DDoubleouble T Troublerouble RRecoveryecovery

SELF HELP FOR THE DUALLY SELF HELP FOR THE DUALLY

DIAGNOSEDDIAGNOSED

Presenter:Presenter:

Howard VogelHoward Vogel

20052005

AcknowledgementsAcknowledgements

• Thanks to all of the consumers Thanks to all of the consumers who are made this presentation who are made this presentation possible by sharing their possible by sharing their experiences,experiences,

• And thanks to the service And thanks to the service providers for their cooperation. providers for their cooperation.

BackgroundBackground

• High prevalence of comorbidity with many High prevalence of comorbidity with many far-reaching treatment implications:far-reaching treatment implications:

• More severe and chronic than single, “pure” More severe and chronic than single, “pure” psychiatric disorderspsychiatric disorders

• Associated with a variety of negative Associated with a variety of negative consequences including clinically, consequences including clinically, therapeutically, psychologically as well as therapeutically, psychologically as well as socially and economically.socially and economically.

• Predictor of negative treatment outcomes for Predictor of negative treatment outcomes for drug users.drug users.

ANDAND• Interaction between street drugs and Interaction between street drugs and

medication.medication.

Self-Help ProgramsSelf-Help Programs

• A group of individuals who share a A group of individuals who share a common problem behavior.common problem behavior.

• They learn to accept their problem, They learn to accept their problem, share their experiences, strengths, and share their experiences, strengths, and hopes.hopes.

• Only requirement for attending is the Only requirement for attending is the desire to abstain from the problem desire to abstain from the problem behavior.behavior.

• No “professional” involvement.No “professional” involvement.• Most are based on some adaptation of Most are based on some adaptation of

the 12-step model.the 12-step model.

Self-Help Programs Self-Help Programs (continued)(continued)

• Recognized as a potentially cost-Recognized as a potentially cost-effective treatment modality.effective treatment modality.

• Often included in aftercare planning Often included in aftercare planning and used as a complement to formal and used as a complement to formal treatment.treatment.

• Little research on self-help.Little research on self-help.• Conducted with AA groups.Conducted with AA groups.• Evidence that involvement self-help Evidence that involvement self-help

group has a positive effect on recovery.group has a positive effect on recovery.

How Self-Help WorksHow Self-Help Works• Self-help contributes to the reduction of Self-help contributes to the reduction of

mental health symptoms in five ways:mental health symptoms in five ways:• 1. Provides a 1. Provides a social networksocial network based on based on

commonly shared experience.commonly shared experience.• 2. Facilitates 2. Facilitates move from help-recipient to move from help-recipient to

helperhelper• 3. 3. Specific ways of copingSpecific ways of coping based on based on

experience are shared.experience are shared.• 4. Those who cope successfully serve as 4. Those who cope successfully serve as

role models.role models.• 5. Provides 5. Provides meaningful structure meaningful structure which which

is self-generated rather than imposed is self-generated rather than imposed from the outside.from the outside.

Traditional Self-Help Traditional Self-Help and the Dually-Diagnosedand the Dually-Diagnosed

• ““ONE DISEASE-ONE RECOVERY.” ONE DISEASE-ONE RECOVERY.” Recovery needs which fall within that Recovery needs which fall within that single parameter are ignored, single parameter are ignored, misunderstood, or stigmatized.misunderstood, or stigmatized.

• DOUBLE STIGMA = DANGER OF DOUBLE STIGMA = DANGER OF MINIMIZING, OR IGNORING THE MINIMIZING, OR IGNORING THE “OTHER HALF” of recovery needs.“OTHER HALF” of recovery needs.

• MISGUIDED ADVICE ABOUT MENTAL MISGUIDED ADVICE ABOUT MENTAL DISORDERS AND MEDICATION can lead DISORDERS AND MEDICATION can lead to non-compliance with medication, to non-compliance with medication, increased psychiatric symptoms, and increased psychiatric symptoms, and substance abuse relapse.substance abuse relapse.

