Alcoholism and Addiction Treatment

Dual Recovery Anonymous

There are many stages during the recovery process which can begin with identifying an addiction problem and learning about the various treatment options available.

We have compiled a broad range of recovery options to help visitors find the treatment that best suits their needs. These include: self evaluation, intervention services, recovery programs, mental health practitioners, detoxification, inpatient/outpatient, online treatment, message boards & chat rooms, outdoor therapy, retreats, sober housing and youth services.

12-Step Programs – Twelve-step programs have long been an important part of the recovery process and the basis for many recovery programs. Developed over 65 years ago by a small group of alcoholics, the AA program provides simple tools for living based on a set of spiritual principles and a reliance on the fellowship of men and women who share their experience and offer their support as part of a lifelong process of recovery. This approach has since been adapted for the treatment of many other addictions, and now includes other self-supporting fellowships such as CA and NA.

Alcoholics Anonymous (AA) (alcoholics-anonymous.org)
A twelve-step program for people in recovery from alcohol abuse. The site provides an online list of central offices and groups in the U.S. and Canada, meeting contact information, a description of the 12-steps and traditions, a listing of AA literature and a bulletin board.

Dual Recovery Anonymous (DRA)
Dual Recovery Anonymous™ is an independent, nonprofessional, twelve step, self-help fellowship organization for people with a dual diagnosis. Our goal is to help men and women who experience a dual illness. We are chemically dependent and we are also affected by an emotional or psychiatric illness. Both illnesses affect us in all areas of our lives; physically, psychologically, socially, and spiritually.

What is Dual Diagnosis?

Dual diagnosis occurs when an individual is suffering with both chemical dependency and a psychiatric or emotional illness. These illnesses can damage a person physically, socially, and psychologically, and thus interfere with normal functioning. The dual disorders may affect each other, and each disorder predisposes relapse in the other disease. At times the symptoms can overlap and even mask each other, making treatment and diagnosis difficult. To fully recover, a person needs treatment in both disorders equally and simultaneously.

Other names for this type of illness are:

• Co-morbid disorders
• Co-occurring disorders
• Concurrent disorders
• Co-morbidity
• Dual disorders

Dual diagnosis can be difficult to identify. Many of the symptoms of drug abuse (such as extreme anxiety, depression, paranoia, delusions and hallucinations) are similar to those of mental illness. Many of the effects on one’s life (severe decline in self-care and functioning) may also be similar. Often, one problem is blamed on the other.

Substance abuse complicates almost every aspect of care for a person with a mental illness. Mental health professionals and families of the mentally ill may underestimate the amount of drugs and/or alcohol dependency among people in their care. There may be several reasons for this:

People with a mental illness may abuse drugs or alcohol covertly. It may be difficult to separate the behaviors due to mental illness from those due to chemical dependency. It takes time to unravel the interacting effects of substance abuse and mental illness

Bipolar Disorder (also know as manic depression) often reveals itself in teens as severe moodiness and unhappiness. Often the first diagnosis is one of depression. Frequently bipolar disorder is initially misdiagnosed. It can take time to properly diagnos bipolar disorder. Treatment includes a combination of carefully monitored medication and professional counseling.

Bipolar disorder manifests differently in teens than in adults. Adolescent cycles are more rapid, adult cylces can be over weeks or months, in children cycles can occur within the same day.

Drug and alcohol use in adolescents with bipolar disorder is common. Dual-Diagnosis is the term used to describe the process of treating a mood disorder along side a substance abuse problem. Symptoms must be analyzed and treated accordingly. Careful and caring counseling, as well a medical attention and proper prescribed medication, are used to treat this combination.

Other conditions which contribute to the risk of adolescents developing a bipolar mood disorder increase with:

• family history of bipolar disorder or other mood disorder
• family history of drug or alcohol abuse
• episodes of severe depression

Factors which can contribute to manic episodes include:

• changes in routine or sleep patterns
• certain antidepressants can trigger manic episodes
• traumatic life event
• abuse or neglect of medication
• using alcohol or drugs

Bipolar disorder, also known as manic depression, is a mental disease that causes severe shifts in a person’s mood. The ups and downs experienced from a bipolar disorder are much different from the normal mood changes everyone goes through. These emotional extremes can result in damage to a person’s degree of daily functioning.

Bipolar disorder typically develops in early adulthood. Some may experience symptoms in late adolescence however, it is not recognized as an illness. A person can suffer from symptoms for many years until the bipolar disorder is properly diagnosed and treated.

In bipolar disorder, changes in mood are experienced on a spectrum or continuous range. The changes in mood can bring on severe changes in attitude and behavior. A person with a bipolar disorder will experience periods of highs and lows. These highs and lows are called episodes of mania and depression.

