In this chapter, we will cover some of the consequences of co-occurring disorders-—-fundamental principles about the behaviors of those who are addicted, the patterns of addiction, and how all of it affects family members. These principles are a starting point in the journey of helping and healing. The points we cover apply to the person with the co-occurring disorder and sometimes to family members as well. Addiction is a family disease, with each member needing to address his or her own issues.
Denial is a complex process of selective perception that prevents an addict from seeing what is causing her pain. Denial includes and involves the family. In the book No More Letting Go, interventionist and author Debra Jay describes addicts as “masters of misdirection.” They can perform sleight-of-hand tricks that seem to make entire events, symptoms, and crises disappear. Addicts often blame others for their problems, absolving themselves of responsibility. By blaming others, they are able to convince themselves that what they’re doing is okay.
Denial spreads when addicts make loved ones feel as if they are at fault. They may use a diagnosis or a condition, such as an anxiety disorder, as an excuse for dysfunctional behavior. “Don’t you understand? My panic attacks make it impossible for me to hold a job.” Some family members want to believe the addict. They feel that the addict needs their undying loyalty and love. Other family members question statements that instinctively don’t ring true, but even they, over time, become conditioned to the manipulation. Other family members don’t buy the stories for a minute but are at a loss for what to do. Before long, family members begin to question their own sanity. They don’t know what to believe about the disease, the addict’s behavior, and the potential consequences, and so they choose to believe what makes them feel safest.
Denial stems from a place of wanting to believe that all will be fine or that all will return to how it was before the addiction reared its ugly head. The addict has lied to family members, and now family members must lie to themselves. Confused by their self-deception, family members do not take appropriate action. They may attend to or treat the anxiety while completely overlooking the addiction. The result is that families spend all their energy reacting, or stamping out fires. As soon as one fire is extinguished, another one lights up.
Denial is what keeps sickness active; it is the oxygen feeding the illness. Family members display denial through a chronic state of crisis fueled by an urgency to fix what is wrong. “More money, new car, rescue for the crisis of the day? No problem; we will make it better, but we will not discuss what is really causing it.” Family members are held hostage so long, they sometimes suffer from Stockholm syndrome, a condition in which people take on the values and beliefs of the one who holds them captive. Family members begin to believe the propaganda of the disease. The -longer they are held captive, the harder it is to break the denial and stagnation. In addition, the unwritten contract is that the loved one will decompensate, or erupt into a rage, if challenged by any alternative reality. The problem is not us or our loved one, but the addiction and the mental illness.
Denial is a huge manifestation of a co-occurring disorder on the part of the patient and the family. As long as there is a lack of dialogue, a lack of action, and a lack of clarity, things cannot and will not change. Breaking denial is the first step toward -healing.
Unconditional love is often seen as the key to helping others. While desirable in many instances, if misapplied to an active addict, it can make things much worse. Meeting the needs of injured or sick family members is instinctive and often plays into one basic fear: They will die unless we help them. There’s a point where love and support can become more harmful than helpful.
As loved ones get sicker, families often try harder and harder, doing more and fixing more and expecting different results. Logic is lost. We see this as a stress response, a reaction to the helplessness, fear, and trauma experienced by the family. Under stress, family members shift between two extremes: either bending over backward to help or erupting into angry outbursts. Some family members provide mood-altering substances for their loved ones in order to avoid trouble. Similarly, some physicians who mean well but are misguided, manipulated, or incompetent provide addictive substances in an attempt to “fix” specific symptoms in a dual disorder patient.
Family members often provide money, support, and care with the best of intentions, but when the dually diagnosed person is protected from facing serious consequences by well-meaning support, he has no real motivation to change. Isolation, dysfunction, and addiction continue. It is important for the family to create expectations and set conditions for support. This may not be easy to do, especially if our loved one is used to getting his way. The assistance of a professional or the involvement of an interventionist may be needed to change the “contract”-—-the unspoken, un-written agreements-—-in a humane, effective, and healthy way.