Traditional Self-Help Traditional Self-Help and the Dually-Diagnosedand the Dually-Diagnosed

• Lack of identification = Lack of identification = NO SOCIAL/EMOTIONAL SUPPORT, NO SOCIAL/EMOTIONAL SUPPORT, NO LEARNING/SKILLS DEVELOPMENT, NO LEARNING/SKILLS DEVELOPMENT,

NO DIRECTION OR PERSONAL NO DIRECTION OR PERSONAL GUIDANCEGUIDANCE

• Individuals with dual recovery needs Individuals with dual recovery needs cannot typically find the HONESTY, cannot typically find the HONESTY, ACCEPTANCE, EMOTIONAL SUPPORT ACCEPTANCE, EMOTIONAL SUPPORT AND SHARED EXPERIENCES which are AND SHARED EXPERIENCES which are critical elements of mutual aid process in critical elements of mutual aid process in traditional self-help groupstraditional self-help groups

• A fellowship of men and women who share A fellowship of men and women who share their experience, strength, and hope with each their experience, strength, and hope with each other so they may solve their common other so they may solve their common problems and help others to recover from their problems and help others to recover from their particular addiction(s) and mental disorders.particular addiction(s) and mental disorders.

• A mutual aid program adapted from 12 step A mutual aid program adapted from 12 step programsprograms

• Primary purpose is to maintain freedom from Primary purpose is to maintain freedom from addiction(s) and to maintain well-being.addiction(s) and to maintain well-being.

• DTR also addresses the problems and benefits DTR also addresses the problems and benefits of psychiatric medication, thus recognizing of psychiatric medication, thus recognizing that for many, having addiction and mental that for many, having addiction and mental disorders represents Double Trouble in disorders represents Double Trouble in Recovery.Recovery.

Double Trouble in Double Trouble in Recovery (DTR)Recovery (DTR)

• No dues or fees for DTR membership; DTR is No dues or fees for DTR membership; DTR is self-supporting through members’ own self-supporting through members’ own contributions.contributions.

• Not affiliated with any sect, denomination, Not affiliated with any sect, denomination, political group, organization or institution.political group, organization or institution.

• From the first group in NYC in 1989, DTR is From the first group in NYC in 1989, DTR is now a nationwide movement. Currently, now a nationwide movement. Currently, there are over 100 DTR groups in the US, there are over 100 DTR groups in the US, 40+ in NYC alone.40+ in NYC alone.

• An average of 15 new groups start each year.An average of 15 new groups start each year.

Double Trouble in Double Trouble in Recovery (DTR)Recovery (DTR)

• A 3.5 year effectiveness study.A 3.5 year effectiveness study.

• Funded by the National Institute on Funded by the National Institute on Drug Abuse (NIDA).Drug Abuse (NIDA).

• Using a 12-month prospective Using a 12-month prospective longitudinal cohort of 310 members longitudinal cohort of 310 members in 25 peer-led DTR groups in NYC.in 25 peer-led DTR groups in NYC.

• Semi-structured interview protocolSemi-structured interview protocol

About the StudyAbout the Study

• MaleMale 72%72%• Median AgeMedian Age 39 years (SD+8.6)39 years (SD+8.6)• African-AmericanAfrican-American 58%58%• HispanicHispanic 16%16%• CaucasianCaucasian 25%25%• OtherOther 1%1%• Primary Income:Primary Income:

– Government Assistance Government Assistance 95%95%– JobJob 3%3%– OtherOther 2%2%

SociodemographicsSociodemographics

• Less than grad/GEDLess than grad/GED 41%41%• HS grad/GEDHS grad/GED 32%32%• Some college or moreSome college or more 27%27%• Living Arrangements:Living Arrangements:• Own apt/houseOwn apt/house 21%21%• Community residence/Apt programCommunity residence/Apt program 52%52%• SROSRO 16%16%• W/friends/relativesW/friends/relatives 11%11%

SociodemographicsSociodemographics

• Ever physically abused Ever physically abused 48%48%• Ever sexually abusedEver sexually abused 36%36%• Legal status:Legal status:• No involvementNo involvement 91%91%• Probation/parole/pendingProbation/parole/pending 7%7%• Seropositive for HIVSeropositive for HIV 6%6%

