The greatest obstacle to successfully treating any kind of chronic illness is compliance—getting patients to follow the directions. Whether the problem is alcoholism, heart disease, or diabetes, there is no shortage of effective treatments. But most patients simply don’t follow their treatment plans.
Recovery from chronic illnesses often requires that patients make profound changes in their lives, often around diet and exercise, that can be hard to sustain. Heart disease provides a clear example.
A friend of ours, Bob, suffered a heart attack a few years ago. He received immediate treatment and survived. The next day, his cardiologist came to speak with him.
“Bob,” he said, “you’re a very lucky man. There’s been almost no damage to your heart. If you change your diet, increase your exercise, and take the medication I’m going to prescribe, you’ll probably never have a second heart attack.”
“I like the sound of that,” said Bob. “It sounds pretty simple.”
“Simple, yes,” said the doctor. “But most people won’t do it.”
“Really?”
“You’d be amazed how many people hear this little speech and then wind up back in the hospital with a second heart attack,” said the doctor. “That is, if they survive the second heart attack.”
“Sobering,” said Bob.
“Which brings up a good point,” said the doctor. “I know you’re a recovering alcoholic, Bob, and that may be a great asset to you now.”
“How so?” asked Bob.
“I think you’ve got a better chance of following through because you’ve learned to follow directions to the letter. For ex-ample, your sobriety demands that you not drink alcohol. Ever. It doesn’t mean 50 percent of the time or 95 percent of the time; it means that you follow your program and you don’t drink alcohol 100 percent of the time.”
“That’s what recovery is all about,” said Bob. “And it’s a better life too.”
“If you can apply the same principles to heart disease that you’ve used in dealing with your alcoholism,” said the doctor, “you’ll be a great success.”
“I’ll do it.”
And he did. It’s been a number of years now since Bob had his heart attack, and not only has he been free of heart problems, but at age sixty-three, he’s in the best shape of his life.
“I had to have the same spiritual awakening around diet and exercise as I did around drinking,” said Bob, looking back on his heart attack. “It’s what made it possible for me to keep following the directions every day.”
Alcoholics Anonymous and other Twelve Step programs provide a recipe for a spiritual awakening that isn’t dependent on religious belief. Twelve Step programs provide the best, most time-tested road map to long-term recovery.
There is an old saying in AA: “Recovery is easy. You just have to change everything.” And when a person has to make global changes in life, it requires an awakening of spirit that is great enough to meet the challenge. Recovery from alcoholism or drug addiction, like recovery from mental health issues, requires the full participation of body, mind, and spirit. It isn’t a matter of taking a pill and waiting for the problem to go away. In fact, most of the printed directions that accompany prescription medications for anxiety and depression suggest that patients engage in therapy and ongoing support.
Spiritual awakening does not mean religious conversion. In fact, one of the reasons that the Twelve Steps in the book Alcoholics Anonymous-—-the Big Book-—-have been so widely studied is that they provide a prescription for this awakening that doesn’t require formal religion. If one has religious faith, that is all well and good, but the program works equally as well for agnostics and atheists. The Big Book contains a chapter called “We Agnostics,” which addresses this issue in a personal and practical way.
What the Twelve Step program does call for is that people identify something greater than themselves to serve as a guiding light. This may be truth, moral principles, or a universal power. Or it may be God as they understand God, whether through formal religion, personal faith, or both. The Twelve Steps make no judgment in these matters. People must decide what they believe for themselves. For many people, the process of questioning and discovering what they really believe can serve as a spiritual -awakening.
Alcoholics who participate in Twelve Step meetings regularly are willing to change their lives for the better. They have the opportunity to learn from people who have successfully overcome similar problems. They are able to draw on the counsel of more experienced members. Because there are no fees for Twelve Step meetings, and because help is freely offered by those who have firsthand experience with recovery, this counsel is often perceived by newcomers as being more valuable than the same advice given by professionals.
The actions of going to meetings on a regular basis, of not drinking or using drugs, of working with a sponsor (or mentor), and of reading recovery literature begin a new routine and a new sense of responsibility. This new responsibility is not aimed at a person or institution, but rather at the health and well-being of the individuals themselves so they can begin to reclaim their lives.
For people dealing with co-occurring disorders, this new sense of responsibility extends beyond a typical addiction treatment and aftercare plan to include the specific steps they need to take to address their mental health issues. Instead of discontinuing their prescribed medication simply because they “didn’t feel like taking it,” patients continue to follow directions. Instead of quitting aftercare treatment because they are bored with it, they will persevere because their actions are in line with a Higher Power or higher principle rather than passing whims.