Just because unconditional love can make matters worse doesn’t mean the opposite strategy will work. Becoming angry, controlling, threatening, judgmental, or harsh are equally ineffective techniques. We have observed patient, loving, and kind families become exhausted and then angry. They change the contract suddenly, taking their loved one to task over minor transgressions. Instead of addressing the larger problems, they blow up over a missed appointment, a dirty car, or a harsh comment. This sudden shift almost always backfires. It fuels shame, confusion, and fear.
Families often get manipulated into supporting their loved one in a lifestyle free of responsibilities, accountability, or structure. Whether “working the system” or “working the family,” the dual disordered manage to use mental illness or addiction as a means of avoiding the daily structure and responsibility that keep most of us healthy. They are too sick, too anxious, too depressed, or too high to hold down a job, to volunteer, or to go to school. When they avoid responsibility, they lack structure in their lives. This avoidance behavior is not due to laziness or mean-spiritedness. It is simply the nature of the diseases.
The absence of a daily routine allows things to stay the same, and over time, things get worse. Sleep patterns reverse, depression gets worse, and confidence deteriorates. The logic is almost always inverted: “My behavior will change once I feel better.” Incidentally, this faulty logic is countered effectively by AA, which stresses action and personal responsibility. Recovery from a co-occurring disorder requires a lot of action on the part of the patient. Recovery programs don’t work by themselves, like a magic pill. Rather, as they say in AA: “It works if you work it.”
Loneliness, isolation, and lack of a personal support system make the addict and family feel worse and tend to amplify negative emotions. Absence of social support increases vulnerability to stress and relapse. We are social creatures; depression, anxiety, and trauma-based disorders, among others, can make people believe that they cannot socialize or function with others. Isolation then becomes a lifestyle, justified by feelings of uniqueness and shame. People suffering from co-occurring disorders tend to stay by themselves or have friends who are usually suffering from similar problems. Once again, the logic is inverted: “I must stay by myself until I feel better.” But isolation feeds the illness. The exact same pattern can affect the family. As a loved one becomes more symptomatic, families isolate as well, overwhelmed by pain and confusion.
If those with co-occurring disorders could redirect the energy they spend on unproductive thinking, they would become a major source of creativity and innovation in the world. Those who suffer from addiction and psychological disorders tend to think a lot. Their thinking patterns are intense, often occurring at night, in a chemically altered state, and in isolation. Most often these thoughts are either impractical or not followed by action.
Depressed and anxious individuals are particularly vulnerable to “ruminative thinking,” an obsessive activity that is both exhausting and nonproductive. Individuals with bipolar disorder may have flashes of brilliance and creativity, but often what they conjure is not original and doesn’t stand the test of daylight. Similarly, marijuana addicts may feel they are brilliant when high, but this notion fades when the effects of the drug have worn off. Those who use hallucinogens can become inspired by perceptions that are trivial in the light of day.
People suffering from addiction and mental health issues tend to skip the planning, preparation, and execution phases of bringing an idea into reality. They often believe that inspiration is enough, so their ideas fall flat, increasing their feelings of despair and hopelessness.
Families can get caught up in the process of over-thinking. They listen with intent, try to be encouraging, and simply become confused and exhausted.
With the exception of steroid abusers and exercise addicts, most individuals with co-occurring disorders have a poor diet and lack physical exercise, amplifying feelings of helplessness, depression, and anxiety. Again, the patient’s thinking tends to be self-defeating: “I will start exercising and improve my diet once I feel better.” The reality is that once a person starts making these positive changes, she starts to feel better.
Seeking quick-and-easy solutions is a characteristic of both psychiatric and addictive disorders. Loved ones may mislead family members into believing that “everything will be okay if I can make this relationship work,” or “I will be fine as soon as I find a better apartment with less noise.” Focusing on one problem out of context and ignoring the larger problems is a common error, and one that is easy to get swept into.
Addicts also tend to want treatments that work as fast as the drugs they abused. They want the pill, prescribed or illegal, that will make them feel better. Antidepressants start to bring relief fairly quickly, but without ongoing participation in Twelve Step meetings, addictive behaviors tend to reemerge. Both families and those with co-occurring disorders need to be careful not to be seduced by the illusion of single-factor quick-and-easy fixes.
