The Emergence of Dual Recovery Treatment
The setting was a psychiatric hospital during a group therapy session. Suddenly, Karen* stood up, opened the Alcoholics Anonymous Big Book to page 58, and read, “Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates.”
“That’s me,” she said. ‘I’ll never recover. I’m doomed.” And she meant it. She, like others, had tried many treatment programs with little success. Over and over, she’d relapse. She just couldn’t quit drinking. Karen also struggled with debilitating depression a result of her uncle sexually abusing her for three years when she was a child. Her repeated suicide attempts had led to several psychiatric hospitalizations. Despair she knew well and voiced it angrily in group.
People who have concurrent mental health’ and substance abuse disorders often called “dual disorders” or “dual diagnosis” face a difficult path. There are many reasons for the challenges they confront.
One of these is that treatment programs historically have not addressed both disorders at the same time. When Karen received inpatient psychiatric treatment, many times her treatment team didn’t even address her alcohol problem as part of the treatment plan. However, it was a treatment issue. By ignoring it, the team made it worse. They actually enabled her drinking by not dealing with it.
Conversely, when Karen was in substance abuse treatment, her treaters ignored her severe depression. They told her she wasn’t successful because she didn’t “work the program” hard enough. In other words, if she were truly following the 12-step program, she’d be able to stop drinking. The treaters blamed Karen’s inability to work the program for her chronic relapses, rather than addressing her depression with treatment that included medications and psychotherapy.
Part of the reason mental health and substance abuse disorder treatments have been separate is that treatment for each is different.
Psychiatric treatment’s goal is symptom relief or resolution of the disorder. Symptom relief would mean a person with bipolar disorder no longer experiences wide mood swings, and resolution would mean a person with a panic disorders would no longer have panic attacks/ People with mental disorders receive treatment in supportive environments that build patients up so they can effectively deal with their problem. Medication is often essential, and the doctor/psychiatrist controls treatment in the medical model.
In contrast, substance abuse treatment’s goal is sobriety or recovery. This means the person would not only be abstinent from the substance, but would be developing positive, non-addictive coping skills, growing interpersonally, and rebuilding a sobriety-centered value system. Treatment can be confrontational to break down people’s denial system so they admit they have a problem, accept their powerlessness over their substance, and learn to work the 12 steps developed by Alcoholics Anonymous. A team of substance abuse counselors, many of whom are successful at recovery themselves, make treatment decisions.
These contrasts long led to separation. People with a dual diagnosis typically bounced back and forth between treatments, never addressing both problems at once. It could become the typical “vicious cycle.”
Fortunately, in the last two decades, there has been a movement to integrate psychiatric and substance abuse treatment. This has been challenging, but fruitful. Programs in mental health and substance abuse are tackling both problems from a dual perspective. Some of the key issues that integrated programs address include the use of medication, spirituality, powerlessness versus empowerment, and confrontation versus supportive styles. It’s not surprising that research shows the programs that treat both disorders are more effective than separate programs.
Yet, there are few dual programs. Why? The reasons are many: separate funding streams, lack of cross-trained professionals, continued differing treatment philosophies, and lack of political will to make changes in the structure and financing of treatment systems. For example, until recently in Michigan, mental health treatment fell under the auspices of the Department of Mental Health while substance abuse treatment fell under the Department of Public Health. Now they are both under the Department of Community Health, which hopefully will help dual people. Despite these hurdles, some facilities are developing integrated approaches. Even within the self-help movement, there is now Dual Recovery Anonymous for people with dual disorders.
Ironically, given the historical differences in treatment, the disorders themselves have many similarities that lend themselves to integrated treatment. Successful dual programs emphasize the parallels between mental health and substance abuse disorders, rather than the differences.
A major similarity is there is no one cause for either of these disorders. Heredity and life circumstances (such as stress) often play a role in producing either a substance abuse problem or a mental health problem.
disruption & isolation from supporters
disruption & isolation from supporters
|Spiritually||centered on self and substance; no room for God||despair creates feeling of separation from or abandonment by God|
|Emotionally||needs met falsely by substance||needs not met; loss of emotional control|
|Mentally||life centered around substance||life centered around difficulty in thinking and functioning|
|Biologically||alters brain chemistry physical damage liver||alters brain chemistry|
The disorders can affect every aspect of a person’s life.
