To the Editor: Research that focuses on the friendships of people with a dual diagnosis of mental illness and mental retardation is not evident in the literature. Virtually all of the friendship literature has focused on people with a single diagnosis of either mental illness or mental retardation. The findings of published studies largely suggest that people with a single diagnosis tend to look to primarily staff members and to other clients with similar diagnoses to be their friends (1). Studies also reveal that people outside the service system are sometimes identified as friends, however challenging these relationships may be (2). Issues related to stigma are among the major obstacles to making friends, according to the reports of people with mental retardation (3).
In an interview study conducted in 2001, a total of 90 people with a dual diagnosis were asked about their friendships. Responses to questions about the person whom they identified as their "best friend" are reported here. Informed consent was obtained from all participants, and the study was approved by the institutional review board of the University of North Carolina at Charlotte. Participants were asked to name the attribute that they like the most about their best friend, what they do together, and what they wish they could do. Responses were compared among four types of friends—other clients, staff members, relatives, and outside friends.
The 90 participants were former class members of a federal lawsuit in North Carolina (4). Although they had formerly lived in institutional settings, almost all lived in the community when the study was conducted. The sample included 51 men (57 percent) and 39 women (43 percent). They ranged in age from 26 to 74 years (mean age, 47±12 years). Forty-five (50 percent) were white, 44 (49 percent) were African American, and one was a Native American. Information on diagnoses was obtained from case records. Seventy-nine (88 percent) had a psychiatric diagnosis, including schizophrenia (32 participants, or 36 percent), affective disorder (32 participants, or 36 percent), and impulse control disorder (15 participants, or 17 percent). All had a diagnosis of mental retardation, either mild or moderate.
Participants most often identified either another client or a staff member as their best friend (55 participants, or 61 percent). Best friends with whom they had the most frequent contact were also clients or staff members. Best friends who were known the longest were more likely to be family members or outside friends. The preferred attributes of a best friend seemed most varied for outside friends. A few best friends were spouses, were members of the same church, or shared an activity like sports. However, more than a fourth of the outside friendships were inactive.
Participants who identified staff members as their best friends (27 participants, or 30 percent) often indicated that the friendship was mutual, but the staff members who were involved usually did not agree. Also, many who identified staff members as friends expressed no desire for help in finding other friendships. This finding suggests that many staff could focus more on teaching friendship skills and facilitating opportunities to develop other friendships. Several projects across the country have extensive experience in helping people with disabilities build and sustain friendships in the community (5). Agencies that serve people with disabilities could also focus staff training on some of the issues that emerge from this study. Follow-up research might consider such questions as what factors best predict the formation and stability of outside friendships, and how the friendships of people with dual diagnoses are similar and different from those of people with a single diagnosis.
This study was supported through a contract with the division of mental health, developmental disabilities, and substance abuse services of the North Carolina Department of Health and Human Services.
Dr. Dudley is affiliated with the department of Social Work in the College of Health and Human Services at the University of North Carolina at Charlotte.