It is easy to become angry with a loved one who is active in his addiction or immobilized by a co-occurring condition. In fact, it is almost impossible not to experience anger, but it is important that family members don’t allow this natural frustration to dictate their actions. Pure anger does not motivate people to change. It feeds the shame mechanism, adds to feelings of abandonment, and will probably just ignite an angry response in the other person. It can also cloud communication, clarity, and the need for change. It may sound simplistic, but it is more effective to be angry at the disease than at the person.
It is perfectly appropriate to be assertive and clear, however, especially in regard to an agreed-upon treatment or aftercare plan. It helps if family members agree to monitor each other’s behavior carefully and seek outside support in the form of Twelve Step groups, professional assistance, and friends.
A major problem in diagnosing co-occurring disorders is that the symptoms of various disorders look identical. Within the mental health arena alone, many, many conditions have overlapping symptoms. Deciding which diagnosis is correct can be tricky, even with high-quality testing. The degree of diagnostic precision for many mental health conditions is not as high as it is for common medical problems. There are no blood tests for depression or for bipolar or anxiety disorders (although medical tests do need to be performed because some medical conditions mimic mental health problems). Making things even more complex is that addictive disorders can also mimic mental health disorders. Lingering damage from drugs and alcohol can result in agitation, depression, sleeplessness, and even hypomania. The shortage of natural chemicals can result in what is known as post-acute withdrawal, a temporary state of mood and cognitive disruption that in some cases looks identical to a bipolar disorder. In the late 1980s, lithium was sometimes overprescribed for early recovering alcoholics because of this overlap. Conversely, as we discuss in chapter 6, the damage of some of today’s addictive drug combinations can result in lasting damage that appears to induce a bipolar disorder.
Diagnosis, which may seem like a simple task in the process of recovery, is actually an art form that requires considerable sophistication and expertise. Having clarity as to which problems are relevant, active, and needing attention can make a huge contribution toward getting better. With co-occurring disorders in particular, one size does not fit all. Accurate and ongoing diagnosis by a multi-disciplinary team employing multiple strategies is needed, and
individual treatment plans are essential.
There is considerable confusion about the concept of acceptance. In recovery, it means accepting things as they are, not as you wish them to be. When people accept that they have a co-occurring disorder, a process of coming to terms with reality follows. A healthy acceptance means the individual focuses on treatment and on learning how to manage the conditions. Acceptance means not being a victim, but taking action; not being in denial, but seeing clearly. A profound reframing occurs: “I am not hopeless, misunderstood, or crazy. I am an addict with an anxiety disorder. I have an illness, and now I will deal with it.” More eloquently stated, it is the well-known Serenity Prayer in action:
God grant me the serenity
To accept the things I cannot change,
The courage to change the things I can,
And the wisdom to know the difference.
What are the things I cannot change? The fact that I have a dual disorder. What are the things I can change? The way I deal with that dual disorder and move into recovery. What is wisdom? Not allowing myself to fall into my old ways of thinking, which cause me to think I can control things I can’t. Similarly, family members need to come to a point of acceptance. Working on clearer boundaries, developing a more accurate view of the reality of the conditions, and letting go of control, perfection, and blame are key factors for healing. We strongly urge families to participate in Twelve Step meetings and in the family programs offered by most treatment facilities. Clarity and freedom from the debilitating feelings are vital for well-being. Increasing the family’s knowledge, accepting the diseases involved, and making correct attributions (not feeling like you caused everything to go wrong) are what facilitate healing. Acceptance frees families to love and frees them from the need to fix or control.
Top-down interventions refer to changes set into motion by the higher parts of the brain such as thought (cognition), self-talk, perception, beliefs, and spiritual beliefs. Top-down interventions include psychological and spiritual interventions. Psychological techniques modify thoughts, which results in changes that affect beliefs, which in turn affect biochemistry and behavior. Spiritual interventions also have a top-down impact. For example, the facilitation of purposeful action, essentially helping others, as included in the Twelfth Step of AA. Top-down changes, whether psychological or spiritual, are powerful and affect all aspects of thought, behavior, and even biology.
