Dual Diagnosis and AA
Dual diagnosis, also called co-occurring disorders or co-morbidity, is one of the most complicated conditions that affect people with mental illness. The heart of dual diagnosis is that the person has both a brain illness and a substance use disorder (SUD). Estimates differ wildly as to how common dual diagnoses are, depending on differing definitions of dual diagnosis, for example. According to SAMHSA, 21.5 million Americans experience both SMI and SUD.
Alcoholics Anonymous, of course, is the best-known support group for alcohol abuse disorders. Narcotics Anonymous focuses on illegal drugs rather than alcohol. But there are fewer opportunities for people with dual diagnoses to find similar kinds of support. There is a group called Dual Diagnosis Anonymous (DDA), but it doesn’t have nearly the reach of the older, more familiar organizations.
So, how do dual diagnoses and substance use disorders share the support group space? Is the standard AA model open to or beneficial for people with dual diagnoses?
I recently spoke with Tony, a friend who has bipolar disorder and alcohol addiction. He’s currently in recovery in a treatment program that addresses both problems. Tony, who has been in the program for around six weeks, has started out in a sober house and with AA meetings. While he discusses his SMI, for now the primary focus of his treatment is substance abuse.
According to Tony, the relationship between AA and SMI support is sometimes fraught with contention. The history of AA doesn’t prohibit people with co-occurring disorders, but in practice, the situation can be different. Tony, in his early years of association with the organization, was dropped by his sponsor when he revealed his dual diagnosis.
Part of the problem Tony has found is that many people involved in AA are biased against the use of psychotropic drugs, even those properly prescribed by a psychiatrist and taken as prescribed. To them, drugs are drugs, and they are universally thought to be addictive. This is, according to Tony, an old-school and literalist interpretation of AA’s principles.
But if a person with a dual diagnosis goes off their psych meds, their condition can deteriorate. And untreated SMI can cause a person to self-medicate with alcohol, creating a vicious cycle. AA literature says that group members should not stop taking doctor-prescribed meds, but the problem persists. People with dual diagnosis may therefore avoid AA.
Of course, people can be addicted to prescription medications (whether they get them from their doctors or not). AA and NA can be extremely beneficial for them. Still, according to DDA, people with dual diagnoses can experience “a sense of ‘symptomatic difference’ between addicts and alcoholics and dually diagnosed persons. Some symptoms may result in disruptive behaviors during meetings, further alienating the dually diagnosed. Many dually diagnosed people experience increased levels of fear, anxiety and/or paranoia in group settings. Additionally, there is a common perception among some more traditional 12 Step members that medical management represents the ‘easy way,’ and do not consider those individuals who take prescribed medications to be ‘clean and sober.’ For these reasons, the feeling of ‘not fitting in’ at traditional 12 Step meetings is common for many individuals with dual diagnosis.”
A report published by the Veterans Administration of Virginia focuses specifically on the combination of PTSD and SUD. It notes, “Substance abuse co-occurring with PTSD is often a chronic disorder that
requires long-term help, which AA may provide” and that “aspects of 12-step activities may address core issues of trauma-related symptoms and enhance treatment outcomes.” However, it also discusses how the faith component of AA can be problematic: “Trauma, and PTSD-specific symptoms of loss of faith and hope for the future, may deter individuals from embracing the concept of a higher power and the directive to surrender…. Trust is shattered such that a benevolent spiritual force is hard to imagine, and so surrender to a higher power may be seen as impossible. Further, hypervigilance and the need to
maintain control are integral parts of a traumatic stress reaction, creating hardships in turning
over one’s will and life to God.”
DDA has developed 5 steps that coordinate with AA’s 12:
1. We admitted that we had a mental illness, in addition to our substance abuse, and we accepted our dual diagnosis.
2. We became willing to accept help for both of these diseases.
3. We have understood the importance of medication, clinical interventions, and therapies, and we have accepted the need for sobriety from alcohol and abstinence from all non-prescribed drugs in our program.
4. We came to believe that when our own efforts were combined with the help of others in the fellowship of DDA, and God, as we understood Him, we would develop healthy drug- and alcohol-free lifestyles.
5. We continued to follow the DDA Recovery Program of the Twelve Steps plus Five and we maintained healthy drug- and alcohol-free lifestyles and helped others.
Tony’s treatment program is focusing first on substance abuse programs, specifically achieving one year of sobriety, though in his shares at group, he does discuss his dual diagnosis. And he finds the spiritual component of his recovery to be essential. After his formal treatment ends in mid-January, Tony wants to continue working in faith-informed service to workers in the field — perhaps in a virtual capacity with the intention of helping prevent burnout.
I’m not in AA or DDA, but it seems to me that some discussion and communication between the two organizations would help matters.