Other CharacteristicsOther Characteristics

• Age 1st emotional/MH problemsAge 1st emotional/MH problems 18 yrs*18 yrs*• Age 1st sought/received help for MHAge 1st sought/received help for MH 22 yrs*22 yrs*• Age 1st diagnosedAge 1st diagnosed 30 yrs*30 yrs*• PRIMARY DIAGNOSIS:PRIMARY DIAGNOSIS:

– SchizophreniaSchizophrenia 43%43%– Unipolar (major) depression Unipolar (major) depression 26%26%– Bipolar DisorderBipolar Disorder 25%25%– SchizoaffectiveSchizoaffective 7%7%– Mood DisorderMood Disorder 5%5%– PTSDPTSD 5%5%

*median*median

Mental Health HistoryMental Health History

• Symptoms past year Symptoms past year 70%70%

• Emotional/mental health past Emotional/mental health past month:month:– Very Troubled Very Troubled 10%10%– ModeratelyModerately 28%28%– Somewhat TroubledSomewhat Troubled 38%38%– Not at allNot at all 24%24%

Mental Health: Past YearMental Health: Past Year

• Ever hospitalized for MHEver hospitalized for MH 89%89%• Ever in outpatient treatmentEver in outpatient treatment 97%97%• Ever on medication for MHEver on medication for MH 100%100%• Median age started medication Median age started medication 24 yrs*24 yrs*• Currently in outpatient MH/MICACurrently in outpatient MH/MICA 91%91%• Length of current enrollmentLength of current enrollment 8 mos.8 mos.• Currently taking medications for MHCurrently taking medications for MH 92%92%*median*median

Mental Health TreatmentMental Health Treatment

• Age 1st used drugs/alcoholAge 1st used drugs/alcohol 14 yrs.14 yrs.• 1st Substance used:1st Substance used:

– AlcoholAlcohol 65%65%– MarijuanaMarijuana 23%23%– HeroinHeroin 4%4%– Crack/cocaineCrack/cocaine 3%3%

• Why started: Peer pressure/to fit inWhy started: Peer pressure/to fit in 63%63%• Primary substance (lifetime):Primary substance (lifetime):

– Crack/cocaineCrack/cocaine 42%42%– AlcoholAlcohol 34%34%– HeroinHeroin 11%11%– MarijuanaMarijuana 10%10%– OtherOther 3%3%

Substance Use HistorySubstance Use History

• Past year Past year anyany drug/alcohol drug/alcohol47%47%

• Any drugsAny drugs 36%36%• Any alcoholAny alcohol 34%34%• Past month Past month anyany drug/alcohol drug/alcohol

9%9%• Any drugsAny drugs 5%5%• Any alcoholAny alcohol 6%6%

Substance Use Past YearSubstance Use Past Year

• Age 1st D&A treatmentAge 1st D&A treatment 28 28 yrs.*yrs.*

• Ever hospitalized for D&AEver hospitalized for D&A 75%75%• Ever in outpatient for D&AEver in outpatient for D&A 96%96%• Currently in outpatient for D&ACurrently in outpatient for D&A 77%77%• Length of current enrollmentLength of current enrollment 8 8

mos.*mos.**median*median

Substance Abuse Substance Abuse TreatmentTreatment

• ““Overall, what has caused you the most Overall, what has caused you the most problems?”problems?”– Substance abuseSubstance abuse 29%29% −− Mental Health Mental Health 17%17%– Both EquallyBoth Equally 49%49% −− Not sure Not sure 6%6%

• ““When you have symptoms, how much do When you have symptoms, how much do you feel like using?”you feel like using?”– Very muchVery much 44%44% −− A littleA little 14%14%– ModeratelyModerately 17%17% −− Not at allNot at all 25%25%

• When/if using...When/if using...– Symptoms get worseSymptoms get worse 69%69%– Symptoms get betterSymptoms get better 16%16%– Symptoms stay the sameSymptoms stay the same 15%15%