A bipolar disorder is diagnosed when a combination of manic and depressive symptoms are present. Symptoms of mania may include, increased energy, racing thoughts, or unrealistic beliefs in one’s abilities and powers. Depressive symptoms can include, feelings of worthlessness, loss of interest, or thoughts of death or suicide.

Severe episodes of mania or depression can include psychotic symptoms. These symptoms may include hearing voices, seeing things that are not there, or strongly believing false concepts. People that have a bipolar disorder are sometimes incorrectly diagnosed as having another severe mental illness such as, schizophrenia.

Most scientists agree that there is no single cause for bipolar disorder. It has been suggested that bipolar disorders may result from a specific gene, passed down from family generations. Other research suggests a combination of factors including a person’s environment to be the cause of the disease. Whatever the cause, a bipolar disorder can be treated and the person can lead a productive life.

Proper treatment can help reduce the manic and depressive episodes experienced by people with a bipolar disorder. Bipolar disorder can be a life long struggle, therefore long-term treatment is strongly recommended. A combination of psychotherapy and medication management has proven to be an effective form of treatment for a bipolar disorder.

Medication management is a crucial component in the treatment of a bipolar disorder. Medications known as “mood stabilizers” can be prescribed to help control the extreme levels of highs and lows. Popular medications for treating a bipolar disorder include, Lithium, Depakote, or Neurontin. Side effects from medications may include weight gain, nausea, or anxiety.

Working closely with a doctor and therapist can improve daily symptoms experienced by a person with a bipolar disorder. A therapist can provide education and insight to a person with a bipolar disorder and their families. The most common forms of therapy used with a bipolar disorder are cognitive behavioral therapy and family therapy.

It is important to keep in mind that a bipolar disorder is a life long mental illness. Even when a person is feeling at their best, they must continue treatment. The mania and depression episodes can occur at anytime and currently has no cure. However, if a person is properly diagnosed and remains aware of their symptoms, they can lead a fulfilling life.

For substance abuse patients, and therapy in general, the effectiveness of treatment is determined as much by the therapist as by any theoretical orientation or patient characteristics. With this dual-diagnosis population, it is often difficult to provide effective therapy. Therapist processes emphasized in Seeking Safety include compassion for patients’ experiences; using coping skills; giving patients control whenever possible to counteract the loss of control inherent in trauma and substance abuse; promoting honesty in contrast to the secrecy, denial and lying that may occur in trauma and substance abuse; meeting patients more than halfway doing whatever is possible within professional bounds to help patients get better; and obtaining feedback about how patients view the treatment. The more severe the patient, the more likely that negative processes may impede the treatment. This includes harsh confrontation, sadism, difficulty holding patients accountable due to misguided sympathy, becoming victim to the patient’s abusiveness, power struggles, and in group treatment, allowing a patient to be made a scapegoat.

What the evidence does suggest, however, is that it is first necessary for clinicians and researchers in the field to begin to address the severity and unique profile presented by dual-diagnosis PTSD and substance abuse victims, particularly women.

A third study of a hundred inner-city outpatient women compared Seeking Safety with relapse prevention treatment (RPT), both in individual format, with a treatment-as-usual (TAU) control condition in a randomized controlled trial (Hien, Cohen, Litt, Miele and Capstick). At the end of treatment, patients in both Seeking Safety and RPT had significant reductions in substance use frequency and intensity, PTSD symptoms, and psychiatric symptom severity, whereas subjects in the TAU comparison group did not show any significant changes. Improvements in PTSD severity were sustained at the six-month follow-up point but not at nine months, for participants in Seeking Safety and RPT. Although statistically significant improvements in substance use and psychiatric severity were not maintained for Seeking Safety or RPT at the six-month follow-up, trends in the direction of lower substance use and psychiatric severity were found.
Finally, a fourth study evaluated a combination of Seeking Safety and exposure therapy for PTSD in a sample of five men (Najavits, Weiss, Shaw, and Muenz). Significant improvements were found in drug use, family and social functioning, trauma symptoms, anxiety, dissociation, sexuality, hostility, overall functioning, meaningfulness, and feelings and thoughts related to safety. Treatment attendance, satisfaction and alliance were very high.

Najavits (2000) contends that Seeking Safety is designed to treat PTSD and substance abuse at the same time. An integrated model is recommended by experts as more likely to succeed, more sensitive to patient needs and more cost-effective than sequential treatment of the disorders. It also is preferred by patients. Yet, many treatment systems for substance abuse and mental health remain separate, leaving patients to integrate treatment themselves. In correctional settings, adding Seeking Safety treatment to existing programming appeared to work well.