Participating in a Twelve Step group provides long-term structure and guidance, functional and healthy peer groups, and a chance to help others. It may seem counterintuitive that people with problems would need to help others, but let’s examine the facts and try to understand this important point.
People recovering from dual disorders are often discouraged and depressed. They aren’t sure how to escape their dilemma, so they sink deeper and deeper into despair. Once they partici-pate in a program of recovery over a course of time, they can draw on their firsthand experience and assure newcomers that it’s okay to be uncertain, that no one will expect them to get better overnight, and that they’ll be accepted. They can help make newcomers feel as if they belong in the group. Feeling accepted, newcomers return and can begin to heal. Here is an example of how this process can work.
Carmen, age thirty-three, has completed treatment for alcoholism and bipolar disorder. She is back home living with her husband and looking for a new job. She is going to AA on a daily basis, including an all-women’s meeting three times per week. After a month, her sponsor recommends that she volunteer as a greeter to welcome newcomers. The next week, a new woman comes to the meeting. Her name is Nicole and she is only twenty-three. Like Carmen, she has recently completed treatment, but she isn’t sure she wants to go to meetings.
“Welcome,” says Carmen, reaching out to shake her hand.
“I don’t exactly want to be here,” says Nicole, looking away.
“I know what you mean,” says Carmen. “I didn’t exactly come here to meet people, if you know what I mean.”
Nicole laughs and shakes hands. They start talking a bit as they walk into the meeting room. Carmen is too new to give advice, but she knows she doesn’t have to. Nicole just needs someone to listen to her and introduce her to the other women. Carmen makes the introductions and shares some of her own story as well.
“I just went off the deep end,” says Carmen. “It was booze and pills and the bipolar stuff. My husband was ready to leave me. But since I got back from treatment, things seem to be working out. But still, we have a long way to go.”
“You don’t look like you were that messed up,” says Nicole.
“Well, I wasn’t wearing a sign on my forehead,” Carmen says with a smile.
They both laugh and keep talking, and when the meeting begins, the women sit together. At the end of the meeting, Nicole speaks to the whole group.
“I was nervous coming here tonight, but my new friend Carmen met me at the door and introduced me to all of you, and I just can’t thank her enough. She made me feel so comfortable. I think you’ll see me here again.”
Hearing these words said aloud to a group of women she respects will make Carmen feel better than anything else could. In a few short minutes, giving a little of herself to a stranger, she stepped into a new world. Now, Carmen’s own tale of addiction, mental illness, and recovery will become a benefit to someone else. Her greatest defects have a chance to become her greatest assets. She will be able to listen and talk with Nicole like few others in Nicole’s life, because Carmen is a recovering addict herself.
People often talk about building self-esteem, but there is really only one way to do it. We must do things that we can respect. If we accomplish things we can be proud of consistently, then we will build a solid base of self-esteem. In our example above, Carmen found she had something unique to give. She has always respected people who helped other people, but she never imagined she could do it herself, particularly with her own problems. Imagine the awakening of Carmen’s heart and spirit when she discovered she could be the one to reach out a helping hand.
In previous chapters, we talked at length about the need to develop new and healthy peers when dealing with mental health problems. Here is the perfect opportunity. We have also talked about the need to find appropriate support and to be able to talk through problems with family and friends. Here are the friends, and they may well understand more than the family. We have also discussed the need to find strong internal motivation and purpose to work through the difficulties of recovery from mental illnesses. Here is the method for developing that motivation and purpose.
The Twelve Steps have helped millions of people in more than one hundred countries since the inception of AA in 1935, yet some people question the efficacy of the Twelve Step approach. People point out that AA is not evidence-based medicine, that it has not been subjected to the kind of rigorous double-blind studies (studies that ensure that neither the researcher nor the subject knows what treatments are being used) required by modern researchers. This is partially true. The Steps were not developed as a result of evidence-based research, but that concept didn’t exist in 1935 with respect to psychology. On the other hand, AA Twelve Step–based treatment has been studied thoroughly. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) and many other institutions have conducted double-blind studies and found AA to be unsurpassed in the treatment of alcoholism. The landmark “Project Match” study by NIAAA provides a good example.
There are those who say AA is a religious program. People of many religions, as well as atheists and agnostics, attend AA meetings, but there is no religious dogma in any Twelve Step literature. While it’s true that the Steps mention the word God, they do not refer to God in any dogmatic or systematic way, which is required in order to be religious. AA literature is consistent in stating that individuals must work out the idea of God for themselves. By contrast, religion presents a specific set of beliefs, or dogma. Some people say AA is not religious enough, but the fact is that Twelve Step programs encourage their members to search out and develop their own beliefs.
