by John F. Seery, MSCRC, CCDP Diplomat
The purpose of this article is to present information on how the recovery of the co-occurring population is ameliorated by their attendance in 12-step support groups. According to Geppert and Minkoff (2003): “When someone has a substance-related disorder and another psychiatric illness, they are said to have co-occurring disorders, co-morbidity, or dual-diagnosis (referring to two co-occurring disorders.”
The support groups critiqued in this writing are the single-focused 12-step support group (AA) and the dual- diagnosed 12-step support group (DD). The information presented in this narration was obtained, with their permission, from people who have attended both single-focused and dual-diagnosed 12-step support groups. My involvement with the subjects of this commentary began over a dozen years ago with my facilitation of a dual-diagnosed 12-step group. In previous years, I had attended both AA and NA meetings, which gave me more than a rudimentary understanding of the dynamics of the 12-step group experience.
In a previous article published in Counselor (Seery, 2010), I reported how members of our 12-step DD group frequently commented on how their recoveries were helped by their attendance in 12-step single-focused support groups. That narrative also provided an elaboration on how the dual-focused 12-step groups differ from the traditional 12-step groups. The specific aspects of how the DD 12-Step support groups contrast with the traditional single-focused 12-step groups is also a component of this discourse.
The members of our 12-step support group who reported being helped by their attendance in single-focused 12 step support groups substantiate the findings of Kofoed, Kania, Walsh and Atkinson (1986) who reported that a meaningful component of the co-occurring individuals recovery plan is single-focused 12-step attendance.
Many of our 12-step group members, now in their 50s and 60s, first attended AA or NA 12-step meetings as a condition of a treatment program or court mandate. Prior to the decade of the 1980s, there was no Dual-Recovery Anonymous (DRA), as that fellowship began in Kanas City in 1989. Additionally, the Double Trouble in Recovery (DTR) fellowship, a mutual aid program adapted from the 12 steps of AA, was started in New York in 1989.
Throughout the history of AA, experts within the fields of mental health and addiction have acknowledged the benefits of AA attendance as an effective piece of the recovery process. One of the first psychiatrists to describe alcoholism as a disease rather than a moral failing or criminal activity was Harry M. Tiebout, MD, who wholeheartedly endorsed AA as an effective force in the struggle against compulsive drinking.
Moreover, Dr. Tiebout served on the board of trustees for AA from 1957 to 1966. Regarding his AA experiences, Tiebout said:
I developed a conviction that AA had hit upon a method that solved the problem of excessive drinking. In retrospect my first two or three years of contact with AA were the most exciting in my whole professional life. Hopeless drunks were being lifted out of the gutter. Individuals who sought every known means of help without success were responding to this new approach. To be close to any such group, even by proxy, was electrifying. In addition, professionally, a whole new avenue of problems of alcohol had opened up; somewhere in the AA experience was the key to sobriety (1999, p. 104).
In a similar manner contemporary addiction experts readily refer to AA as a valuable piece of the recovery process. For example, Gorski and Miller (1986) proclaim, “Alcoholics Anonymous is the single most effective treatment for alcoholism. More people have recovered from alcoholism using the program of AA than any other form of treatment. It is for this reason that AA needs to be a vital part of any recovering alcoholics sobriety plan” (p. 52).
A DD group attendee discussed how she sustained sobriety for more than one year with consistent 12-step AA attendance. She prefaced her chronicle by stating that prior to that she was unable to sustain abstinence for more than a few weeks. Our member further elaborated on how during that period of her AA attendance and abstinence from alcohol use, the psychotropic medications prescribed for her bipolar symptoms were working. In fact, they so effectively held her symptoms under control that she came to mistakenly believe that her illness was cured. Based on that faulty conviction, she discontinued her medication regimen. It seems she fell victim to what Dr. Bernard Salzman (1991) cautioned against in his reporting on the importance of maintaining a psychiatric medication when it’s working effectively. As he states:
Once these long-term maintenance programs have eliminated symptoms for a few months some people are apt to stop their medications without notifying their doctor. Essentially they believe that since the medication is no longer needed—they have no symptoms—they have been cured of the underlying problem—their illness. Unfortunately this is not only unwise but unsafe. Only their doctor is trained to determine whether the treatment should be changed or halted. The very lack of symptoms could be the primary reason for continuing the drug regimen rather than discontinuing it (p. 6).