Bottom-up interventions refer to the non-thinking aspects of our being: the biological aspects including the primitive, non-thinking parts of our brains. Bottom-up interventions are just the opposite of top down-—-that is, when biology is impacted by medicine, food, environment, or other physical factors, thinking and beliefs are affected. Changes to nutrition, medication, rate of breathing, aerobic exercise, and sleeping are bottom-up interventions. For example, the use of an antidepressant may alter the biological circuits that feed a fear response to spiders. If that circuit is interrupted, the perception of spiders is likely to change. Bottom-up interventions can have a powerful influence on biology, and this impacts perception, belief, and behavior and may even impact spiritual beliefs.
One of the most potent factors in any recovery program is a patient’s increase in structured activity. Almost all inpatient treatment programs have a rigorous schedule; hours are defined in terms of recreation, group therapy, lectures, and mealtimes. The increased activity empowers clients through required action and gives them less time to isolate and engage in nonproductive thinking. It is simply a reality of human nature: We need structure and routine, at least to a certain extent. Too much time feeds depression and rumination. Structure imposes expectation and shifts the pattern. Family members can find ways to help increase structure after treatment. Ideas for how to do this are usually part of the aftercare plan.
Because most patients have gotten accustomed to staying inactive with family support, changing the rules will likely result in less than full compliance unless there has been adequate preparation. Before changing the status quo, families should plan ahead. Working closely with the appropriate aftercare and program professionals will help patients and families transcend resistance to change.
Good communication is an art form. Family members know that their loved one can manipulate them in ways that sabotage any discussion about the condition or the process of change. Sufferers will have an emotional outburst, have an anxiety attack, threaten suicide, or act out in any way necessary to silence the family member attempting to confront them. The wrong thing to do is to try to shout them down or shame them. We may win a battle, but we will lose the war.
The only effective confrontations are those that are embedded in a loving message. Although this so-called “care-frontation” sounds simple, it is not. Skilled professionals can help family members avoid becoming too harsh or too soft in their discussions with a loved one. Families need to learn how to remain objective, yet supportive. It is often easiest to do this when at least two family members talk to the loved one.
If, for example, a loved one is failing to live up to her aftercare plan by not attending therapy meetings and not taking prescribed medications, it might be appropriate to say the following: “Jane, we all made an agreement in treatment that you would go to your psychologist twice weekly and take Zoloft. I know you haven’t refilled your prescription, and you haven’t been to a session in more than a week. We agreed on what would happen if you refused to follow the aftercare plan, and I’m willing to enforce that agreement. Do you want to continue living here, or do you want to go to a halfway house? You must make a choice. You either honor your agreements or you move out.”
What the family is saying here is that the patient’s actions will determine what level of care she needs. If she really can’t follow through with her agreement, then she needs a higher level of care, namely the halfway house. The family members are not being -punitive, they are merely acknowledging the fact that they aren’t able to give her the amount of support she needs. The patient, for her part, must do the hard work necessary to move out of her illness and into recovery. This kind of reality therapy is very effective, even with seriously ill patients. There are no shortcuts.
Individuals who have co-occurring disorders tend to suffer from a condition called “terminal uniqueness.” As the phrase implies, they
believe that they are the only ones who have ever had this series of problems and that no one can possibly understand them or help them. This helps them to “compare out” from others who are in recovery, and thus avoid the hard work of recovery. We are all unique, but the path of addiction is predictable. The addict progresses by finding similarities he has with other recovering people.
Finding new and healthy friends and social support is required not only for addiction recovery but also for psychological disorders. Often these new friends will be found in Twelve Step groups. There are also co-occurring disorder support groups. These meetings are sometimes referred to as Double Trouble meetings. Specific disorders also tend to have support meetings, some of which have Twelve Step foundations and others that focus only on the psychiatric condition. Meaningful relationships with peers will help protect loved ones from engaging in self-deceptive thinking, because recovering friends are able to challenge faulty thinking. This is particularly vital when “primitive” urges take over, whether in the form of fear, depression, or cravings.
A healthy peer can provide the top-down feedback that will interrupt a craving or an impulse, or even a panic response. Having support is vital. As they say in AA, “Your head is like a bad neighborhood. You should never go there alone.”
Similarly, families may benefit from extra support. Attending aftercare groups, support groups, and individual and family therapy sessions are all options worthy of serious consideration. It is easy to slide into old patterns of behavior. Adding support systems and outside feedback can protect families from the stresses and uncertainties of dealing with a distressed love one who struggles with co-occurring conditions. When family members take care of themselves, they are better able to take care of their loved one.
