an individuals
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characteristics, substance(s) consumed and his or her environment (Brochu, Landry, Bertrand,
Brunelle, & Patenaude, 2014). Addiction trajectories are not continuous over an individuals
lifetime and include initiation, periods of use, relapse, abstinence and remission (Brochu et al.,
2014). We were particularly interested in certain factors that strongly influenced addiction
trajectories such as exposure to treatment and other care system dimensions. We paid particular
attention to how an individuals co-occurring mental health problems modulated his or her
addiction trajectories.
2.1. Participants
This study was part of the Community-University Research Alliance Program (CURA), a
larger research initiative about addiction and service use trajectories of people with SUP. In all,
127 CURA participants were recruited in hospital emergencies, local community service centers
and criminal courts in two regions of Quebec (Canada): Montreal, a large urban center; and
selected from the CURA sample, based on the following criteria: 1) having been diagnosed with
one or more psychiatric condition(s) in the last 5 years, according to the Quebec Medical
Insurance Board (RAMQ) data base (Table I); 2) having consulted a psychiatrist in the last 5
years, according to the RAMQ data base; and 3) current use of one or more psychiatric drugs
Participants average age was 39.7 years, and over half were women (53.5%). Only one
fifth lived in couples (20.9 %) and almost two thirds had children (62.8%). Many participants
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(69.8%) had at most a high school education, and most (60.5%) had annual incomes of
trajectory approach, participants were interviewed at two measurement times over a 1-year
interval to examine evolution of drug use. Forty-three participants were interviewed at Time 1
and twenty-eight at Time 2. The follow-up rate after a year (65.1%) was comparable to rates
obtained by other studies of drug users (Patenaude & Brunelle, 2014). The interviews
documented participants addiction trajectories (Brochu et al., 2014). More specifically, the
interview schedule included questions about the following: participants experiences of first
for substance abuse problems; evolution of their addiction trajectories, and impact of services
and other factors; history of service use; participants experiences of episodes of service use;
participants perspectives on the collaboration between the different services received and the
health providers involved; and participants general assessments of services received and their
influence on addiction trajectories (Patenaude & Brunelle, 2014; Table IV). Ten members of the
CURA research team interviewed the participants, who were asked to sign consent forms and
given financial compensation of CAN$25. Before the interviews, each participant completed a
questionnaire that included questions about service use (social, health judicial and correctional
services) and prescription medication intake (Patenaude & Brunelle, 2014; Table II).
All interviews were recorded digitally and transcribed. A thematic analysis of interview
contents (Miles & Huberman, 1994) was performed, using a mixed coding grid, which included
predefined interview themes but also left room for new emerging themes. Using a
service use, mental health problems and critical life events were particularly targeted in analysis
of the themes. An initial version of the coding grid was presented to the research team, who
tested this analysis tool. Two members of the research team coded the interview contents under
The trajectory approach guided the thematic analysis and allowed us to use life course as
the organizing framework to classify relevant themes that emerged from the interviews. This
approach facilitated identification of different mental health conditions, patterns of drug use and
critical events across participants lifespans. A cross-sectional analysis was also performed to
This study was approved by the ethics committee of the Centre hospitalier de lUniversit
toxicomanie of the Centre Dollard Cormier Institut universitaire sur les Dpendances (CDC-
IUD-09001).
3. Results
Two groups of mental health experiences were identified, based mostly on participants
psychiatric diagnoses as well as on critical life events, service use and recurrent elements in
addiction trajectories. The first is the multiple disorders experience, representative of persons
diagnosed with two or more psychiatric disorders (anxiety disorders, schizophrenia, mood
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disorders, and/or personality disorders); this was the most common experience in our sample.
These individuals typically received a psychiatric diagnosis long before their substance abuse
problems were acknowledged. Several participants reported early onset of drug/alcohol misuse,
use of drugs perceived as hard, and adverse childhood experiences (victimization); they also
reported intensive use of health services and held critical views of addiction services. The second
is the anxiety disorder experience, representative of individuals mainly diagnosed with only an
anxiety disorder. During the interviews, several participants did not mention having a mental
health condition. Others stated having transitory anxiety problems, and reported late onset of
drug/alcohol misuse, use of legal and illegal drugs perceived as soft during most of their
addiction trajectories, as well as moderate use and mostly positive view of health services. It is
important to point out that anxiety disorders are highly comorbid and, accordingly, most
participants reporting multiple disorders had been diagnosed with anxiety disorders. A
comparative analysis of both groups of mental health experiences showed similarities and
In the following section, quotes from participant interviews are used to illustrate
interrelated barriers and facilitators that influence addiction treatment-seeking at the individual
and health system levels. To protect participants confidentiality, we have assigned pseudonyms
to participants and to anyone or any place referred to by name during the interviews.