It is important to note that integration in Seeking Safety means attention to both disorders in the present. It does not mean asking patients to discuss their pasts in detail. Despite the known efficacy of trauma processing for PTSD, such work may not be safe for substance abusers until they have achieved a period of stable abstinence and functionality. Correctional settings, in particular, may be unsafe, as inmates may be destabilized by such treatment. In Seeking Safety, integrated treatment means helping patients understand the two disorders and why they so frequently co-occur; teaching safe coping skills that apply to both; exploring the relationship between the two disorders in the present, such as using a substance to cope with flashbacks; and helping patients understand that healing from each disorder requires attention to both.

For example, the topic “honesty” combats denial, lying and the “false self.” “Commitment” is the opposite of irresponsibility and impulsivity. “Taking good care of yourself” is a solution for the bodily self-neglect of PTSD and substance abuse. The language throughout emphasizes values such as respect, care, integration and healing. By aiming for what can be, the hope is that patients can summon the motivation for the hard work of recovery from both disorders. (Najavits, 2000)

While originally designed as a cognitive-behavioral intervention, the treatment was expanded to include equally strong attention to interpersonal and case management issues. Interpersonal topics now comprise one-third of the sessions, and case management begins in the first session and is addressed at every subsequent session throughout treatment. The interpersonal domain is an area of special need because PTSD most commonly arises from traumas inflicted by others, both for women and men. Interpersonal issues include when to trust others and how to avoid re-enactments of abusive power, both as victims and perpetrators. Similarly, substance abuse often is initiated and encouraged in negative relationships. The case management component of the treatment helps patients obtain help with problems such as housing, job counseling, HIV testing, domestic violence and child care.

Stephanie Covington has created a trauma specific model for women as well in 2003. In the introduction to her program, Covington (2003) discusses the integrated treatment approach focusing on women. “The connection between addiction and trauma for women is intricate and not easily disentangled” (p. 16). She goes on to discuss that the treatment provider cannot assume, when reviewing a patient with both addiction and trauma, that one is a primary problem and the other a secondary one. “Nor is it always beneficial to delay working on trauma symptoms until the client as been abstinent for a minimum time” (Covington, 2003, p. 16).

Women exposed to trauma and addicted to alcohol or another drug are considered to be at higher risk of mental disorder (Covington, 2003, p. 16). Studies, including those by Najavits, Weiss, and Shaw (1997) that indicate that comorbid mental disorders, medical problems, psychological problems, inpatient admissions, interpersonal problems; lower levels of functioning, compliance with aftercare, and motivation for treatment; and other significant life problems are more common among those with PTSD and substance abuse compared to among those that have one or other of the problems.

Co-occurring disorders are complex and the historical division in the fields of mental health and substance abuse typically result in contradictory treatments (Covington, 2003, p. 16).

Her model calls for a self-guided, quasi-self-help approach to healing dual-diagnosis PTSD and substance abuse. For example, the outline for one session focuses around asking the client to think of “recent incidents” (p. 191) of trauma, “substance use, self-harm, or other recent acting out behaviors”. The purpose of the exercise is to put the patient in touch with their “red-flags”, the triggers of their self-harm behavior.

Long-term reviews of treatment courses have yet to be conducted and a great deal more information must be assembled before it is possible to draw sustained conclusions about the methods of treatment that have a high degree of success for dual-diagnosis patients. There are a number of reviews of Seeking Safety, however. To date, four studies have evaluated Seeking Safety, the treatment program developed by Lisa Najavits; one of the four studies was conducted in a correctional setting. In all the studies, the patients had PTSD and substance use disorder. The first two studies evaluated groups that met twice a week for three months. The first study was a pilot, with the treatment in group format (Najavits, L.M. et al. 1998). Of twenty-seven outpatient women enrolled, seventeen (63%) completed the minimum six sessions. Results for these seventeen women showed an average attendance rate of 67% of sessions, as well as significant improvements in substance use, trauma-related symptoms, suicidal thoughts and risk, social adjustment, family functioning, problem-solving, depression, cognitions about substance use and didactic knowledge related to treatment.

The second study evaluated Seeking Safety in a correctional setting (Zlotnick, Najavits, and Rohsenow). Seventeen women participated in the trial, which used a group version of the treatment. The attendance rate was 83% of sessions and measures of client satisfaction were high. Of the seventeen women, nine (53%) no longer met criteria for PTSD by the end of the three-month treatment period; at a follow-up three months later, 46% still no longer met criteria for PTSD. Substance use could not be assessed while the women were in the prison’s controlled environment, but a follow-up six weeks after release from prison indicated that 70% did not meet criteria for substance use disorder. The recidivism rate was 39% at a three-month follow-up, which is typical of this population. A study is under way to evaluate whether providing additional Seeking Safety sessions after release from prison might be beneficial.

