As an addiction psychiatrist, I have been working directly with individuals who have co-occurring conditions (formerly known as “dual diagnosis”) and their families for over 30 years. I have also directly managed almost every kind of program imaginable that has provided service to individuals with co-occurring conditions. I have worked directly providing training, technical assistance and consultation to all kinds of clinicians, programs, agencies, provider organizations, managed care organizations, and county and state systems all over the country. I want to share with you some of the most important things that I’ve learned (and taught) about how people with co-occurring conditions can make progress toward what we can call “dual recovery”.
Recovery: Many people automatically associate the term recovery with “recovery from addiction”. However, in the past few decades, the concept of recovery has expanded dramatically. We talk about recovery for people with serious mental illness, trauma, and chronic physical conditions as well as recovery in relation to traumatic life events like divorce and loss of a loved one. As this concept has evolved, so has our understanding of recovery.
Recovery is not recovery “from” a condition, but recovery of a human being who may have one or more serious and persistent conditions. Conditions may be medically diagnosed like addiction, bipolar disorder and diabetes, or, conditions may refer to other painful and persistent life circumstances. Recovery is a process, not an event, during which the person “recovers” pride, self-worth, hope, dignity, and meaning, even though the condition may persist, symptoms (e.g. cravings, mood swings) and disabilities may persist, and the need for continued treatment and support may persist. Recovery happens over time and is ongoing, so the person is engaged in a continuing spiritual process that brings greater meaning and serenity to his or her life over time.
In this regard, anyone with any condition, and anyone with many conditions, can experience the hope and promise of recovery.
Most people have many conditions! If we look at epidemiologic data, as well as the experiences of most people who are struggling with addiction or anything else, most suffer from “co- occurring conditions”. That is, “Co-occurring conditions are an expectation, not an exception.” People struggling with addiction are more likely to struggle with co-occurring mental health conditions than people in the general population. These conditions can precede the addiction or sometime emerge during the course of the addiction but nonetheless, they persist indefinitely once sobriety has been attained. These conditions may include serious mental illnesses such as bipolar disorder, schizophrenia, major depression, anxiety disorders, PTSD, and ADHD, as well as the general effects of trauma (emotional, physical and sexual abuse as well as stressful life events), personality disorders, cognitive challenges, and a wide variety of other challenges. If you are suffering with two or more co-occurring MH and SA conditions- you are not alone. You can get better and achieve a happy, meaningful and successful life!
Below are some very basic principles and suggestions that you can apply in your own life or to help someone you love. These principles are designed to make your journey “simpler” (though there is no shortcut to recovery).
The Principles of Dual Recovery
1. Welcoming: “Co-occurring” is an expectation, not an exception. Welcome yourself into the recovery process, exactly as you are.
One of the challenges you may face as a person with co-occurring conditions is feeling like a “misfit” in both the mental health world and in the substance abuse world. This feeling may lead to strong feelings of shame and failure, feelings of being uniquely screwed up, often combined with an undercurrent of self-blame for being so sick in the first place. Many co-occurring mental health conditions, as well as substance use issues are related to past and present experiences of “trauma” (emotional, physical, and/or sexual abuse). This sense of self-blame becomes a continuation of the abuse, this time in your own thoughts which make it hard for you to feel that you are even worthy of getting well. This is why “welcoming yourself” is such an important step.
Welcoming may sound corny, but it really works. Find your own welcoming speech and say it over and over to yourself: You are an amazing person who has had the courage to recognize that you have BOTH mental health and substance problems. This is very common, and you deserve credit for showing up- exactly as you are – to try to make changes. You deserve as much or more help as anyone else because you are likely to be having a very hard time. Don’t worry…. you are in the right place and you can begin making progress toward addressing all your issues slowly over time in order to have a happy, hopeful, beautiful and meaningful life.
2. Hope: Hope fuels the journey. Identify your most important vision for a happy, successful meaningful life, and use that vision every day.
The starting place for hope is recognizing that people with any condition can experience the promise and hope of “recovery”. This further means that even though you may have two or more conditions that can be “chronic” or “lifelong”, you have every ability to achieve a happy, meaningful and successful life that can be even more spiritually rewarding than a life led by someone who has neither mental health nor substance use issues.