Medications can make a vital contribution to recovery and to relapse prevention. Not too many years ago, addiction treatment professionals viewed any psychiatric medication as improper. People suffering from depression were told that antidepressants were addictive and should not be used by addicts. Others were told that medication blocks emotions and stunts the healing process. This is simply not correct, unless the client is improperly medicated or overmedicated. The lowest dose for best effect is the goal. As we have stated previously, many dual disorders do not require medication or may only require medication for short-term stabilization. On the other hand, some people may require medication on a long-term basis. Medication, if properly managed, can be a major contributor to recovery from both addiction and mental -illness.
While even the most optimistic pharmacologists do not envision biological cures for either addiction or the complex spectrum of mental illnesses, many exciting developments are evolving. There are medications available now that-—-for some patients-—-reduce cravings for some drugs, interrupt the high from opiates, and possibly decrease the craving for alcohol in problem drinkers. Studies are under way to see if specific mood stabilizers will reduce cocaine urges. Although there are no silver bullets, exciting research efforts currently under way are likely to help considerably. Anti-addiction medicine is in its infancy, but other aspects of treatment will always be required. It should be noted that these medications only offer an additional tool in the patient’s recovery program. They do not, under any circumstances, take the place of Twelve Step meetings and ongoing therapy. Medical treatment for specific symptoms is only one factor in a multifactor problem. Co-occurring disorders require multiple strategies and approaches, not just medication.
Decades of psychological research have shown consistently that while medication helps, so does therapy. In fact, non-medicinal therapies are equally effective for some, but not all, psychological disorders. When medication is required, the best outcome is derived from combining it with therapy. As the case studies in the rest of the book will show, medications often play a crucial role, especially in the beginning of the recovery process.
Medications are helpful, but sometimes overprescribed. Become an informed consumer along with your loved one. Knowledge is power, and plenty of information is available. Be careful, however, of Web-based information. Many Web sites are oriented toward sales, not objective knowledge. See the back of the book for sites we recommend.
Some people tend to either fear medications or overestimate their -curative power. We tend to trust psychiatrists who take a minimalist approach: fewest medications, lowest effective dose, and shortest time of use. Some severe conditions may require more aggressive medication and other biological therapies. Remember, too, that for many psychological conditions, medication management can be lifelong, and a blessing.
Be wary of addictive medications, especially sleep and anti-anxiety medications such as benzodiazepines, which appear to help the psychological condition but can fuel the addiction. Natural and herbal additives may be appealing, but their doses are difficult to calculate, and mixed with other medication, they can be disastrous.
Exercise and diet are important for everyone. For those suffering from co-occurring disorders, a healthy regimen is imperative. Healthy lifestyle changes, such as in diet and exercise, can make a huge difference in terms of mood, perception, and sense of well-being. Exercise tends to restore natural stimulants, such as serotonin, and a whole host of chemicals that elevate mood naturally. Proper nutrition (not simply swallowing vitamin pills) adds to this effect. (Be careful of supplements. Some can have harmful consequences, and some may interfere with prescribed medication.) For those who do not have full-blown genetic or injury-related psychiatric imbalances, nutrition and exercise can be some of the most powerful biological treatments available.
It is important to remember that, for those who suffer from psychological conditions, especially anxiety disorders and depression, additional vigilance in self-care is mandatory. People with normal biology may not be as affected by disruptions in dietary or exercise regimens. For people with co-occurring disorders, even minor lapses can result in a significant mood change. For an in-depth look at this subject, as well as practical advice on diet and exercise for recovering people, see The Wellness-Recovery Connection by John Newport, Ph.D.
When either or both parts of a dual disorder are active, the patient is likely to have a negative outlook. It just goes with the territory. Recovery requires a change in worldview. A positive outlook and a sense of hope are essential. Hope is powerful medicine. As stated by historian and writer Lewis Mumford, “We can live three weeks without food, three days without water, and, yes, we can even live three minutes without air, but we cannot live without hope.”
It has been said by those in AA, “Recovery is easy. You just have to change everything.” It is impossible to face this daunting task without hope. For some people, simply attending Twelve Step meetings and seeing the success of other people is a source of great hope.