Four major types of individual-level barriers and facilitators were identified in the
interviews: 1) denial or minimization of problematic drug use; 2) fear of being labelled an addict;
Several participants reported that prior to their first referral to an addiction service, they
did not see their substance use as problematic, which delayed their seeking addiction treatment.
use as medication that helped them to deal with distress in their everyday lives.
Ive never seen that [substance use] as a major problemIve always seen it as the
wrong medication, as self-medication [] because I started using it when things werent
going wellI used it after an argumentit helped me to stabilize, like medication would.
(Debbie, 28)
challenging to accept that they had substance use problems because they used substances
perceived as soft (e.g. cannabis, over-the-counter medications and/or alcohol), did not experience
I didnt really admit I had a problem. I said to myself, Im not doing anything bad. I
was at home, I smoked my little joint. For me it wasnt a big deal. [], my life was
normalI realized it last year, when she [the psychologist] told mebut I didnt think I
really had a problem. I hung out with people who use, but from there to saying I had a
problemI could say that about a junkie, someone who injects, but me, I didnt know that
someone who smokes pot could really have a problem. (Dafn, 31)
They reported that this lack of awareness triggered defensive reactions on their part when
a health provider tried to address their substance use problems or to refer them to addiction
treatment. In the case of participants characterized by the multiple disorders experience, help-
seeking was linked to what they perceived as mental health issues, and they were not prepared to
accept that they also had addiction problems. For example, Denise was disappointed and stopped
seeing her case worker when he wanted to focus his intervention on her SUP instead of on her
negative thinking:
I went to Hospital 9 because I had dark thoughtsI wasnt feeling good. And they
referred me to a psychologista social worker in City 43. Andbecause I had dark
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thoughts, I talked about everything that was wrong: my boyfriend cheated on me, I was
going to lose the little kid we wanted to adoptand I dont know why, but he told me that
I had a SUP. And when he realized I had a SUP, he just wanted to fix that, but I didnt
need it then [], I wasnt ready. So I stopped seeing him because of that. (Denise, 31)
mental health problems before being referred to addiction services did not want to be seen as
addicts. As mentioned, several of these individuals resisted accepting their drug use problems
and starting treatment because they feared additional stigmatizing and pathologizing labels.
According to my principle of hating all things dramatic, I find awful when somebody
says, Oh, yes, I should go to detoxification, Im an addict, Im really an addict. I find it
disgusting! You know, major depression [her diagnosis] is a big word, its so dramatic
that Ive never wanted to say, Im depressed. Ive always said, [] I know real pain,
I know real suffering. When he [the health provider] told me: You have a drug
problem, I thought, Christ, we arent in a film! Stop it! (Barbara, 18).
treatment because they feared being identified as addicts by health providers or other clients who
knew them. This was a major source of distress for those working in health or social services
who wanted to protect their confidentiality. For example, a specialized educator who worked
with children in a community center feared seeing her clients parents at an addiction facility:
I try to stay away from organizations where I know I could meet up with the parents of
those that I work withbasically all parents who use go to Treatment Center 1. The
mother of the little girl who is my main case is in residential treatment in Treatment
Center 1I dont want parents coming to my place of work telling me: Hey, Ive seen
you there (Berthe, 22)
Many participants social networks were constituted of active drug users. In these
individuals immediate environments, drug and alcohol misuse was normalized to the point that
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they found it challenging to acknowledge the negative impacts of substance use. Several of them
characterized by the multiple disorders experience reported the strong influence of relatives and
My father was a polydrug user. He did all possible drugs in his life [] I pretty much
smoked my first joints with [him]. He wasnt a father to me. He was a friend, but not a
father. (Angle, 29)
Consequently, several members of their immediate social networks did not encourage
participants to seek addiction treatment; but once when they were in treatment, those relatives
and friends triggered their relapses. This was the case for Debbie, who explained how her
recovery process was affected by having a partner who is an active drug user, and that drug use
that people who were or had been in addiction treatment fostered their seeking help and
commitment to treatment. As Carlos pointed out, having these people around him helped him to
stay on track and showed him that it was possible to overcome his SUP.
I have friends who have the same type of problem as me and have overcome it [with
therapy]. There are people in my family who also have the same problem. I know other
people like this, who work in [addiction] help services. So, its through them that I have a
lot of possibilities. I already have a support networkthat encourages me to continue.
