Some thoughts on Co-Occurring Disorders and Recovery

September is National Alcohol and Drug Addiction Recovery Month, and the first week in October is Mental Illness Awareness Week.

Personally, I’m looking forward to the time when Congress designates a Co-Occurring Disorder Recovery Month, given the numbers of people living with both substance use and mental disorders concurrently, and the impact on their lives and the lives of their families.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), Co-occurring substance abuse disorders and mental disorders are both common and highly complex phenomena that have been estimated to affect from 7 to 10 million adult Americans in any one year (U.S. DHHS, 1999b; SAMHSA National Advisory Council, 1998).

From the U.S. Surgeon General’s 1999 report on mental health: "Forty-one to 65 percent of individuals with a lifetime substance abuse disorder also have a lifetime history of at least one mental disorder, and about 51 percent of those with one or more lifetime mental disorders also have a lifetime history of at least one substance abuse disorder."

This includes 47 percent of individuals with schizophrenia having a substance abuse disorder (more than four times as likely as the general population); and 61 percent of individuals with bi-polar disorder having a substance abuse disorder (more than five times as likely as the general population).

Additionally, the presence of severe mental illness may create additional biological vulnerability so that even small amounts of psychoactive substances may have adverse consequences for individuals with schizophrenia and other brain disorders (Drake et al., 1989). In other words, for people living with severe mental illness, even small amounts of alcohol or drugs can lead to a devastating cycle of relapse, decompensation, and hospitalization.

We used to call these co-existing and interactive disorders “dual disorders” and still do at times as a kind of language short-cut, but in fact that’s a misnomer. In most situations it is unusual for an individual to only have two single disorders. More frequently people are living with several psychiatric conditions. If they use abuse substances, more often than not they use multiple substances. We are continuing to see untreated or under-treat medical conditions and chronic pain issues that impact people’s mental status, level of functioning, resiliency, and drug use.

People are complex. If we don’t address these multiple co-occurring conditions, be they mental health, physical health, and the risk factors punctuated by substandard living conditions, joblessness, homelessness, stigma, disempowerment, isolation and exclusion from the community, we cannot work with individuals and their families towards real recovery.

In 1991, BHI re-focused its services to specialize in the area of “dual-diagnosis.” When we began, this was a new field with limited research, and we were learning daily along with the other front-runners. This is still a young field, although there is much more information on what works, better and more effective practices, and refining treatment and services to meet the needs of the individual. We know that change happens predictably in stages, and the most effective treatment happens when it is matched to where the individual is at in their stage of recovery. We are doing much better at designing services to be stage-based, including for people who are at the earliest stages (pre-contemplation) to those who are much further along, in action stage, or have achieved stability. We also recognize that stages of recovery are fluid and the path may have bumps and curves, periods of relapse, or times when symptoms and the need for additional support become more acute.

Yes, we’re doing much better. We’re more sophisticated. And like the quote on my office wall from Michaelangelo, we are still learning. Sometimes we make mistakes, and hopefully, as an agency, we use those to grow from there. Just like our clients.

Some of the more important things we’ve learned:

People with mental illness, and co-occurring disorders, can and do recover.

From the landmark Courtney Harding studies in 1987 showing 45% – 68% recovery, to the most recent cross cultural studies of more than 1000 persons with schizophrenia from 14 countries, showing 60% recovery across objective scales of disability and functioning (Hopper et al 2007), we know that recovery is possible and attainable.

What does recovery mean? How do we define it?

Robert Lieberman in his text Recovery from Disability, a Manual of Psychiatric Rehabilitation (2008) talks about recovery being defined in objective and subjective ways, as well as on a continuum of process to outcome. He cites some objective criteria:

“People are said to have recovered if they have no symptoms that seriously intrude on their daily functioning or quality of life, are living independently, managing their own money and medication, working or attending school in normal settings at least half-time, participating in social and recreational activities and events with peers in normal community sites at least once per week, and enjoying reasonably cordial family relationships.”

“Subjectively, the recovery experience comprises having hope for a brighter future, taking personal responsibility for one’s life, and being empowered with skills, supports, and respect to make decisions that offer satisfaction and meaning in daily living.”

“…The process of recovering is a journey that features liberation from symptoms by “getting a life” despite an illness with persisting symptoms. The process of recovery is quickened by exchanging alienation for meaningful relationships, responsibility for oneself rather than dependence on others, and integration into the community.’ (pg 20).

We cannot predict who will recover, according to either objective or subjective criteria. And individuals and families will all have their own conceptualization of what constitutes recovery for them. But we do know that the kinds of relationships we have with individuals and their families, and the types of services and combinations of evidence-based practices provided, can significantly influence the outcomes, as well as the process of recovery. We will speak to this subject more in future postings.

I also encourage you to read a synopsis of a training for families on recovery provided at a NAMI (National Alliance for Mentally Ill) meeting by our own Rebecca Woolis, MFT. Rebecca is the Program Director for the Bonita House Creative Living Center, a Wellness and Recovery Center located in Berkeley. She is also a leading authority in working with families of people living with mental illness. Rebecca is the author of When Someone You Love Has a Mental Illness. This is a wonderful, practical, hands-on guide that has helped families for years. The book has now been translated into a variety of languages and is being used internationally as well. We are proud to have Rebecca as part of our Bonita House team.