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Substance use and mental disorders

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As highlighted in the previous article, in Part Two we will discuss the unhealthy or rather complicated relationship between substance use and mental illness. Remember how I stated that we have to be mindful of differences in culture when talking of substance abuse; that remains the case. However, we need to have an idea of a standardised approach that endorses substance abuse. For this one, I will borrow a page from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR) and a few screening tools that we use to assess for substance abuse.

For this one, let us go ahead and adopt a more diagnostic approach. This is likely to benefit colleagues with a special interest in addictions counselling or therapy seekers with limited information to understand what they are struggling with. So, from a diagnostic perspective there are three things to pay attention to, type or class of drug (10 classes highlighted in the DSM-5-TR), diagnostic criteria and culture related to diagnostic issues. The DSM-5-TR warns us that all drugs that are taken in excess have in common the ability to directly activate the brain reward systems, which are involved in the reinforcement of behaviours and establishment of memories. This poses the concern of quantity used, which we will discuss shortly.

The DSM-5-TR provides us with Substance-Related and Addictive Disorders, under which there are 10 separate classes of drugs namely alcohol; caffeine; cannabis; hallucinogens (with separate categories for phencyclidine [or similarly acting arylcyclohexylamines] and other hallucinogens); inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants (amphetamine-type substances, cocaine, and other stimulants); tobacco; and other (or unknown) substances. I absolutely like that the manual indicates these 10 classes are not fully distinct. This is important to know when making a diagnosis because there might be overlapping symptoms depending on the drug of choice.

After this, we inquire about symptoms to determine if the client meets diagnostic criteria. It might be helpful to think of it this way, someone can experience a traumatic event but not meet criteria for post-traumatic stress disorder (PTSD). Similarly, an individual can be using cannabis but not to a point where they have an addiction.

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There are 11 criteria to take into consideration. I will not go into this as it is a lengthy discussion point. What is important to establish is whether the client’s symptoms fit criteria for substance-related use and then determine severity and specifiers. This means mild, moderate, or severe symptoms which can be gathered from client reports or family members. As you can imagine, these steps are crucial in making clinical decisions or treatment suggestions for the client in question.

Even though there is mention of alcohol in the 10 classes of drugs, there is a section allocated to alcohol-related disorders. This is divided into Alcohol Intoxication, Alcohol Withdrawal, Alcohol-Induced Mental Disorders, and Unspecified Alcohol-Related Disorder. They also have their diagnostic criteria and specifiers. For example, someone that has alcohol intoxication is likely to also be faced with alcohol withdrawal later on, but it differs with clients.

Now, the part I personally find interesting is that there are diagnoses associated with substance classes. It is near impossible to explain this one without the table. But simply put, some mental disorders are closely linked to the use of certain drugs or vice versa. These include psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive compulsive disorders, etc. Think of it this way, psychotic disorder is a stand-alone disorder, but try and realise how someone who consumes excess alcohol can develop psychotic disorder.

For bipolar and related disorders, we want to exercise the same caution in that with Bipolar I, diagnostic criteria includes inflated self-esteem or grandiosity, more talkative than usual or pressure to keep talking. As you may very well see, someone with a substance-related disorder is likely to display behaviours that are referred to as “high.” See how displaying behaviours that qualify as being “high” with grandiosity which presents itself as an expansive or euphoric mood? Basically, what this means is that we have to be mindful in making a mental disorder diagnosis if there is reported excessive substances or alcohol use.

Think of someone whose mood wanes, and they experience depressive highs and lows. They might choose to overuse alcohol or drugs to get a “high” brought about by chemical substances. When the counsellor consults with this client, do they diagnose them with substance related disorder, alcohol use disorder, or a depressive disorder? This makes you think because no one client can be diagnosed with everything all at once. Providers also need to be mindful of the severity of the addiction as this informs whether treatment can be offered in outpatient services, or it needs in-patient treatment options. Sometimes, it becomes an issue of, if the client is impaired from overuse of chemical substances, can you even be successful at offering individual therapy in the traditional sense?

