1

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

outcomesincreased symptom severity, higher probability of relapse and rehospitalisation,

medication noncompliance, infectious disease and compromised physical healththat translate

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

qualitative perspective (Treolar & Holt, 2008).

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.

2. Approach and Methods

We conducted a qualitative study grounded in the interpretative tradition (Giordano,

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

Mauricie-Centre-du-Qubec, a rural and semi-rural area. Participants were recruited by service

providers, following detection of a SUP. Forty-three individuals with concomitant MD were

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

prescribed by a doctor, according to the service use questionnaire (Table II).

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

CAN$20,000 or less (Table III), quite low by Canadian standards of living.

2.2 Interviews and Questionnaires

Semi-structured interviews lasting an average of 90 minutes were conducted. Using a

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

detection/referral to substance abuse services; participants experiences of first service request

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).

2.3. Data analysis

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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

phenomenological perspective, participants experiences, interpretations of their substance and

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 defined themes with the help of NVivo 9 software.

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

identify points of convergence and divergence in thematic categories of participants accounts.

This study was approved by the ethics committee of the Centre hospitalier de lUniversit

de Sherbrooke (CHUS 2010-208-09-188) and by the Comit dthique de la recherch en

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

differences in participants treatment-seeking behaviors, which will be identified below.

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.

3.1. Individual Level

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;

3) influence of social networks; and 4) knowledge of addiction services.

3.1.1. Denial or Minimization of Substance Use Problems

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.

They perceived psychotropic substances as sources of pleasure or relaxation, and substance

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)

Participants characterized by the anxiety disorder experience found it particularly

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

major health consequences, and could lead normal lives.

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)

3.1.2. Fear of Being Labelled an Addict

Participants characterized by the multiple disorders experience and diagnosed with

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).

Some participants delayed their addiction help-seeking and/or struggled to pursue

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)

3.1.3. Influence of Social Networks

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

peers at key moments of their addiction trajectories, such as at initiation:

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

is central to her couples dynamic.

The biggest obstacle to abstinence is my boyfriend [laughs]Were two and theres a

whole dynamic associated with the couple thatis [difficult] to break. Thats my biggest
challengeI ended using because of the temptation that he puts in my nose face you
smell it and you want to take a puff. (Debbie, 28).

In contrast, some participants characterized by the multiple disorders experience stated

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)

3.1.4. Knowledge of Addiction Services

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

have on their lives:

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

addiction center, and gone to two addiction self-help groups.

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)

3.2. Health System Level

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,

3) relationships with health providers, 4) therapeutic approaches, and 5) availability of

psychological support.

3.2.1. Waiting Time

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

was the case for Crystal:

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)

3.2.3. Health Providers

Some participants, especially those characterized by the multiple disorders experience,

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,

which had negative impacts on addiction help-seeking.

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
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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

as on their addiction help-seeking, treatment engagement and recovery process.

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)

Participants characterized by the multiple disorders experience especially appreciated non-

judgmental health providers who could see beyond the latters psychiatric diagnoses and view

them as whole individuals.

3.2.4. Therapeutic Approaches

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

some residential programs.

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)

Conversely, participants considered that individual therapy and/or personalized

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:

We talked a lot about my anxiety, my pastwhen I was sexually abused by my father, we

talked a lot about the impact that it hadnow I have an eating disorder, anorexiawe
made the links between what I experienced and what Im experiencing now []. It made
me understand myself understand my reactions and then understand that I use to calm
my reactions. This helped me a lot. (Berthe, 22)

3.2.5. Availability of Psychological Support

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
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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

instances such as the criminal court.

[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).

Results of this study also contribute to research on facilitators to addiction treatment

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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

facilitators already in place and replicating them to boost their effects.

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,

therapeutic approach and availability of psychological supportthat influence help-seeking

experiences of many participants. However, the help-seeking behaviors of participants

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

providers. In contrast, participants characterized by the anxiety disorder experience tended to

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

barriers and facilitators encountered by each group.

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

people with co-occurring MD and SUP (Marel et al., 2016).

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

and make their recovery possible.

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-

structured interviews to be the most appropriate methodological choice.

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

(SSHRC) through the Community-University Research Alliance Program (CURA).

Conflict of interest

The authors report no conflicts of interest associated with this publication.

 22

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