(Carlos, 30)
Some participants, typically those characterized by the anxiety disorder experience, were
not aware of the support available for their drug use problems. They denied/minimized their SUP
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and dealt with their consequences on their own. When they encountered specialized services,
they were pleasantly surprised by the positive effects that, for instance, addiction therapy could
It was my lawyer who proposed it [start therapy]. He came to see me, to see if I wanted
I started therapy very fast, at night. I didnt know what therapy was at all []. In any
case, I dont regret it. Its been too good for me, to be young and learn to live with
myselfmy vision of things has changed a lot [] Im better with myself. (Gildor, 35)
Participants also stated that information about addiction services was not easily accessible
and they had to search for it on their own. Finding out about the resources available facilitated
access to a wider number of services and allowed them to better meet their needs. For example,
since she was first referred two years before the interview, Bernadette has been in residential
treatment twice, received individual therapy, group therapy and psychological counselling in an
Im happy to know the addiction resources here because they help me change []. Were
really lucky to have all these services. But its too bad that the services arent advertised
more. Im not sure if people who need them are aware of the services here. I find it sad. It
would be something to suggest...theres not enough [information]. But once youre in,
youre guided according to what you need. It fills your whole schedule! (Bernadette, 31)
Participants also identified several barriers and facilitators to the health system that
influenced their addiction help-seeking. Among the most relevant were 1) waiting time, 2) costs,
psychological support.
Several participants in the multiple disorders experience group reported having to wait
for long periods of time before getting addiction treatment. They recounted that being confronted
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with lengthy waiting lists to get a caseworker and/or enter residential treatment undermined their
motivation to seek help. Moreover, some participants with severe SUP who underwent medical
detoxification in a hospital relapsed while they were waiting to enter residential treatment. This
I went through the outpatient service, so there was a waiting list. I went three, four times,
I moved my ass becauseI started withdrawal and I didnt want to go through it twice.
But I went through two withdrawals. I relapsed between the time [I left the hospital] and
when I entered Treatment Center 1. (Crystal, 31)
Conversely, participants characterized by the anxiety disorder experience were not very
critical of waiting lists; this could be related to less severe SUP or denial/minimization of the
problem. They reported that programs such as a service corridor between some hospital
emergencies and treatment centers accelerated access to residential treatment. They also pointed
out that several addiction centers offered alternative services that could be accessed immediately.
Yes, the waiting time for a caseworker is long, but there are other tools that help you in
the same wayOK, you need help quickly, but youre going to get it in six weeks, cant
you stick it out? They [the health providers] put you in contact with the others, they give
you an emergency number, they give you help programsin some places, you can go
every day of the week! (Brian, 38).
3.2.2. Costs
Most participants had low incomes and when describing their service use, they indicated
how their socioeconomic conditions (e.g. underpaid or no job, unstable housing and lack of
transportation) limited their access to and pursuing treatment. Despite Canadas universal health
care system, some addiction treatment costs are not covered, and not all participants could afford
them. For example, several individuals identified major barriers to seeking and committing to
residential treatment: high cost of addiction centers (mostly private); weekly transportation costs
(from the center to the clients residence); and/or other expenses associated with their stay.
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Even if I basically found that it was a great treatment center, I left because I couldnt pay
[the fees]. You get thereand you have to pay for stuff it was expensive. When I was
there, it was $350 a month[then] you have the transportation costs, the admission, $40
for them to store your clothes. (Brian, 38)
Other participants appreciated the free addiction services, which suited their needs and
constituted a facilitator to seeking and committing to treatment. In the following quote, France
presents a very positive opinion of the addiction therapy and psychological counselling she has
received at no cost.
Im luckybecause I dont have a great salary and having services like these, for free!
The people here [the health providers] arent paid much for what they do, really. Im
very happy! I can only give good marks to the services Ive received until now in City 1.