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After the DSM-5-TR mouthful, someone might still be unclear on what co-occurring disorders are, seeing how complex it can be to make such diagnoses. Substance Abuse and Mental Health Services Administration (SAMHSA) defines co-occurring disorders as the coexistence of both a mental illness and a substance use disorder. In his book, Charles Atkins, MD said, “I sometimes use the metaphor that treating co-occurring disorders is like assembling a Thanksgiving meal, where you’re firing – literally – on all burners. Some things must be carefully watched lest they get ruined, while other dishes can simmer on the back of the stove. The front burner items must be immediately tended to.”

What does this mean in the context of Lesotho? It means multiple things that solicit different responses depending on the who and what. Personally, I think it requires that we invest in teaching providers the intricacies of mental disorders diagnosis, teaching counsellors treatment planning for people living with co-occurring disorders, for the government to invest in a good addictions recovery centre for in-patient treatment care. We continue to make the mistake of thinking that Mohlomi psychiatric hospital is the final destination for all mental disorders. We can benefit from an independent addictions and rehabilitation referral centre, with adequately trained stuff.

In part 3, the last article in the co-occurring disorders series, I will highlight measurements commonly used to assess substance-related and addictive disorders, alcohol related disorders, and treatment options including the 12-step AA programme. I will provide local services and resources available in Lesotho.
Until Next Time!

The author works as a Psychotherapist. She holds a Master’s in Counseling Psychology. She has certifications in Global Health Delivery, Policy Development & Advocacy in Global Health, Leadership & Management in Health, as well as Fundamentals in Implementation Science. Her views are independent and not representative of her professional roles. She is ambitious about equitable health delivery, health policy and decolonized mental health approaches.

’Makamohelo Malimabe

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Insight

Down in the Dump: Conclusion

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I closed last week by recording the dreadful news that trashy Trump had been elected called to mind WB Yeats’s poem “The Second Coming.” This is the poem whose opening lines gave Chinua Achebe the phrase “things fall apart.”

Yeats observes “Things fall apart, the centre cannot hold / Mere anarchy is loosed upon the world.”

It was written in 1919 and controversially uses Christian imagery relating to the Apocalypse and the Second Coming to reflect on the atmosphere in Europe following the slaughter of the First World War and the devastating flu epidemic that followed this.

It also reflects on the Irish War of Independence against British rule.

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In lines that I can now read as if applying to the recent American election, Yeats mourns: “The best lack all conviction, while the worst / Are full of passionate intensity.”

And then I can visualise Trump in the poem’s closing lines: “What rough beast is this, its hour come round at last, / Slouching towards Bethlehem to be born?”

Trump is certainly a rough beast and isn’t the choice of verb, slouching, just perfect? For a non-allegorical account of the threat posed by the Dump, I can’t do better than to quote (as I often do) that fine South African political journalist, Will Shoki. In his words: “Trump’s administration simply won’t care about Palestinians, about the DRC, about the Sudanese.

It will be indifferent to the plight of the downtrodden and the oppressed, who will be portrayed as weak and pathetic. And it will give carte blanche [that is, free rein] to despotism and tyranny everywhere.

Not even social media, that once revered third-space we associated with subversion and revolution in the first quarter of the 21st century can save us because Silicon Valley is in Trump’s back pocket.”

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So what follows the triumph of the Dump? We can’t just sit down and moan and bemoan. In a more recent piece of hers than the one I quoted last week, Rebecca Solnit has observed: “Authoritarians like Trump love fear, defeatism, surrender. Do not give them what they want . . . We must lay up supplies of love, care, trust, community and resolve — so we may resist the storm.”

Katt Lissard tells me that on November 7th following the confirmation of the election result, in the daytime and well into the evening in Manhattan, New York, there was a large demonstration in support of the immigrants Trump despises.

And a recent piece by Natasha Lennard gives us courage in its title “The Answer to Trump’s Victory is Radical Action.”

So, my Basotho readers, how about the peaceful bearing of some placards in front of the US Embassy in Maseru? Because the Dump doesn’t like you guys and gals one little bit.

One last morsel. I had intended to end this piece with the above call to action, but can’t resist quoting the following comment from the New York Times of November 13th on Trump’s plans to appoint his ministers.

