Can 12-Step Programs Treat Dual Diagnoses?

Effective treatment needs to include both the substance use disorder and the co-occurring disorder in an integrated approach because the two conditions build on each other.

Thirty-three percent of people with mental illness also have a substance use disorder (SUD); that number rises to 50 percent for severe mental illness. Fifty-one percent of people with SUD have a co-occurring mental health disorder. Effective treatment needs to include both the SUD and the co-occurring disorder in an integrated approach because the two conditions build on each other. People with mental illness may turn to substances to alleviate symptoms and severe substance misuse can cause lasting psychological and physiological damage.

12-step programs are free, prolific, and available throughout the world. These mutual-help organizations are designed to facilitate recovery from addiction, but are they suitable for treating the large segment of people with addiction who also have other mental health conditions or psychiatric diagnoses?

A 2018 meta-analysis  undertook a literature review on 14 years of studies related to dual diagnosis and Alcoholics Anonymous (AA). This extensive quantitative look into the effiicacy of AA for people with dual diagnosis found that participation in AA and abstinence “were associated significantly and positively.” The research supports the clinically-backed notion that an integrated mental health approach that encourages participation in mutual help programs is the best approach for treating patients with comorbid SUD and mental illness.

Does it Depend on the Dual Diagnosis?

There is enormous variation in mental illnesses, so does the potential effectiveness of 12-step programs change based on the type of disorder or diagnosis? The co-founder of AA, William Wilson (known as Bill W.), was afflicted with a co-occurring disorder. Wilson struggled with “very severe depression symptoms” and today his mental health issue may have been diagnosed as major depressive disorder.

A study published in the Journal of Substance Abuse Treatment followed 300 alcohol-dependent people with and without social anxiety disorder who went through hospital-assisted detox followed by participation in AA. Social anxiety disorder is characterized by an intense fear of being rejected or disliked by other people. This study found that there was no significant difference in relapse or abstinence rates between the two groups and concluded that social anxiety disorder was “not a significant risk factor for alcohol use relapse or for nonadherence to AA or psychotherapy.”

Do Sponsors Matter?

People with dual diagnoses tend to participate in 12-step programs like AA as much as people with just SUD and receive the same benefits in recovery. Those people with co-occurring conditions may actually benefit more from “high levels of active involvement, particularly having a 12-step sponsor.”

In many 12-step mutual help organizations, people enter into an informal agreement with another recovering person who will support their recovery efforts and hold them accountable for continued sobriety. This one-on-one relationship of sponsor and sponsee has been compared to the “therapeutic alliance” that is formed between patients and their clinicians. The therapeutic alliance is positively correlated with treatment outcomes and abstinence.

The therapeutic alliance is one of the most important aspects of effective psychotherapy, as it helps the therapist and the patient to work together. The relationship is based on a strong level of trust. Patients need to feel fully supported, and know that that their therapist is always working towards the best possible outcome for the patient. In the sponsor-sponsee relationship, a similar level of trust and belief is essential if sponsorship is going to be beneficial.

As with therapy, it may take many tries with many different people to find the right fit. Not all people are suitable to be sponsors and not all sponsorships go well. A sponsor is generally expected to be very accessible to their sponsee, and available at any time, day or night. They are supposed to help with completing the 12-steps, and they often provide advice and suggestions from their own experiences. It’s a lot of responsibility.

A strong therapeutic alliance has been found to be an excellent predictor for treatment outcomes. Does that mean a failed therapeutic alliance could derail treatment? In short, the answer is yes. Trust is critical to healing from any mental illness.

Trauma and the Therapeutic Alliance

Traumatic events have a serious impact on mental health. People with mental illness are at a higher risk of being further traumatized and people who are traumatized are at a higher risk of developing mental illness than the general population. Childhood trauma “doubles risk of mental health conditions.”

Recovery from trauma is based on empowering the survivor and developing new connections to life, including re-establishing trust. Judith Herman, a leading psychiatrist specializing in trauma is adamant that recovery is not a solitary process. This may be why 12-step programs have been successful in helping some people recovery from trauma.

Being a sponsor to someone who has been traumatized requires a fine balance between listening and giving space. Herman explains that survivors need to know they’re being heard when telling their story. At the same time, “trauma impels people both to withdraw from close relationships and to seek them desperately.” Meaning that when the sponsor does not go away, their motives may seem suspect in the eyes of the survivor. Yet, if the sponsor doesn’t stay, it can reinforce negative self-appraisal and stoke a fear of abandonment.

Individuals with psychological trauma can struggle to modulate intense emotions, such as anger. A sponsor or therapist has to have healthy boundaries with a sponsee/patient if the relationship is going to work. Providing good sponsorship is a huge undertaking that requires a firm commitment.

The good thing about the 12 steps is that they are considered a long-term program which encourages revisiting the steps many times to sustain successful recovery. This is useful in terms of trauma recovery because most trauma is never fully resolved. A traumatized person will likely experience reappearance of symptoms; traumatic memories can surface in different stages of life. Stress is a major cause of these recurrences and having a place to process these events as they come up is important.

Do 12-Step Programs Have a Role in Treating Dual Diagnoses?

Integrated holistic treatment that addresses how the two conditions interact and affect each other will provide the best outcomes. Ultimately, what we want is to improve quality of life and to return to ordinary life with an open door to future support when necessary. The research shows that when the principles of 12-step programs are integrated with other treatments, we see improvements in self-esteem, positive affect, reduced anxiety, and improved health.

Further research is necessary to compare 12-step programs with other emerging mutual and self-help organizations, as they have been around for less time and there are fewer published studies on their efficacy.