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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Co-Occurring Disorders:
Integrated Dual Disorders Treatment

Integrated Dual Disorders Treatment Workbook

Chapter 14: Self-help

INTRODUCTION
Self-help is a recovery-oriented process where peers share their experiences, strengths and hope to help others overcome a variety of illnesses and behaviors. A variety of peer-support organizations exist for people who are working toward recovery or who are in recovery from problems related to substance use disorders: Alcoholics Anonymous (AA), Cocaine Anonymous, Narcotics Anonymous, Rational Recovery, Double Trouble and Dual Recovery Anonymous (specifically for people with dual disorders), and others. This chapter describes a woman with bipolar disorder, alcohol dependence, and cocaine dependence who begins to use AA. This chapter covers how self-help groups work, how to help your clients use them, and what to expect when your clients go to them.

VIGNETTE
Joanne is a 30-year old woman with bipolar disorder, alcohol dependence, and cocaine dependence. She has been going to the local mental health center for treatment for ten years and attended treatment groups for the past two years without making much progress. About a year ago, she had a manic episode during which she was charged with driving while intoxicated. She felt unjustly charged, and discussed the issue with her counselor and her peers in the group. After some months of discussion, she accepted that she would have to follow the judge's recommendation to do something about her substance use.

In the last six months, Joanne tried to avoid drugs, but whenever she went out with friends, she couldn't resist the temptation to get high with cocaine. Her case manager pointed out that after the high, she seemed to be more depressed for several days. Joanne became discouraged about quitting because she didn't want to stay away from her friends who were using. Joanne's case manager asked her if she had ever tried a self-help group like AA to stay sober and as a way to meet sober people. Joanne replied she had gone to one meeting several years ago, but she didn't like it. She didn't feel like she fit in and she didn't want to have to talk in front of a big group of people that she didn't know. The case manager explained that there are many different AA meetings and encouraged Joanne to try several, suggesting that maybe she could find a group where she felt more comfortable. They obtained a meeting list and picked out a few meetings that were close by at times that were good for Joanne. The case manager offered to attend a few meetings with Joanne so she wouldn't have to go by herself. They picked open speaker meetings in which Joanne would not have to speak. The two attended the meetings and then talked about how it felt on the drive home. Joanne said she felt nervous, but also relieved that she was not alone in her attempt to get sober.

With Joanne's consent, her case manager approached another recovering client about helping Joanne to find meetings that she liked. The case manager introduced Joanne to this person and Joanne agreed to attend more meetings with her. Joanne finally found two women's meetings in which she felt comfortable and began attending them regularly on her own. After a few months of attending, she met a woman she liked and trusted, and asked the woman to be her sponsor. She and Joanne began talking and attending meetings regularly.

INTRODUCTION TO SELF-HELP
The term self help refers to a process of working towards recovery from mental illness or substance abuse with a group of people who share the same problem. The most widely used form of self-help for drinking problems, Alcoholics Anonymous (AA) is an organization of people who use mutual support groups, sponsorship, the 12 Steps, and the 12 Traditions to recover from substance use disorders. AA was founded in 1935 and has millions of active members in over 100 countries.

AA is an invaluable but free resource that enables many people to attain and sustain recovery. Though AA is often referred to as a support system or an adjunct to treatment, it is actually a remarkable organization that offers people with substance use disorders virtually everything known to be helpful in recovery. AA offers a regular activity, a new way of seeing the world, sober friends and supports, hope, role models, spirituality, cognitive-behavioral strategies for change, emergency help, a way of making amends for past mistakes, and an opportunity to help other people. Many other successful approaches to self-help have been modeled on AA.

SELF-HELP AND THE 12 STEPS
AA is based on the 12 steps to recovery, the 12 traditions, and mutual responsibility. AA is the model upon which many other self-help groups are based, including Narcotics Anonymous, Cocaine Anonymous, and Dual Recovery Anonymous (specifically for dually diagnosed people). 12 step meetings are self-help groups run by non-professional people who are themselves working on recovering from addictive disorders. Clinicians who refer clients to 12-step meetings should attend some open meetings to see what they are like. They should understand the meaning of sponsorship and of AA's concept of a higher power (discussed later in this chapter). They should be familiar with local meetings, including self-help groups that understand and accept people who are taking medicine, as these groups will be the most accepting of people with dual disorders.

The 12 steps are guidelines to recovery (See Table 1). The founders of AA believed there was a process that people went through to achieve sobriety. They wrote this process down in a step-by-step way for others to follow. The process of working on the 12 steps in a peer-group setting with a sponsor helps people to stop using alcohol and drugs and to stay sober by helping them develop skills and supports.

People learn by reading from self help literature, by observing the unsuccessful and successful coping strategies of others in groups, and by being coached by their sponsor and peers in the groups (see below.) The AA model of self-help works in many ways, and numerous books have been written about recovery through 12-step programs. For example, psychologists have pointed out that 12-step programs help people learn to manage their feelings, to reduce their use of avoidant and destructive coping strategies, and to increase their use of healthy cognitive and behavioral coping strategies.

AA is not a religious organization, but it does have a spiritual component. The steps talk about a higher power. In 12-step meetings, people are encouraged to believe that a higher power can be anything outside of themselves that can help them to change their addictive behavior, though many people do think of a higher power as God. To participate in AA, it is not necessary to believe in a higher power, but it does play a role in many meetings. Some meetings open or close with the Serenity Prayer or the Lord's prayer. Rational Recovery is a self-help organization that uses principles of AA without the emphasis on religion or higher power.