Some critics also say that going to meetings frequently is like a substitute addiction, and it somehow undercuts the free will of the individual by substituting a kind of “groupthink.” But there is nothing unusual about devoting an hour a day to any new pursuit, especially one that requires a lifestyle change. A rigorous diet and weight-loss plan would require at least that much time. For someone who has quit using drugs or alcohol, finding an hour a day is very easy. Indeed, one of the principal problems in early recovery is filling the hours that used to be devoted to intoxication. AA provides a way to do this in a healthy manner.
Many offshoots of the original Twelve Step groups of Alcoholics Anonymous have developed over the years to address a wide range of issues. These include Narcotics Anonymous, Cocaine Anonymous, Al-Anon (for the family members of alcoholics), Emotions Anonymous (for mental health issues), Food Addicts Anonymous, Gamblers Anonymous, Sex Addicts Anonymous, Families Anonymous, and many more. All these groups use the Steps with only slight modification to address their focal area.
Alcoholics Anonymous began in 1935, and when the fledgling organization grew to one hundred sober alcoholics (in 1939), they decided to try to write down the steps they had taken to achieve sobriety. Long-term recovery from alcoholism was a foreign idea at that time, and they wanted to capture in words what they had done to accomplish this feat. That is why the Steps are written in the past tense, because this is what the individuals had done to achieve sobriety. It is also why they are written in the plural form, from the point of view of “we.” For people in recovery, “we” can be a very important concept, because isolation often leads to relapse.
So what are the Twelve Steps of AA? We will take a brief look at them, try to bring a little clarity to the program, and suggest how the Steps are applicable to mental health problems. (The Steps have been slightly modified by groups such as Dual Recovery Anonymous, but their essence remains the same.) A more complete introduction to the Steps can be found in the book Twelve Steps and Twelve Traditions, published by Alcoholics Anonymous.
The admission by alcoholics that they have a problem is the necessary beginning point of recovery. With addiction and mental health issues, this is especially important because denial is a primary feature of the illnesses. So people with co-occurring disorders must state in a clear and unambiguous manner that they have a problem and it is damaging their lives.
People have sometimes misunderstood the use of the word powerless to mean that the alcoholic cannot help but drink and has no personal responsibility in the matter. The Big Book, and many volumes of recovery literature, makes it crystal clear that powerless refers to the inability to control drinking once the drinking has begun. Step One is an admission that all attempts at controlled drinking have ultimately failed and that the drinking life has become unmanageable.
The concept of powerlessness can be very negative for survivors of abuse, oppression, and trauma. For those who have trauma-based difficulties, the concept of powerlessness may be either terrifying or just plain unacceptable. But Step One focuses entirely on addiction and does not extend to issues other than the use of mood-altering substances, as real as they might be. Powerlessness is restricted to the realm of addiction.
The most important action in Step One is admitting there is a problem. Overcoming denial is a central issue in both addiction and mental illness. By taking Step One, dually diagnosed patients put denial behind them and begin moving into the solution. Of course, denial can creep back from time to time, and that is why the continuing admission of Step One is so important.
Albert Einstein said, “The brain that has the problem cannot solve the problem.” Many people with co-occurring disorders struggle for years trying to find a solution to the problem within themselves and fail repeatedly. Step Two defines a new and more successful strategy. It says that the power to be restored to sanity will come from outside the individual. Step Two describes the all-important experience of “coming to believe” that this help is available and that it will work. It is often said that “God works through people.” Alcoholics Anonymous and other Twelve Step programs demonstrate this fact every day. For people who have difficulty with a spiritual point of view, the concept of help coming from other people, from outside the self, is still powerful. The most important point of Step Two is that people come to believe that relief is possible, that they don’t have to have all the answers, and that they can be restored to health and wholeness (the root meaning of the word sanity, from the Latin sanus).
If this can be tied to a belief in God or a Higher Power, the process may be easier. However, many recovering people have trouble in this area, and so they must search out their beliefs to find out what is important to them. This quest for meaning can be all-encompassing, and it gives added dimension to the recovery process.
For people with co-occurring disorders, there is often a lack of faith or an outright anger at God for their afflictions. The resolution of these issues, often over time, provides a solid basis for recovery. Note that the Step says “came to believe,” not “believed.” It is a process, not a foregone conclusion.