(France, 46)
considered that they had not developed close or personal relationships with most health providers
encountered throughout their addiction trajectories. Participants stated that health providers did
not dedicate enough time to them, lacked the knowledge or experience to address their
problems, and did not treat them in a caring manner. Moreover, they reported occasionally
feeling judged by health providers because of their substance use and/or mental health problems,
I felt extremely judged. He [the health provider] asked me to bring a list of the
medication I had in my medicine cabinet []. I wrote three little pages. He got mad and
said, It doesnt make sense! You have to be hospitalized. I said, I dont take them all
at once. He didnt want to hear anythingI felt he was judging and blaming me I had
the impression of almost having a father in front of me []. He suggested that I meet
with a caseworker but Im more defensive now because of that [experience]. (Denise,
31)
In contrast, several participants reported meeting health providers who were emphatic,
respectful and humane. Moreover, many considered that caseworkers who were former
15
substance users had a deeper understanding of their problems and were very supportive, although
a few participants stated that they found these health providers had confrontational attitudes
toward current drug users. A number of participants also established relationships of trust with
health providers, which had positive impacts on understanding their addiction problems as well
For me, caseworkers are people who I can completely trust and who have experience to
intervene with people who have drug problems and are affected psychologically [].
With the caseworker and the psychologist, I looked back on my life []. Everything that
brought me to use for so many yearsand it allowed me to quit [her addiction problem].
And Ive stopped using! (France, 46)
judgmental health providers who could see beyond the latters psychiatric diagnoses and view
Several participants stated that the therapeutic approaches of certain treatment centers and
individual health providers deterred them from seeking help and committing to specific
programs. Most of them strongly criticized confrontational interventions; some did not feel
comfortable in group therapy (disclosing their personal problems or talking publicly), while non-
religious participants disliked the 12-step approach of self-help groups (e.g. AA and NA) and
What I liked the least [of the treatment center]It was too authoritarian for a place like
that. It was [an old approach] from the confrontation time. I didnt like being confronted.
(Donald, 32)
I think there were six or eight [in the therapy group]. I said [to the health practitioner],
Look, my problems, I dont really want to talk about them in front of everybody [] I
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came here looking for help, and you want me to discuss my problems with the group? I
dont want to. This is what I said and then I left. (Anas, 42)
There are several philosophies in rehabilitation center programs that I dont particularly
believe in, like the one Self-help Group A. I dont believe in them because Im an atheist.
So Ill never adhere to their spiritual side. (douard, 21)
therapeutic approaches tailored to their specific needs had positive impacts on treatment
engagement. Along this line, some participants characterized by the multiple disorders
experience reported that addiction treatment programs with mental health and/or psychological
components helped them to fully face their problems and strengthened their commitment to the
recovery process. For example, Berthe appreciated the psychological support she received in
Treatment Center 1 because it helped her discover connections between certain traumatic events
from her past, her psychiatric problems and her substance use:
Several participants considered that they did not receive adequate psychological support to
address what they perceived as the emotional problems at the root of their drug use. They felt
that caseworkers and health practitioners in general lacked mental health training and could not
give them the support they needed. Some participants characterized by the multiple disorders
experience were particularly critical of their psychiatrists, stating that these professionals were
quick to prescribe medication (they called psychiatrists pill givers) without discussing their
psychological problems. Participants considered that psychologists could provide them with
17
behavioral tools to manage their addiction problems. However, there were lengthy waiting lists
to see these professionals (few psychologists are covered by universal health care in Quebec), as
well as costly additional fees, and/or access to these professionals had to be through other
[The psychiatrist], hes been seeing me for a year. But it wasnt psychological help, it
was psychiatry he hasnt given me the tools to quit [her drug use]. I tried to get
psychological help, but I didnt get it! But it was the judge who ordered psychological
help because I asked him. So, Im going to get it [soon]. But, should you have to go to jail
to get a psychologist? Well, it looks like it. (Batrice, 49)
4. Discussion
We have explored barriers and facilitators to addiction treatment-seeking at the personal and
health system levels, as perceived by study participants. This has allowed us to elucidate in part
the high rates and negative consequences of substance misuse among people with co-occurring
MD and SUP. Most barriers identified at both levels are consistent with those in the literature on
help-seeking among this population (Bellack et al., 1999; Mojtabai et al., 2014; Hartwell et al.,
2013; Niedecker et al., 2009; Primm et al., 2000; Slayter, 2010; Treolar & Holt, 2008). However,
our study participants identified certain barriers to addiction treatment such as fear of double
stigmatization (being labelled mentally ill and an addict) and lack of psychological support that
have not been reported in previous research. Hartwell et al. (2013) suggested that the stigma of
dual diagnosis may complicate access of ex-inmates to addiction treatment after release, as it did
in a previous study about mental health services (Hartwell, 2004); however, their results were not
conclusive. In other populations, such as sexual minorities with substance use problems, double
stigmatization has been observed as a barrier to addiction treatments (Flores-Aranda, Bertrand, &
Roy, 2014).