Association between Mental Association between Mental HealthHealth

and Substance Abuseand Substance Abuse

• ““Overall, what has caused you the most Overall, what has caused you the most problems?”problems?”– 1-3 months1-3 months 12%12%– 4-12 months4-12 months 25%25%– 1 year or more1 year or more 64%64%

• ““When/If you have symptoms, how much do When/If you have symptoms, how much do you feel like using?”you feel like using?”– Through a therapistThrough a therapist 41%41%– Through a friend/assocThrough a friend/assoc 19%19%– At drug treatment prog.At drug treatment prog. 16%16%

• ““When/If using...When/If using...– Twice a week or moreTwice a week or more 37%37%– Once a weekOnce a week 60%60%– Less than once a weekLess than once a week 3%3%

Self-Help: DTR AttendanceSelf-Help: DTR Attendance

• Length of attendance:Length of attendance:– 1-3 months1-3 months– 4-12 months4-12 months– 1 year or more1 year or more

• Frequency of attendanceFrequency of attendance– Twice a week or moreTwice a week or more 7%7%– Once a weekOnce a week 60%60%– Less than once a weekLess than once a week 3%3%

• ““How did you first hear about DTR?” (Top 3)How did you first hear about DTR?” (Top 3)– Through a therapist Through a therapist 41%41%– Through a friend/assocThrough a friend/assoc 19%19%– At a drug treatment prog.At a drug treatment prog. 16%16%

Self-Help: DTR AttendanceSelf-Help: DTR Attendance

• Importance of DTR in recoveryImportance of DTR in recovery– Very importantVery important 85%85%– ModeratelyModerately 13%13%– A little/not at allA little/not at all 3%3%

• Importance of other DTR members in Importance of other DTR members in recoveryrecovery– Very importantVery important 79%79%– ModeratelyModerately 15%15%– A little/not at allA little/not at all 6%6%

Self-Help: DTR and Self-Help: DTR and RecoveryRecovery

– Currently attending Alcoholics AnonymousCurrently attending Alcoholics Anonymous73%73%

– Currently attending Narcotics AnonymousCurrently attending Narcotics Anonymous 64%64%– Speak about MH in AA or NASpeak about MH in AA or NA 49%49%

• Reasons for attending other 12-step groups Reasons for attending other 12-step groups (Top 2)(Top 2)

– To stay clean and sober/deal w/drug issuesTo stay clean and sober/deal w/drug issues51%51%– To hear other’s storiesTo hear other’s stories 18%18%

• Reasons for not attending other 12-step Reasons for not attending other 12-step meetings (Top 2)meetings (Top 2)– DTR meets my needs, don’t miss groups.DTR meets my needs, don’t miss groups. 32%32%– Don’t feel accepted/comfortable.Don’t feel accepted/comfortable. 17%17%

Self-Help: Other 12-Step Self-Help: Other 12-Step GroupsGroups

• ““Why do you come to DTR?”Why do you come to DTR?”– To identify with, relate to other dually diagnosed To identify with, relate to other dually diagnosed

people 38%people 38%– To stay clean and sober 22%To stay clean and sober 22%– For help, support, acceptance, understanding, For help, support, acceptance, understanding,

and respect 20%and respect 20%

• ““How has coming to DTR affected your How has coming to DTR affected your life and your recovery?”life and your recovery?”– Give me hope, support, encouragement, a new Give me hope, support, encouragement, a new

outlook on lifeoutlook on life 20%20%– Better understanding of self, issues, dual-Better understanding of self, issues, dual-

diagnosis 20%diagnosis 20%– I don’t use, I stay clean and sober, I am restored I don’t use, I stay clean and sober, I am restored

to sanityto sanity 19%19%

Findings: In their own Findings: In their own words...words...