The authors of the Big Book added italics at the end of Step Three—as we understood Him—to underscore the personal nature of faith and belief. AA does not dictate the faith or the belief. Rather, each person must discover and accept his own belief in his own way. For people new to recovery, clarifying their beliefs and living by them are essential.
For people suffering from addiction and mental health problems, the subject of free will is loaded with contradictions. We all have free will, but in the disease of addiction, free will is perverted and made to serve the illness. It is not free will that drives a person to the liquor store at 9 a.m. or to the crack house with the rent money. It is craving. It is not free will that decides to quit medication and therapy; it is the brain disease.
People recovering from mental health and addiction problems know from experience that they must hitch their wagon to a new star. A new decision must be made. They must stop turning their will and their lives over to addiction and mental illness. Instead, they must make a leap of faith and entrust themselves to a Higher Power—God, as they understand God.
Step Three does not say that alcoholics turn their lives and their wills over to God, because this is not possible with free will. Rather, the Step urges a person to turn her will over to the “care of God,” to make her will congruent with God’s will. For agnostics or atheists in Twelve Step programs, the concept of God has sometimes been changed to G.O.D.: Good Orderly Direction or Group of Drunks. In other words, they have made their ideals and the fellowship of AA their Higher Power.
But there is no need to be too abstract. For many alcoholics, Step Three is as simple as this statement: “I’m going to do what I’m supposed to do, instead of what I want to do. Tonight, that means I’m going to an AA meeting instead of a bar.”
These two Steps naturally go together. In fact, many people in recovery talk about “completing a good Fourth and Fifth Step.” It is one of the great milestones in early sobriety.
Recovery demands rigorous honesty, and because of the nature of addiction and mental illness, this has often been in short supply. One of the surest ways to build this new foundation of truthfulness is to be completely honest about the past. The inventory should be done in writing and with the guidance of a sponsor. The first three Steps will not last long without honesty, and one of the chief reasons for relapse is a failure to do a thorough Fourth and Fifth Step.
It is hard to write the inventory, but it is even harder to admit all of these wrongs to another human being. It can be a wrenching experience, but it paves the way for a healthy sense of humility and humanity and opens the door to learning, growth, and change.
Once the Fourth and Fifth Steps have been completed, newly recovering people are faced with their shortcomings. Typically, they must come to grips with the fact that they’ve been selfish, self-centered, angry, irresponsible, or resentful. These “defects of character” must be addressed, and the Twelve Steps suggest a method for resolving them. The idea here is that selfish people aren’t going to bring an end to their own selfishness. Instead, a Higher Power must be employed to get the job done. Rather than confront these defects of character with pure willpower, a spiritual approach is suggested. It is interesting to note that an entire Step is devoted to getting “ready” to have these defects removed. Family members of people with co-occurring disorders will -recognize this stubbornness right away. It should be noted that the concept of being ready to do these things is not the same as being comfortable with doing them. Humility and readiness often come from a realization that nothing else has worked and that change is necessary. People in treatment and early recovery are urged to cultivate this kind of readiness.
These are two more Steps that naturally go together. They recall the old maxim “actions speak louder than words.” Debts must be paid, apologies must be made, and wrongs must be righted wherever possible. In taking the actions laid out by these Steps, people start to feel good about themselves for a very simple reason: They are doing things that they themselves can respect. It is impossible to build up self-esteem simply by talking about it. Action is necessary, and in Steps Eight and Nine, people begin taking actions that lead to greater self-sufficiency and self-satisfaction.
It is ironic that people have criticized Twelve Step groups as absolving people of responsibility. These Steps show how important it is to take concrete action to address past wrongs. When people talk about “working the program,” they are referring to all Twelve Steps and not just those that can be accomplished -mentally.
Steps Ten, Eleven, and Twelve are often called the maintenance Steps. They are meant to reinforce the work that’s been done and to prevent backsliding. Nowhere is this as evident as in Step Ten.
The prompt admission of any wrongs is a clear signal to the rest of the world that a recovering person is trying to live his life on a new basis. How often has the dually diagnosed individual tried to cover up in the past? How often has he lied? In Step Ten, people are urged to maintain a close watch on their behavior and to be truthful in all their activities.
