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Madness and Addiction: Treating the Mentally Ill Chemical Abuser
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39 Presentation MADNESS AND ADDICTION: TREATING THE MENTALLY ILL CHEMICAL ABUSER BILLY E. JONES, M.D., M.S.1 NORMAN D. KATZ, Ph.D.2 ON the morning of June 8,1991, Kevin McKiever*, a homeless mentally ill man, killed Alexis Welsh, a young woman who was routinely walking her dog on Manhattan's Upper West Side. McKiever was identified by the victim before she died, and he was observed by witnesses before, during, and after the crime. When apprehended by the police a short time later, however, he could not remember the episode. This terrible and senseless murder quickly came to symbolize the belief that the city had become unlivable. It also became a part of the ongoing debate about the viability of deinstitutionalized care for the mentally ill. Yet, an important fact was overlooked. McKiever was not merely mentally ill. He was also a substance abuser. The real issue in the McKiever case is not the merits of institutional versus community-based care. Rather, it is how to deal with the mentally ill chemical abuser (MIC A). Our seeming inability to meet the needs of the dually diagnosed has called into question the appropriateness of the services we do provide. As Michael Stone noted in New York Magazine: Given the severity of McKiever's illness, it's unlikely that any therapy would have made him whole again. But there is little doubt that McKiever's 14-year career in the streets made his painful symptoms worse and led to drugs—especially crack—in an effort to get 1 Commissioner, Department of Mental Health, Mental Retardation, and Alcoholism Services, 93 Worth Street, New York, NY 10013 2 Director, Office of Prevention, Advocacy, and Public Education, Department of Mental Health, Mental Retardation, and Alcoholism Services, 93 Worth Street, New York, NY 10013 * The names of both the accused and the victim are used because of the broad media coverage of the crime. Journal of Health Care for the Poor and Underserved, Vol. 3, No. 1, Summer 1992 40 Mentally 111 Chemical Abusers rid of them. Even if the system couldn't cure him, it could have stabilized his condition with medication and with housing in a secure, therapeutic setting.1 The problems posed by those with the dual diagnosis of mental illness and substance abuse are enormous. In our urban centers, MICA patients have become the population served by the public sector. New York City's Health and Hospitals Corporation estimates that 45 percent of those admitted to city hospital psychiatric emergency rooms have a dual diagnosis of mental illness and substance abuse (New York City Health and Hospitals Corporation, personal communication). A disproportionate percentage of such patients are poor or minorities. Increasingly, New York City's homeless MICA population is African-American or Hispanic males. Nearly half of all minority patients in city hospital psychiatric emergency rooms also have a substance abuse illness, and one-quarter of minority patients on psychiatric inpatient units have a dual diagnosis (New York City Health and Hospitals Corporation, personal communication ). National statistics also reveal the close relationship between mental illness and substance abuse. Estimates indicate that 50 percent of young chronic mental patients abuse substances.2 In reviewing data from the National Institute of Mental Health Epidemiologic Catchment Area Program, Regier et al. found that for persons with any drug disorder diagnosis other than alcoholism, more than 50 percent have at least one other mental disorder. Of those with alcohol disorders, 37 percent had a second mental disorder and 29 percent of persons with mental disorders have a lifetime diagnosis of a substance disorder .3 The case of Kevin McKiever yields a good deal of information about mentally ill chemical abusers. In many important respects, McKiever typifies the dually diagnosed. He was often uncooperative and manipulative. Having both mental illness and substance abuse illnesses made it difficult for him to obtain mental health treatment. When care was provided, McKiever and his various therapists became frustrated. He was not receptive to traditional therapies.4"6 McKiever appears to be typical in other important respects. He is young, minority, and homeless. Older patients served by the mental hygiene system tend to be either mentally ill...