Write down your vision of a happy life. Keep that vision in front of you and use it to energize your own “integrated recovery” plan. Write what you really hope for and shoot high: “I want to feel like a person who is proud of who I am when I look in the mirror”. “I want relationships with friends and family that are loving and meaningful, where I value both what I give and what I receive.” “I want to engage in meaningful work or other activity”. “I want a place to live that feels like home”.
3. Strength-based: Supersize your strengths by focusing on what you have done right.
When you have more than one type of issue it is likely that your story will include many ups and downs. It is natural to want to focus on your failures and to feel like you have to “confront” yourself in order to make progress. This “deficit-based” approach becomes
progressively less helpful as you face more challenges. Instead, you need to be “strength-based” in order to energize your existing capacities to make progress. How do you do this? Remember the following:
a) The more challenges you have, the more strength it’s taking you to even live your life, as well as to make progress.
b) In a strength based framework, there is no such thing as a “chronic relapser”. There are only people like all of us who are recurrently successful. Start by thinking about the periods of time (even if short) in which you did well. What strengths did you use every day for all of your issues to be successful? Write down all the things that you did right, and all the things you are doing right at the present moment. You will begin to realize how much you actually have to work with and will start feeling stronger. The next steps involve building your current strengths so that you do better in the future, rather than tearing yourself down.
4. Time: Progress occurs slowly for both types of issues, one day at a time.
The process of recovery for people who have multiple co-occurring conditions takes time. There is a tendency for people to seek a “program” that will address all their co-occurring issues in a few weeks or months. However, this is more often than not disappointing. While a program may be helpful in getting you started, many people get started without such an intervention. In either case, the “real” work is making small steps of progress for each issue over time. It is important to celebrate your actual progress “one day at a time” for each issue, rather than constantly being upset because you haven’t been “fixed” yet. There is a lot to learn, and no one can possibly learn it all at once.
5. Partnering for Progress: Identify a helpful team that will work with you on all your issues.
Now that you are in the right frame of mind for your recovery journey, you need to start pulling your team together to help you along the way. You need a team that can work with you as partners, help you with all your issues in small steps, and hang in there with you in a way that is empathic, hopeful, and strength based over time. Who should be included? Start with the most positive people you can find in your environment – family members and friends, as well as anyone you can find who has lived and experienced recovery (especially dual recovery) and who is willing to support you on your journey. Next, look for professionals who can help you as well. Find at least one counselor who is comfortable working with you as a partner to help you figure out how to manage ALL of your issues. Even though they may not be expert in all, they should be willing to work with you to seek the best possible input on each issue to guide your progress. I often recommend that people start not by committing to a program, but by finding the best local expert in the field of co-occurring addiction and mental illness and getting an excellent assessment along with recommendations for ongoing care. Recognize that using medication is appropriate to help your mental illness, but even when medicine works; it rarely works perfectly or instantly and still requires you to learn how to manage “normal” painful feelings, as well as ongoing symptoms of your illness. You need good partners to help you find the right approaches. Also, recognize that medications (anti-craving agents such as naltrexone or acamprosate, for example) are increasingly used as helpful interventions to support sobriety, along with other types of treatments and self -help recovery programs. Work with your teammates to explore all the available tools and decide which ones are best for you over time.
6. Integrated Recovery Planning: Develop your own personal “recovery plan” to guide your progress.
It is helpful to have some structure to organize your recovery journey. I recommend a template in which you begin by writing down your hopeful vision. List all of the issues (e.g. Substance use, mental health, health, relationship, job etc.) that affects your progress toward your vision and then identify all the strengths you have been using to do at least something right for each issue. Then you ask yourself, “What is the next baby step I need to take for each issue in the next month in order to make a little more progress?” Then for each issue, write down your “baby step” objective, the help you will need to learn how to take that step and how to recognize when you’ve actually accomplished it. This forms your integrated “plan” that will keep you focused over the next month or so.
The following principles guide the content of the plan and the work that you need to do.