As the DD member continued her story, she explained how soon after her self-imposed medication regimen cessation, the symptoms of her bipolar disorder returned. We have known for decades that emotional instability increases the likelihood of relapse (Marlot & Gordon, 1980).
Bipolar illness is a cyclical mood disorder with alternating episodes of depression and mania. To capture a sense of the magnitude and breadth of bipolar symptoms it is helpful to refer to Geppert and Minkoff (2003) and what they have to say about how bipolar symptoms differ from normal feelings:
Like the distinction between major depression and normal sadness, mania/hypomania, and normal experiences of happiness or increased energy differ in that, with bipolar disorder, the euphoric and irritable moods last longer; usually are not a reaction to a positive outside event; are usually more severe and persistent, often involving dangerous or risky activities that cause trouble at home and work. People who are manic may enjoy the experience, but they frequently feel out of control; they cannot slow down when they want to, are much more irritable with people they love. Studies show 50 to 80 percent of persons with a bipolar disorder abuse substances; 15 percent of people with bipolar disorder commit suicide (p. 20).
Our group member closes her commentary by describing how shortly after the return of her bipolar hypomania symptoms and depression she was using alcohol daily. Her family, concerned by her out of control behaviors, committed her to a local hospital. There she went through detoxification treatment and afterward her mental health symptoms stabilized.
A fellow 12-step DD group member asked the woman if she thought the relapse would have occurred had she been attending regular meetings. The woman responded,“I cannot say for certain, but at almost every meeting of ours, medications are discussed at length, and frequently group members reveal failed attempts of living their life without their medications. All of those who have shared such stories soon relapsed into a life of chaos and mood-altering substance use.”
I recalled an AA group member once telling me, “It seems with the passing of time some people begin to entertain ideas of drinking once again. At AA 12-step meetings, experiencing a newcomer tell their tale of insanity acts as a crucial reminder of the pernicious thing that navigated our lives prior to our recovery.” With such experiences in mind, I believe 12-step attendance is an effective tool to help prevent relapse for individuals who have dual diagnoses with addictions or alcoholism.
With respect to the overall recovery of the co-occurring population, in my estimation, it is the goal of psychopharmacology to reduce one set of symptoms without making another set of symptoms worse. When this is the treatment mind-set, the challenge for the clinician is to reduce psychiatric and drug and alcohol symptoms in terms of their intensity, frequency and duration with minimal side effects. When this objective is established, then it becomes the dual-diagnosed individual’s responsibility to report any changes in their symptoms or medication side effects to their physician to maintain their mental health stability and prevent a relapse.
My years of working with the dual-diagnosed population has forged my conviction that maintaining one’s medication regimen is a vital tenet of any co-occurring individual’s recovery plan. Furthermore, the frequent discussion of the prominent role of medication represents an ongoing reminder of medication as an indispensable component of the dual-diagnosed life.
Geppert, C. M. A., & Minkoff, K. (2003): Psychiatric disorders and medications: A reference guide for professionals and their substance-dependent clients. Center City, MN: Hazelden Publishing.
Gorski, T. T., & Miller, M.. (1986). Staying sober: A guide for relapse prevention. Independence, MO: Herald House.
Kofoed, L., Kania, J. Walsh, T., & Atkinson, R. (1986). Outpatient treatment of patients with substance abuse and coexisting psychiatric disorders. American Journal of Psychiatry, 143, 867-872.
Marlatt ,G. A., & Gordon, J. R. (1980). Determinants of relapse. In P. O. Davison and S. M. Davidson (Eds.), Behavior medicine: changing health lifestyles, 410-452. New York: Guilford Press.
Salzman , B. (1991). When you need to take psychiatric medications. Center City, MO: Hazelden Publishing.
Tiebout, H. (1999). Harry Tiebout: The collected writings. Center City, MO: Hazelden Publishing.