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Co-occurring Disorders and Recovery

Often in recovery, we will hear the term co-occurring disorders.

What exactly does that term mean?

According to the Substance Abuse and Mental Health Administration (SAMHSA), co-occurring disorders, previously referred to as dual diagnoses, are the co-existence of both mental health and a substance abuse disorder.

Mental health disorders that often come into play with substance abuse and addiction include depression, bipolar disorder, anxiety, post-traumatic stress disorder (PTSD), schizophrenia, and obsessive-compulsive disorder (OCD).

According to Psychology Today, examples of co-occurring disorders include combinations of depression and cocaine, depression and opiate addiction, anxiety and benzodiazepine addiction, schizophrenia and marijuana addiction, opiate addiction, PTSD, and anxiety cocaine addiction. These groupings can include other mental health and/or chemical substances.

These mental health disorders are often challenging to diagnose while a person is actively drinking and/or using because many chemical substances can promote depression, anxiety, schizophrenia, and other mental illnesses.

Initially, addicts might experience relief from their depression and anxiety by drinking and/or using. But after they develop a tolerance to their drug of choice, the drug stops making them feel good and backstabs them. This makes addicts drink or use more in a desperate effort to feel good. But often, they end up feeling more depressed. Then, they might resort to ingesting even more or adding another drug to their chemical cocktail.  At that point, they might overdose or die.

Another important factor to address when it comes to co-occurring disorders is that it is often difficult to discern if the mental illness or the substance abuse disorder came first.

This dilemma parallels the “What came first? The chicken or the egg?”

Like I did, some self-medicate with drugs and/or alcohol to alleviate symptoms of depression and anxiety. Sometimes addicts shop around from drug to medicine until they find the right fit. Basically, that’s how I “coped” with my own mental illness. I tried speed, moved onto codeine, and then experimented with heroin. Luckily, I only tried heroin twice, thanks to experiencing horrifying withdrawal symptoms. Shortly after that, I was introduced to cocaine while I was bartending in a club on the Upper West Side in New York City. Somehow, I could afford my habit, and after several years, cocaine pulled a number on me.

My last coke experience reminded me of the 1979 sci-fi film, Alien, starring Sigourney Weaver. During the film, Kane (played by John Hurt) becomes the host for the Alien, a creature that later bursts out of his chest.

During my last rendezvous with cocaine, I truly believed that I had a rat scuffling around, underneath my rib cage, inside my chest cavity. I know that sounds crazy, but that’s what I imagine. I honestly thought that the rat would burst out of my torso just like the Alien erupted out of Kane!

Instead of getting clean, I shopped around for another drug.

I did not care for hallucinogens. I tried acid once and had a bad experience. And, I wasn’t keen on marijuana.

So that’s how I ended up an alcoholic.

Years later, when I saw a psychiatrist in Brentwood, California, I did not tell him that I was an alcoholic. He diagnosed me with OCD and prescribed Celexa, a selective serotonin reuptake inhibitor (SSRI), along with Cymbalta.

I am sure my meds did not mix well with the booze.

Four years after I got sober, another psychiatrist diagnosed me with bipolar disorder. She made a more accurate diagnosis because I did not have a substance abuse disorder masking my mental health issue.

And there are some addicts whose substance abuse disorder precedes their mental illness.

Ecstasy is a good example of a drug that can cause depression or anxiety because chronic abuse of that particular drug leads to a permanent mood disorder.

Clients with co-occurring disorders are more challenging to treat than those with just substance abuse or mental health disorder.  These individuals are more vulnerable to relapse, but once they get clean and sober, their mental health issues can worsen without proper treatment.

The bottom line is that newly clean and sober addicts who suffer from co-occurring disorders require clinical, evidence-based care. And it’s hard to find the right care. Just going to a therapist who has no clue about substance abuse or only participating in a traditional peer recovery group might not be enough.

Clinical, evidence-based treatment addresses both substance abuse and mental health disorder. This treatment program ideally includes group and individual therapy, participation in a peer recovery program, life skills coaching, and experiential therapies, including psychodrama, bio-sound therapy (for trauma), art therapy, and music therapy.

Evidence-based practices include cognitive-behavioral therapy (CBT) and motivational interviewing.

CBT is used to treat mood disorders like depression and anxiety. Clients are taught to challenge damaging thought patterns about themselves and their negative thinking about the world.  CBT uses a hands-on, practical approach. Addicts tend to get lost in their heads and often hate themselves. Sometimes their self-esteem is so destroyed that they feel like the world hates them.

While they might have undergone a toxic relationship with a parent or partner or are experiencing estrangement from a loved one, their negative feelings about the world are not based on reality.

CBT helps them change negative thinking into positive attitudes and behavior. Usually, CBT is combined with psychotherapy, which allows the therapist to create an individualized treatment plan for each client.

Participation in a peer recovery program, like AA/NA, helps addicts receive ample support. By learning to rely on a Higher Power and each other, addicts learn how to maintain their sobriety one day at a time.

A comprehensive clinical, evidence-based program will offer 12 steps, processing groups. The staff takes clients to AA/NA meetings and helps them work through their actions. Often therapists and addiction counselors are in recovery themselves, and under their guidance, clients are wisely educated on the 12 steps.

It is also important to remember that AA founder Bill Wilson suffered from depression. After he got sober, he searched for help outside the 12 steps.

Many AA members were disturbed by Wilson’s depression, and some actually said that Wilson was not working the program! Even Wilson himself believed the same thing and said,

“I used to be rather a guilt-ridden about this…I blamed myself for inability to practice the program in certain areas of my life.”

Depression is a mental illness and requires the help of licensed professionals.

Even the Big Book, which Bill Wilson co-authored with Dr. Bob Smith, says, “We are convinced that a spiritual mode of living is a most powerful health restorative. … But this does not mean that we disregard human health measures. … Though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are indispensable in treating a newcomer and in following his case afterward.” 

That excerpt alone reiterates the fact that clients with co-occurring disorders require dual diagnosis support.  By participating in a comprehensive, evidence-based program, they have an excellent chance of maintaining their sobriety, rebuilding their lives, and truly comprehending the beauty of recovery.

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