7. Integrated Primary Treatment: All your issues are primary. The key to success is to take the best small next step for each issue at the same time.
Many people with co-occurring conditions get “stuck” trying to figure out which problem is “primary”. Am I drinking to cover up my depression? Am I depressed because of my drinking? What we have learned is very simple and important: it doesn’t matter how the problems got there… it only matters that they are there, they are persistent, and they need attention. Success is built on treating each issue as “primary” – that means that each issue (whether it is a “diagnosis” or a more tangible problem like “finding a job”) is important in its own right. It means that the best intervention for people with multiple issues is the best next small step for each issue at the same time. Find the small step that you can and will do for each issue. If it feels too overwhelming or confusing, take a smaller step!!!!
8. Stage-matching: The correct intervention for each issue must be matched to your stage of change for that issue. Most people are familiar with the concept of stages of change:
• Pre-Contemplation -Don’t bug me about that.
• Contemplation -I’m willing to think about whether to change but I don’t want to change.
• Preparation- I need to find a small step to start.
• Early Action – I’m taking some steps, but not following all the recommendations.
• Late Action- I’m working as hard as I can to be stable and successful, but I need help to be more consistent.
• Maintenance- I’m stable and trying to stay that way.
What you are probably less familiar with is the application of stages of change to people with multiple issues.
If someone asks you, “What stage of change are you in?” the correct answer is always “For which issue?” Stage of change is issue specific, not person specific. The best next step and outcome for each issue has to be stage matched.
So in your plan, write down which sentence best works for you for each issue, and then think about how to move a little bit forward in that stage. You may be “Late Action” for sobriety, in that you are trying all the recommendations you have been given, but you need to learn how to apply what you have learned more consistently, while you may be in “Early Action” for depression, where you are just realizing that you might need antidepressants, but are not sure it’s the right decision, so you agree to try medication just for a few weeks. You may be in “Pre-Contemplation” to quit smoking, where the challenge is to just make it easier for you to even think about smoking (Contemplation), by considering questions like: “What is the right amount of smoking for me right now?” and “How well is my current smoking plan working for me in helping me achieve my goals?” These are examples of stage matched interventions for each issue.
In your recovery plan, write your “stage of change” next to each issue, so you can be sure that your intervention and plan is “stage- matched”.
9. Skill Building: Progress comes through learning new skills. Learning requires practice, rehearsal and repetition in small steps with lots of support over time.
As a person with co-occurring conditions, it is easy to find people who will provide you with recommendations for one or more of the issues that you struggle with. Often, you will recognize that these recommendations are helpful and you may be pretty good at repeating what you have been told: “Don’t drink. Go to meetings. Ask for help” “Take your medication as prescribed” However, even though the recommendations may seem deceptively simple, the real challenge for people with co-occurring conditions is to learn a whole new set of skills for managing multiple conditions. I call this “Learning the skills you need to succeed.”
Learning occurs through practice, and usually the practice has to occur for you with a lot of attention to detail and a willingness to work with your team of partners to support your continued learning and practice. Be aware that nothing you have to learn is all that simple… so give yourself a break, and be willing to learn in small steps.
One set of skills are called “Self-management skills” – Things you do on your own to help yourself deal with a particular challenge. For example, if you are supposed to take medication regularly, how do you organize yourself to do that, knowing that no one is perfect at taking medication? Or, if you are supposed to “not drink”, what skills do you use to refuse offers of alcohol or drugs from other people? How do you practice and improve any set of skills- through trial and error, in small steps over time.
For each issue that you are taking action on in your recovery plan, think about how your “action step” can identify one or two new skills or behaviors, and then practice them in various situations over the next period of time.
10. Accelerating Assistance: The better you get at asking for help sooner rather than later, the faster you will make progress.
For managing each issue you face, there are skills you will learn relatively easily, and others in which you will need help to make progress. It is important to remember that asking for help is a skill, and there is no easy way to master that skill effectively for multiple conditions. When managing multiple conditions, you need to learn to ask for help in many ways. First, you have to learn to ask for help for each issue you face. Second, for each of those issues, you are likely to need to learn to ask for help from professionals (including prescribers), friends, family, and peers (as in 12 step programs).