• ““How would your life be different now How would your life be different now if you hadn’t come to DTR?”if you hadn’t come to DTR?”– I would be using/getting highI would be using/getting high 32%32%– I would be confused, lonely, searching for helpI would be confused, lonely, searching for help

16% 16%

• ““Overall, what has changed in your life Overall, what has changed in your life since you started attending DTR?”since you started attending DTR?”– Greater self-esteem, respect, acceptance, Greater self-esteem, respect, acceptance,

understand for self and others 21%understand for self and others 21%

• Goals and hopes for the next year:Goals and hopes for the next year:– Vocational/job mentions????Vocational/job mentions???? 47%47%– HousingHousing 30%30%– Stay clean and soberStay clean and sober 29%29%– EducationalEducational 20%20%

Findings: In their own words..Findings: In their own words..(Cont)(Cont)..

• As part of it’s effort to educate about dual diagnosis, DTR As part of it’s effort to educate about dual diagnosis, DTR organized dialogues where consumers and service organized dialogues where consumers and service providers exchange ideas and concerns outside of the providers exchange ideas and concerns outside of the therapeutic environment.therapeutic environment.

• One question is: “What has been your most difficult One question is: “What has been your most difficult struggle in your recovery from dual-diagnosis?”struggle in your recovery from dual-diagnosis?”

• Proceeds from ten dialogues held in New York State in Proceeds from ten dialogues held in New York State in 1996 and 1997 representing over 200 participants were 1996 and 1997 representing over 200 participants were combined to eliminate redundancy.combined to eliminate redundancy.

• The resulting list of 36 items was incorporated into the The resulting list of 36 items was incorporated into the baseline questionnaire of the study. Specifically, the baseline questionnaire of the study. Specifically, the question was: “Following are issues and situations that question was: “Following are issues and situations that people may struggle with during their experience dealing people may struggle with during their experience dealing with these issues in recovery.”with these issues in recovery.”

• The answer categories were on a 4 point Likert-type The answer categories were on a 4 point Likert-type scale: Very difficult to deal with/to do, moderately scale: Very difficult to deal with/to do, moderately difficult, a little difficult to deal with, and not at all difficult, a little difficult to deal with, and not at all difficult.difficult.

Recovery ChallengesRecovery Challenges

• Working, finding/keeping job:Working, finding/keeping job:– Very difficultVery difficult 46%46%

• Dealing with feelings Dealing with feelings

(anger, pain, shame, guilt)(anger, pain, shame, guilt) 46%46%

• Fear of picking upFear of picking up 44%44%

• Having money problemsHaving money problems 41%41%

• Dealing with inner conflictsDealing with inner conflicts39%39%

Recovery Challenges: Most Recovery Challenges: Most DifficultDifficult

• Accepting a Higher PowerAccepting a Higher Power• Very DifficultVery Difficult 13%13%

• Following a program such as the 12-stepsFollowing a program such as the 12-steps16%16%

• Not being accepted at other 12-step groupsNot being accepted at other 12-step groups19%19%

• Being open minded, listeningBeing open minded, listening 20%20%

• Asking/accepting help and supportAsking/accepting help and support22%22%

Recovery Challenges: Least Recovery Challenges: Least DifficultDifficult

• Interest in self-help is growing rapidly in the context Interest in self-help is growing rapidly in the context of managed care health service deliveryof managed care health service delivery

• The single focus (one disease-one recovery) of The single focus (one disease-one recovery) of traditional self-help groups is an important part of traditional self-help groups is an important part of their appeal to members. However, it often falls their appeal to members. However, it often falls short of meeting the needs of those with multiple short of meeting the needs of those with multiple recovery needsrecovery needs

• Self-help groups designed to embrace the dually-Self-help groups designed to embrace the dually-diagnosed, such as DTR, provides a safe forum where diagnosed, such as DTR, provides a safe forum where the combination of mutual support and acceptance, the combination of mutual support and acceptance, honesty, and role modeling creates a feeling of self-honesty, and role modeling creates a feeling of self-confidence and empowerment that is helpful in the confidence and empowerment that is helpful in the struggle for staying clean and taking one’s struggle for staying clean and taking one’s medicationsmedications

• DTR members credit DTR for giving them the ability DTR members credit DTR for giving them the ability to stay on the path of their double recovery. “For me, to stay on the path of their double recovery. “For me, coming to DTR was like coming home.”coming to DTR was like coming home.”

ConclusionConclusion

The EndThe End