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I’m not sure a satirical gibe was intended (the clue is in the repeated use of the word “defence”), but it made me guffaw nonetheless. “Trump will nominate Pete Hegseth, a Fox News host with no government experience, as his defence secretary. Hegseth has often defended Trump on TV.” You see, it’s all about the Dump.

  • Chris Dunton is a former Professor of English and Dean of Humanities at the National University of Lesotho.

 

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A question of personal gain

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Recently, an audio recording featuring the distressed MP for Thaba-Bosiu Constituency, Joseph Malebaleba, circulated on social media. The MP appears to have spent a sleepless night, struggling with the situation in which he and his associates from the Revolution for Prosperity (RFP) party were denied a school feeding tender valued at M250 million per annum.

In 2022, Lesotho’s political landscape underwent a significant shift with the emergence of the RFP led by some of the country’s wealthiest individuals. Among them was Samuel Ntsokoane Matekane, arguably one of the richest people in Lesotho, who took the helm as the party’s leader and ultimately, the Prime Minister of Lesotho.

The RFP’s victory in the general election raised eyebrows, and their subsequent actions have sparked concerns about the motivations behind their involvement in politics.

In an interview with an American broadcasting network just after he won the elections, Matekane made a striking statement, proclaiming that he would run Lesotho exactly as he runs his business.

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At first glance, many thought he was joking, but as time has shown, his words were far from an idle threat. In the business world, the primary goal is to maximize profits, and it appears that the RFP is adopting a similar approach to governance.

Behind the scenes, alarming developments have been unfolding. A communication from an RFP WhatsApp group revealed a disturbing request from the Minister of Communications, Nthati Moorosi, who asked if anyone in the group had a construction business and could inbox her.

This raises questions about the RFP’s focus on using government resources to benefit their own business interests.

The government has been embroiled in a series of scandals that have raised serious concerns about the ethical conduct of its officials. Recent reports have revealed shocking incidents of misuse of public funds and conflicts of interest among key government figures.

Over the past two years, the RFP has been accused of awarding government contracts to companies affiliated with their members, further solidifying concerns about their self-serving agenda. For instance, vehicles purchased for the police were allegedly sourced from suppliers connected to a Minister’s son and MP.

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The MP for Peka, Mohopoli Monokoane, was found to have hijacked fertiliser intended to support impoverished farmers, diverting crucial resources away from those in need for personal gain.

Such actions not only betray the trust of the public but also have a direct impact on the livelihoods of vulnerable communities. Monokoane appeared before the courts of law this week.

While farmers voice their concerns regarding fertiliser shortages, it seems that Bishop Teboho Ramela of St. Paul African Apostolic Church, who is also a businessman, is allegedly involved in a corrupt deal concerning a M10 million fertilizer allocation, benefiting from connections with wealthy individuals in government.

The procurement of fertiliser appears to be mired in controversy; recall that the Minister of Agriculture, Food Security and Nutrition, Thabo Mofosi, was also implicated in the M43 million tender.

The renovation of government buildings with elaborate lighting systems was contracted to a company owned by the son of an MP. The RFP’s enthusiasm for infrastructure development, specifically road construction and maintenance, is also tainted by self-interest, as they have companies capable of performing these tasks and supplying the necessary materials, such as asphalt.

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Minister Moteane finds himself in a compromising situation regarding a lucrative M100 million airport tender that was awarded to his former company. Ministers have even gone so far as to award themselves ownership of diamond mines.

Meanwhile, the nation struggles with national identification and passport shortages, which according to my analysis the RFP seems hesitant to address until they can find a way to partner with an international company that will benefit their own interests.

The people of Lesotho are left wondering if their leaders are truly committed to serving the nation or simply lining their own pockets. As the RFP’s grip on power tightens, the consequences for Lesotho’s democracy and economy hang precariously in the balance.

It is imperative that citizens remain vigilant and demand transparency and accountability from their leaders, lest the nation slide further into an era of self-serving governance.

In conclusion, the RFP’s dominance has raised serious concerns about the motives behind their involvement in politics. The apparent prioritisation of personal profit over public welfare has sparked widespread disillusionment and mistrust among the population.