As part of your recovery plan, think about where you are very good at asking for help already, and then identify next “baby steps” to practice new learning. Common examples include:
• Developing a great partnership with your prescriber to work on identifying over time the right medication for you, with the fewest side effects: How do you learn to really share what is going on and ask for what you need?
• Asking for help with each issue when you are in trouble: How do you practice calling and asking for help and support when you have cravings? How quickly can you tell someone if you “pick up” and get help to stop?
• Asking for help to manage uncomfortable feelings or MH symptoms: How easily can you share with counselors, family, or peers (or sponsor) when you are having a hard time with MH symptoms, to get support through the day?
• Finding a support system that is “co-occurring friendly”: How do you develop a core support system of people who are comfortable with your having both issues? How can you find Dual Recovery meetings – or “co-occurring friendly meetings” – in your community?
11. Rounds of Applause: Reward is the best way to support ongoing change.
The journey of recovery can be painfully slow and frustrating. It will be easy for you to expect more of yourself than you can possibly achieve all at once. Remember, even though you may have a long way to go, you are still making progress. Be sure to encourage each tiny baby step of progress by giving yourself a big round of applause.
If you have ever taken a course in psychology, you were taught that “reward is a more effective way to support learning than punishment.” Yet, even though we know this, we tend to try to punish ourselves into success… which often pushes us backwards. The framework of “positive contingent learning” is a “best practice” for people with multiple serious challenges. In fact, it is one of the core elements of 12 Step recovery programs – you get a round of applause from a room full of people for being sober just one day.
Think about applying that approach to every area of progress – you figured out how to take your medication a bit more consistently – round of applause. You asked your prescriber a tough question about why the medications doesn’t seem to work well – round of applause. You asked someone for help for the first time when you were having cravings – BIG round of applause.
12. Continuing the Journey: Maintaining forward progress when you run into a wall.
You have a lot of opportunity to work your way down the list, starting with welcoming and hope, identifying your strengths, engaging your partners, and putting together a recovery plan. You have made some progress and you have worked pretty hard, but suddenly you find yourself slipping backwards. Maybe you relapse on drugs or alcohol or your medication for mental illness isn’t working as well. You get really frustrated because you feel like you have not made as much progress as you wish. Your goals seem a long way off and impossible. You encounter a loss or disappointment. What do you do?
When you get discouraged, it is tempting to abandon the principles and try to find a short cut or quick fix to pull you out of the doldrums, but generally that’s not going to get you where you need to go. The key recommendation is this:
When you feel that the principles aren’t working, it’s time to go back and apply those principles even more vigorously.
• Go back and welcome yourself for being such an amazing person.
• Put your hopeful vision in front of your eyes.
• Think about all the amazing strengths you have been using to make progress for each and every issue.
• Recognize that progress occurs slowly, and focus on smaller and easier steps.
• Think about your partners and how important they are to helping you.
• Review and update your recovery plan.
• Find an easy small step for each issue that is strength-based,stage-matched, and involves learning a new skill for either self- management or asking for help.
• Give yourself a big round of applause for taking those next steps.
• Keep on going.
You are an amazing human being who is making enormous progress in the face of multiple challenges. You deserve to be happy and to get all the help you need to achieve your goal of a beautiful and meaningful life. You are a miracle.
Kenneth Minkoff, M.D. is a board-certified psychiatrist and is currently a clinical assistant professor of Psychiatry at Harvard Medical School. He is a senior systems consultant for ZiaPartners in San Rafael, CA. Kenneth is recognized as one of the nation’s leading experts on recovery oriented integrated services for individuals and families with co-occurring mental health, substance use, and health conditions, plus other complex needs, and has published dozens of articles in this field. Along with his partner, Christie A. Cline, MD, MBA, Dr. Minkoff has developed a framework for integrated systems and services development, and a toolkit to help programs and clinicians to make progress. Dr. Minkoff and Dr. Cline have provided integrated system consultation in over 40 states, 7 Canadian provinces, and 4 states in Australia.