seeking and engagement. To our understanding, ours is one of the few studies (Treolar & Holt,
2008; Hartwell et al. 2013) that has identified aspects contributing to addiction help-seeking and
commitment to treatment from the perspective of people with co-occurring MD and SUP
(influence of relatives and peers in treatment, knowledge on how to navigate addiction services,
fast and free access to available addiction resources, relationships of trust with health providers,
and availability of psychological and/or mental health support). Although further research is still
needed, our findings may shed light on the design of interventions oriented toward strengthening
We have also explored how two different experiences (multiple disorders experience and
anxiety disorder experience) in people with co-occurring MD and SUP have shaped these
individuals ability to seek and pursue addiction treatment. Primm et al. (2000) reported
significant differences in the profiles of patients with concomitant disorders (people with less
severe disorders and no schizophrenia, and those with schizophrenia) getting treatment either in
an addiction or a mental health setting. This study showed that while individuals in the substance
abuse treatment group had been diagnosed with less severe disorders and none with
schizophrenia, most people in the mental health treatment group had schizophrenia. Although we
focused exclusively on addiction services, our results confirm Primm et al.s insights about
heterogeneity within the population of individuals with co-occurring MD and SUP, and how
these differences affect service utilisation. We have identified certain factorssuch as cost,
characterized by the multiple disorders experience were more affected by their fear of being
labelled addicts, influence of social networks, lengthy waiting times and relationships with health
19
deny or minimize their SUP, did not have enough information about addiction services and did
not perceive waiting times as a major obstacle. The trajectory approach has enriched our
understanding of ways in which diverse groups of people with co-occurring problems relate with
services over their life courses, and allowed us to identify similarities and differences in the
Our results on barriers to addiction- treatment seeking could also have implications for
health providers training and education. A number of participants considered that these
professionals lack the psychological knowledge to help them address what they perceived as
emotional problems at the root of their SUP. Participants also felt stigmatized by certain health
providers due to their mental health and addiction issues. This finding is consistent with previous
studies on access barriers to mental health and primary health care services (Ross et al., 2015).
Further research in the field of addiction services is still needed, but it has been suggested that
addressing those gaps in the training of health providers translates into better addiction care for
Our study results also show that participants appreciated and requested addiction
treatment models that include psychological and/or mental health components. This could be
related to participants perceiving their SUP as having psychological roots or, like other authors
have suggested, primarily as mental health problems (Mojtabai, 2005). Participants also stated
that the limited availability of psychological support within the health system could endanger
their commitment to addiction treatment. These findings suggest a need for collaborative
addiction treatment models that integrate both mental health and psychological dimensions;
those models have proven advantages over other treatment approaches (Marel et al., 2016).
20
Moreover, the implementation of a no wrong door approach allows health providers to guide
and actively support users looking for facilities that meet their individual needs (National
Treatment Strategy Working Group, 2008) for psychological support and/or treatment. This
approach can be an important starting point to address the specific demands of this population
Certain limitations of our study should be underlined. Due to its qualitative design, the
sample studied does not intend to be representative of all people with co-occurring MD and SUP.
However, it is composed of individuals with different types of mental health disorders who use a
variety of legal and illegal drugs. In this sense, some results could be applied to similar
populations. We also identified two mental health experiences and compared the ways in which
each of them related to addiction help-seeking barriers and facilitators. Although the distinction
between testimonies of people characterized by each experience is not always clear, we have
tried to emphasize the differences as well as the similarities in their search for addiction
treatment. Moreover, our study is based on semi-structured interviews and social desirability
could have been induced. Nonetheless, the interviewers non-judgmental attitudes helped control
this potential bias. We could have used other qualitative techniques such as participant
observation to enhance our study results. But since the goal was to explore participants
experiences and their interpretations across their addiction trajectories, we considered semi-
5. Conclusion
This study has explored barriers and facilitators that influence addiction treatment seeking at the
personal and health system levels, from the perspective of people living with co-occurring MD
21
and SUP. The interventions to address the barriers and strengthen the facilitators identified by
participants will improve the quality of addiction services and expand their reach, which may
reduce the high rates and negative consequences of SUP among people with MD. In addition, the
mental health experiences we identified suggest that interventions should take into consideration
the characteristics of different groups of people with co-occurring MD and SUP to design
strategies tailored to their diverse needs and expectations. Finally, the study results also suggest
that integrated addiction service models with psychological and mental health components and a
no wrong door approach are required to address the needs of this population.
Acknowledgements
This study was funded by the Social Sciences and Humanities Research Council of Canada
Conflict of interest
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