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As Lesotho navigates this critical juncture, it is essential that its leaders are held accountable for their actions and that the nation’s best interests are placed above those of individuals.

Only through collective effort and a strong commitment to transparency and accountability can Lesotho ensure a brighter future for all its citizens.

Ramahooana Matlosa

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Insight

Down in the Dump: Part One

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Attentive readers will recall that some weeks ago, I scribbled a series of pieces on elections due to be held in the UK, France, South Africa, and the USA. These elections were unusually critical for the well-being of their countries and even that of the world.

The results of the last of these elections are now with us and we are faced with the devastating news that Donald Trump is heading back to the White House.

I can hardly think of worse news to swallow or to equip the world to survive the years ahead.

The Dump, as I call him, is one of the most odious, dangerous, untrustworthy individuals currently inhabiting planet Earth. To cite a few of his demerits: he is a convicted felon; he believes climate change is a hoax; he is a sexist and a racist (one of his former military advisers has gone so far as to describe him as a fascist).

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He is a snuggle buddy of the Russian dictator Vladimir Putin and will probably discontinue aid to Ukraine as it resists invasion by Russia. Western European allies such as France, Germany and the UK are dismayed at his victory, as he holds the principles of democracy and constitutionalism in contempt.

As for Africa, well, he once described it as a “shit country,” so don’t look forward to much support from him.

Readers who spent time at the NUL will remember my dear colleague Katt Lissard who is now back home in New York. She spent some years with us as a Professor specialising in Theatre studies and was the Artistic Director of our international Winter / Summer Institute for Theatre for Development.

Many activists in the USA like Katt, who don’t see themselves as part of the political mainstream, chose to campaign for the Democrats and Kamala Harris in the hope of keeping Trump and the far right out of power. Confronted with the news of Trump’s victory, she sent an email to friends noting this was “just a brief check-in from the incomprehensible USA.”

She then explained: “We’re in shock and the early days of processing, but white supremacy, misogyny and anti-immigrant bias are alive and well and driving the boat here.” So, how do Katt and millions of decent, like-minded Americans plan to weather the storm?

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Katt explained: “We were deeply depressed and deeply furious as it became clear that one of the worst human beings on the planet was going back to the White House, but we are still breathing and know that we will in the days ahead begin to formulate plans and strategies—and not just for heading north across the Canadian border.”

Picking up on that last point, it may well be that many decent Americans might just up and off across the border; Canada had better prepare for an avalanche of applications for residence permits.

And not just from Americans; in, for example, the American university system alone there are many many Africans employed in high positions (Professors and such-like), who must now face the fact they are living in a country whose leader despises them and who may opt to get out.

In her email written to her friends, once the news from hell had been confirmed, Katt quoted a piece by Rebecca Solnit, one of the most exciting writers at work in the USA today (readers may remember that I have previously reviewed two of her books for this newspaper, Whose Story is This? and Recollections of My Non-Existence).

Now Solnit is a feminist and at the heart of her work is a dissection of the way women have been marginalised in the USA (let’s remember that Kamala Harris, the Presidential candidate who lost to Trump, did so partly because so many American males could not bring themselves to vote for a woman.

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I am thinking of the kind of male who invaded the White House when it was announced Trump had lost the 2020 election, bare-chested and wearing cow-horn helmets on their numbskull heads).

Solnit has this to say on our response to the Trump victory: “They want you to feel powerless and to surrender and to let them trample everything and you are not going to let them.

You are not giving up and neither am I. The fact that we cannot save everything does not mean we cannot save anything and everything we can save is worth saving.

You may need to grieve or scream or take time off, but you have a role no matter what, and right now good friends and good principles are worth gathering in.

Remember what you love. Remember what loves you. Remember in this tide of hate what love is.” And then: “A lot of us are going to resist by building solidarity and sanctuary.”

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What is so morale-boosting about Solnit’s piece is not just her vision but also her command of language.
Her writing is so crisp and elegant. Language comes at us at its best, of course, in literature, and when I heard that the Dump was on the move back to the White House, I immediately recalled one of the most startling poems in the English language, “The Second Coming” by the Irish poet WB Yeats.

I’ll kick off with that next week.

To be concluded

Chris Dunton

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