For others, early recovery is a time to connect or reconnect with core beliefs. Questions of faith and ultimate meaning aren’t academic to those who have been devastated by these illnesses. Many patients suffering from co-occurring disorders have had the experience of having a drug as a Higher Power. What will be the guiding influence now? Will it be religious faith or moral values or a personal spirituality? Something must fill the void and provide a motivating force for action.
Once hope is restored, progress is almost inevitable. We cannot continually provide hope for our loved ones, but we need to include it in our thinking and in our language. Superior treatment programs include a focus on the spiritual dimension. Whether the client has well-formed religious beliefs or none at all, she must expend real effort to build the hope necessary for recovery. It is a huge factor and a sustaining force in the quest to transcend dual -disorders.
It is instructive to think of Step Two of the AA program, which describes what chronic alcoholics have had to do in order to overcome their illness: “Came to believe that a Power greater than ourselves could restore us to sanity.” The Step states that it is only necessary to believe that such a thing is possible. In essence, this is an application of top-down change-—-hope provides soothing at a psychological and neurological level.
The healing factors cited on the previous pages can be simplified as four vital factors needed for recovery from co-occurring disorders. These factors apply to the family members as well as to the loved one with a co-occurring disorder.
The first factor is biology. Biology refers to all the factors that affect physical well-being. This includes medicine, diet, exercise, and healthy sleeping patterns. Scrupulous self-care provides a stronger foundation for sustained change. It is important that you and your loved one be diligent in following the directions given by treatment professionals. Do not be your own doctor.
The second factor is psychology. Psychology includes thoughts, perceptions, and the messages of one’s inner voice. Altering thought patterns and perceptions requires considerable work and guidance. Sponsors and clinicians participate in this process. Working the Steps, especially working on acceptance, requires open-mindedness and a willingness to accept new knowledge, thoughts, and perceptions. It requires realism and truthfulness about the nature of the problem and the nature of the solution. Working the Steps facilitates the letting go of self-blame and the illusions of control or omnipotence.
The third factor is interpersonal. Interpersonal refers to the support systems used on a daily basis. Recovery from addiction and co-occurring disorders does not occur in isolation. Healthy friends and supports are vital. People in long-term recovery often advise newcomers to “stick with the winners.” New attitudes and behaviors require active, healthy supports.
The fourth factor is spiritual. Spirituality involves more than religion. You need not be religious in order to have a positive spiritual system. Core beliefs often drive perceptions in an almost automatic way. That is, thoughts, or cognitions, are profoundly impacted by spiritual processes. A spiritual vacuum or a highly negative spirituality can interfere with the effectiveness of the other three factors. A direct dialogue about spirituality, in a non-threatening, non-dogmatic manner, can be a potent healing factor for co-occurring psychological issues and is an emphasized area of focus for Twelve Step recovery. Addiction counselors, sponsors, and mental health providers participate in the realm of spiritual change. Spiritual changes refer to the highest level of organizing beliefs and attitudes.
Treatment does work, and recovery has become a reality for many. When we are in the midst of chaos, it is difficult to see how to facilitate change. A well-coordinated, well-timed set of interventions that address all the issues outlined in this chapter will vastly increase the likelihood of success. Formulating an action plan may require the help of professionals and/or an interventionist. We have discussed general principles-—-what helps and what hurts. In subsequent chapters, we will provide more specific information about disorders and treatment.
While we cannot change the behaviors or attitudes of those who are suffering from co-occurring disorders, we have the power to change how we react to them. Recovery is a process, and we can model that process for our loved ones by reaching out for help in a variety of ways. We can get expert advice, attend support groups, and shop wisely for treatment. We can learn as much as possible about specific psychological conditions and seek accurate diagnoses and comprehensive treatments. We can be patient and persistent-—-the more complex and severe the co-occurring combinations, the more hope, information, guidance, and support we need. Although we won’t know it right away, our positive example of change and growth will help to inspire our troubled loved ones.
-Excertpt from At Wit's End, by Jeff Jay and Jerry Boriskin, Ph.D., published by Hazelden. Copyright©2007, all rights reserved.