Both disorders can be progressive. Examples are people who start out as social drinkers and whose addiction grad-ually develops and people who may have periodic “blue” or down periods that get worse each time until they are in a clinical depression. For both, the progress of the disorder can be slow or fast. Without help, the disorders tend to progress and create crises, loss of relationships and jobs, and financial and/or legal problems.
At this time, there is no cure for either a mental health or substance abuse disorder. Even if symptoms are gone for a long time, the potential for relapse is generally always there. People with addictions can never use their substance of abuse again even in small quantities. People with mental health disorders may-have to stay on medication, continue psychotherapy, or make permanent lifestyle changes to avoid the stress that could trigger a relapse. People with dual diagnosis have difficulty with those words “no cure.” Someday, we may conquer these disorders. Bill W., a founder of AA, recognized that if alcoholism was ever cured, it would be through the medical community. There is always hope.
Denial is strongly characteristic to both disorders. Clinicians cite denial of alcohol abuse/dependency as the most difficult problem. Why? It means facing the loss of the substance, coping with feelings of guilt and failure, dealing with the stigma of having an “addiction” or “mental illness,” and perhaps facing underlying wounds from childhood.
The primary aspect of both disorders is loss of control. In chemical depen-dency, it’s the loss of control over one or more substances. It means either people cannot control their use once they start or have no ability to abstain. In mental health disorders, the loss of control is more varied. In depression, it could be when people lose so much energy, they can’t take care of themselves. Or they’re in such despondency and despair, they become suicidal, losing the ability to see any other options. With anxiety, the loss of control can take the form of the person experiencing extreme moments of panic for no obvious reasons. With a bipolar disorder, some people lose control of their moods, experiencing severe mood swings. And with psychotic disorders, people may lose a sense of reality by experiencing hallucinations, delusions, or confusion.
The impact on the whole family is significant for both disorders. Families experience disruption because other members don’t understand the disorders and the effects the disorders can have on them. Enabling, blaming, and conflicts are common. Education and family treatment are important components of the family’s recovery. Many families receive support from self-help groups like Alanon, which is for friends and family members of a loved one with alcoholism.
With all these factors, people with dual disorders can be easily overwhelmed and tend to experience significant powerlessness. They need powder to manage their symptoms, to treat these disorders, and to prevent the harmful consequences their disorders cause their families, friends, and themselves. When they can’t control the disorders by themselves, they can equate powerlessness with hopelessness. That’s what Karen was feeling.
The paradox facing people in dual recovery is they must accept the powerlessness over both disorders as they empower themselves with help from others to manage the disorders and live stable, sober, fulfilling, healthy lifestyles. This is exactly where the 12 steps start, with the First Step, the explicit concept of powerlessness and the implicit need to humbly reach out by asking for help from fellows and our higher power.
This can be difficult for people just starting in recovery. One key is to embrace the powerful slogan: KEEP IT SIMPLE. There are so many issues in early recovery, so many losses, so many big lifestyle changes, it can be overwhelming. People have to make sure they don’t take on too much. The other disordered aspects of their lives will gradually fall into place, but they can’t expect to fix everything at once. They need to focus on just staying stable and abstinent.
When Karen shared her despair, she received some honest feedback from another group member, Juanita. First. Juanita told Karen that Karen had taken the quote out of context. The Big Book goes on to say, “There are those, too, who suffer from grave emotional and mental disorders, but many of them do recover if they have the capacity to be honest.”
Juanita said, “What works for me is M&Ms. No, not candy. My 12-step meetings and my medications.” Juanita kept it simple. And she was right. Karen, however, had never consistently followed a 12-step program, stayed abstinent, and followed through with mental health treatment for any period of time. Listening to Juanita’s success gave Karen what she needed hope.
Dual recovery for people with dual disorders is possible. Powerlessness does not mean hopelessness and despair. Powerlessness can, instead, mean the first step to a new, empowering life. But like anything worthwhile, it’s doesn’t come easily. It’s a lot of hard work for the people and their families. Slogans like “Keep it simple” and “Remember your M&Ms” give focus to day-to-day living and goal-setting.
Joseph Koblev, M.S.W., Coordinator of Dual Diagnosis Semices, has worked at Pine Rest since 1995. He provides psychotherapy with patients, develops programming, trains and consults with staff, and sewes as liaison with community substance abuse programs. He earned his B.A. at Aquinas College, attended Catholic seminar]’, and graduated from Grand Valley State University with his masters degree is social work.
Names find circumstances of people have been changed to protect confidentialitv.