People who have been successful in recovery strive to improve. In Step Eleven, this striving is aimed at improving knowledge and understanding of a Higher Power and at gaining the strength to do what is right. Prayer and meditation are presented as the principal tools for this job, although for an agnostic or atheist, this will be limited to meditation or reflection. But by this stage of their development, newly recovering people will have resolved the God dilemma in their own personal way. Step Eleven is a universal prescription for spiritual growth and presents the essence of recovery in one sentence. It assumes the need for improvement and thus the existence of shortcomings. It proposes a Higher Power as the agent of change, instead of the individual. It helps to take people with co-occurring disorders outside themselves and provides them with a greater purpose and a method for attaining that purpose. It mentally directs people away from the negativity of their illnesses and into a positive vision of their lives. Finally, it directs people to a higher calling and a greater vision of themselves.
In our earlier example of Carmen volunteering to be a greeter at the AA meeting, we see how the message is usually carried. Twelve Step groups often say they are “programs of attraction, not promotion,” so there is no proselytizing or public advertisements. These programs have worked well for decades, and their success speaks for itself.
It’s not hard to imagine how a person would have a spiritual awakening after having gone through the process of admission, inventory, making amends, and so on. It is a practical method for changing a person’s life. The first one hundred men and women to get sober stated in Step Twelve that they wanted to practice the principles of honesty, openness, and willingness in every aspect of their lives. “We are not saints,” says a well-known passage from the Big Book. “The point is, that we are willing to grow along spiritual lines.”
Given what we have written in previous chapters, it is easy to see how this process will benefit people dealing with mental health problems as well. The initial Steps of the program are a recipe for the kind of awakening required to make great changes. When working Step One, a person lays the groundwork for honesty by admitting the nature of the problem. It can be modified in a person’s mind, for example, to say “I’m powerless over my depression, and it’s made my life unmanageable.” Steps Two and Three move from the problem to the solution: a Power greater than oneself. For depression, this may mean medication and treatment in addition to the traditional methods we discussed. Most important, it means following through and doing what one is supposed to do—positive action—instead of what one wants to do—negative action. The inventory and confession of Steps Four and Five could be helpful to anyone, but they are essential to someone in therapy and can help to deepen the therapeutic process as greater levels of honesty are attained.
Just like exercise equipment, the Twelve Steps don’t work on their own or without effort. From time to time, we will hear a family member say, “She went to AA, but it didn’t work.” But we know that the wisdom of the old-timers in AA is more to the point: “It works if you work it.”
We believe that if addiction is present with mental health problems, an appropriate Twelve Step group should be part of any treatment and aftercare plan. There may be exceptions to this rule, but they are highly unusual.
A paranoid schizophrenic who was recovering in AA made the following remarks: “When I stop going to meetings, it means I’m going to stop taking my medication. When I stop taking my medication, I start hallucinating, and all hell breaks loose. The next thing I know, someone is tying me to a gurney and putting me in a locked ward. So today, I’ll go to a meeting.”
Whether the problem is depression, anxiety, bipolar disorder, or any of the many mental health diagnoses, the support of a Twelve Step group will help with treatment plan compliance and long-term recovery.
Some people who are dually diagnosed have not always felt comfortable at AA meetings because they had different issues they needed to discuss. While it’s true that a minority of AA meetings won’t welcome a discussion of co-occurring disorders, most are very open to the topic, if the right approach is taken. Since it is an AA meeting, it’s best to talk about the chemical dependency side of the equation first and the mental health side second. This simple change will make almost any discussion acceptable. Younger members of AA who have been through treatment are more accepting of these issues, and we fully expect that any resistance will fall away over time. After all, Step Two talks directly about AA members being “restored to sanity,” so the issue of mental health isn’t foreign.
It is our belief that the Steps hold promise for all of medicine, which will slowly unfold over the next few decades. Acute illnesses such as malaria are being conquered one by one. But chronic illnesses such as diabetes, heart disease, and addiction require changes in the lifestyle and habits of the patient. We think the practice of the Twelve Steps and the active participation in a recovery group are some of the surest methods available to make change happen and to safeguard progress made.
Families wrestling with co-occurring disorders need patience, courage, and tenacity. These mental and spiritual qualities provide the foundation for professional treatment and long-term recovery, for without them the treatment process may never begin, or it may bog down in the face of setbacks. It’s often said in Twelve Step meetings: “Don’t quit before the miracle happens.” This can be difficult if we try to face both psychiatric and addiction issues by ourselves. Twelve Step meetings, both for patients and families, often provide the power to push on to higher ground. Never underestimate the importance of hope, faith, and teamwork in successfully treating co-occurring disorders.
-Excertpt from At Wit's End, by Jeff Jay and Jerry Boriskin, Ph.D., published by Hazelden. Copyright©2007, all rights reserved.