DIFFERENT TYPES OF 12-STEP MEETINGS
In the vignette, the clinician attended an open speaker meeting with Joanne. The difference between open and closed meetings is that anyone interested may attend an open meeting. Closed meetings are just for people who admit to having a problem. There are many types of AA meetings. In speaker meetings, someone tells the story of his or her illness and recovery. Discussion meetings involve open discussion, and people bring up problems they are having with their addiction. In step meetings, one of the steps is read aloud and discussed. In Big Book meetings, a chapter in the Big Book of Alcoholics Anonymous is read, and people discuss it. Clinicians should help clients choose which meetings they would feel most comfortable at. People never have to speak at a meeting other than to say they pass, but a discussion meeting is not a good place to start for someone who feels uncomfortable speaking in a group. Mental health clinicians who refer clients to 12-step meetings need to understand AA and types of meetings; they should definitely attend some open meetings to see what they are like.

SPONSORSHIP
In the vignette, Joanne finds a sponsor. A sponsor is someone with stable (usually 4 or more years) sobriety. Sponsors often talk to people they sponsor daily, go to meetings with them, and socialize with them. Sponsors guide a person through the steps of the program and help when a person has an urge to use substances. Many sponsors make themselves available day or night. People are encouraged to get a sponsor of the same sex. Persons who are willing to be sponsors usually raise their hands at meetings. When your client is looking for a sponsor, they need to pick someone they like and trust, as this is important to developing close relationship with them. Often groups will have a list of temporary sponsors, who agree to take phone calls or give rides to meetings to support someone until they find the "right" sponsor for them.

WHO SHOULD GO TO 12-STEP MEETINGS?
Who should go to self-help meetings? The meetings are helpful for persons who want to go, for persons who have no sober support network, and for persons who like the idea of peer support rather than or in addition to professional supports. Since AA and other self help groups are so widely available, affordable (free), and offer so many different tools and supports for recovery, everyone should be encouraged to try them. Participation in 12-step groups for people with dual disorders can be a very positive experience even if the person does not have the cognitive ability to embrace the 12 steps and traditions. When a dually disordered person finds a "home" group, he often experiences a sense of acceptance and community that was previously missing from his life.

Many 12-step meetings rely on the concept of accepting that one is an "addict" and using this self-identification to accept help from others and to avoid substance use. Some dually diagnosed people with psychotic disorders have difficulty tolerating this type of self-concept, which is experienced as a threat to self-esteem. Clients who are clear that they do not want to attend and clients who are very angry should not be pushed to attend 12-step groups. However, they may find AA more congenial at a later stage of their recovery process. Sometimes people have difficulty with accepting the concepts of powerlessness and character defects. Additional readings or reinterpreting the steps with more empowering concepts can be useful.

Table 2 outlines the steps the case manager took to help Joanne get involved with self-help groups. In the vignette, the clinician had a meeting list, so it was an easy task to sit down with Joanne and pick out some meetings. If you don't have a meeting list, you can always look AA up in the yellow pages. People with severe mental illnesses who are symptomatic often need more help than Joanne did to use 12-step groups. They may need an introduction to the ideas used in these groups. They may need explicit coaching about what to wear, how to act, and what to say. A case manager or counselor may need to go to meetings with a client for a longer period of time. Some clients will need social skills training to learn the skills to interact appropriately at 12-step meetings before they are ready to attend. While at meetings, clinicians can greet people and shake hands to model social skills. It often helps to discuss the meeting afterward to clear up any misunderstandings. If meetings for people with dual disorders, such as Double Trouble or Dual Recovery Anonymous, are available, many of these difficulties are eliminated.

Clients should be instructed about some of the unwritten "etiquette" expected at self-help meetings. For example, remind your client that who he sees and what he hears at the meeting is confidential, that is the "Anonymous" part of the program. When someone is talking, you remain in your seat. If coffee and/or food is provided, you might provide a donation and only take one helping. If the meeting is non-smoking, you can't smoke. For people with dual disorders, this type of orientation will help them be accepted by the group.

OPTIONS IN SELF HELP
Many self-help options are available. In the vignette, Joanne was able to successfully use AA as a support system. Initially, she had some ambivalence because she had tried it once and didn't feel like she fit in. Many dual disordered clients feel this way. There are different reasons for these feelings. Some people are uncomfortable with the spiritual aspect of the program. An alternative might be Rational Recovery where spirituality is not a part of the program. Another reason dual disordered people feel uncomfortable is that their mental illness makes them feel like they don't belong. A Dual Recovery Anonymous group might help solve that problem. If Joanne had not succeeded in AA, her clinician might have encouraged her to try Narcotics Anonymous or Cocaine Anonymous, which directly addresses addiction to substances other than alcohol. If a dual disordered person tries and really dislikes 12-step programs, a clinician should look for alternative ways to support that person's recovery.

Recommended reading
We strongly recommend The Dual Disorder Recovery Book (Hazelden, Center City, Minnesota, 1993) for a discussion of self-help and recovery for persons with dual disorders. Additionally, George Vaillant's book, The Natural History of Alcoholism (Cambridge, MA, Harvard University Press, 1995) offers a brilliant analysis of natural pathways to recovery and explains how self-help and treatment can enhance the process.

To learn more about 12-step programs, consider reading The Big Book by Alcoholics Anonymous World Services, Inc. Staff and Rational Recovery by Jack Trimpey (Pocket Books, 1996).

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