Programs other than ‘Seeking Safety’ have been introduced, but few have any research backing. The ATRIUM Model, Addiction, Trauma, Recovery — Integrated Model, was introduced in 2001 by Dusty Miller and Laurie Guidy. They contended that twelve sessions of treatment per week running to 1.5 hours at a time, structured according to their treatment model, were sufficient to treat both substance addiction and trauma issues. Each session of treatment is structured to allow a didactic component, a progress component to allow participants to share their own experiences relevant to specific session topics, and an experimental component to introduce new ideas during each session that may facilitate further recovery. Claims about the effectiveness of the ATRIUM model include reference to its use among Latina women; due to its success among this population sample, the ATRIUM manual and associated handouts were reportedly translated into Spanish. Homeless individuals and their families have also been cited as groups assisted by the ATRIUM model for group therapy. The addictions discussed in the ATRIUM model include not only substance dependency, but eating disorders, self-injury, and forms of self-sabotage like compulsive spending, gambling, sexual addiction, cyber addiction, and self-destructive relationships. The co-occurring disorders essentially outlined as part of the ATRIUM treatment model are not limited to PTSD either; anxiety, depression, psychotic episodes, personality disorders, and relation challenges are also identified as separate issues co-occurring with the range of addictions outlined.

Evans and Sullivan published a book on the dual diagnosis for clinicians in private practice that explains the 12 step model and how to integrate it into sessions and treatment. They provide a comparison of PTSD and substance abuse in table form, reporting on the range of symptoms that PSTD suffers and substance abuse sufferers have in common, and other elements such as treatment goals and interventions. Their findings are that there are many similarities in the courses and applied treatments of the disease. The similarities in etiological factors are listed as genetic influences, life experiences, neurophysiological components, and family-of-origin issues; all of which are factors in the development of both PTSD and addiction issues. Similarly, the courses of the diseases are identified as being somewhat similar. For PTSD the course is described as “variable onset, variable course, fatal: suicide, chronic disorder, triggers and relapse, ongoing recovery” whereas the course for substance abuse is “variable onset, progressive, fatal: death, chronic disease, triggers and relapse, ongoing recovery” (Evans and Sullivan, 1995 p.97)

However, within their book they describe the client as often times needing detox and inpatient services, which does not allow the client to get the PTSD education and stabilization when it is needed, immediately after the abstinence, when PTSD symptoms surface, if the substance abuse facility is not Trauma informed or trauma specific in services provided.

Evans and Sullivan (1995) make five key assumptions in the opening chapter of their book. The first is that a large portion of troubled clients seen in a clinical setting has a history of childhood trauma. Successful treatment must include safely working through the memories of abuse in an experiential way “but only after the clinician and client have laid a base of safety and skill” (p. 1). The validity of this assumption is questionable in practice because there is strong evidence that most clinicians do not have the knowledge base or the skills to establish the necessary safety base.

Najavits et al (1997), identify treatment as crucial, “not only because of the prevalence and severity of co-occurring PTSD and substance abuse, but also because treatments that are typically used for PTSD or substance abuse alone may be insufficient for their combination”. Problems of using treatments suited to one or other of the disorders with patients that have dial diagnosis are numerous. One problem is that specific treatments for PTSD or substance abuse issues may have negative effects on patients who have both disorders; two researchers (Abueg and Fairbank, 1991; Solomon, Gerrity, and Muff, 1992) suggested that “behavioral exposure and flooding models, which are quite successful for PTSD-alone, are…ill-advised for patients with substance abuse because their emotional intensity might too easily trigger a substance abuse relapse” (Najavits et al, 1997). Other issues with established treatment methods are discussed: Alcoholics Anonymous (AA) and other twelve-step self-help groups are identified as potentially problematic for dual-diagnosis patients because of elements such as “the presence of males at most meetings, the philosophy of not focusing on the past, and [the idea of surrendering to a higher power as part of the AA philosophy]” (Najavits et al, 1997); substance abuse treatments that are heavily confrontational in approach may re-evoke traumatic experiences (Najavits et al, 1997; Nace, Davis, and Gaspari, 1991). Issues with clients I have observed with my own clients include an inability to sit in meetings due to high activation, relational and trust problems with other group members and their sponsor, lack of understanding within the fellowship regarding PTSD, some who are on medications are shamed for this because they are “not really clean”, although that seems to be shifting some. As a result of some of these conflicts, the client may feel further shame and may then turn to substances to cope.

No empirically validated standard of care exists for PTSD-alone although Curtois, Chu, and Briere have each developed models for treatment. In her own review of treatment practices, Curtois (1999) also attempts to establish the history of PTSD treatment and current standards in Chapter Nine of her treatment principles and guidelines for dealing with PTSD sufferers who were also victims of sexual assault.

The model of integrated treatment, methods for treating both the PTSD and substance abuse together in dual-diagnosis patients has much evidence to support its efficiency and, at the very least, it appears valid that dual diagnosis PTSD and substance abuse is not the same as either PTSD-alone or substance abuse-alone. As to what constitutes the most effective treatment for women with PTSD and substance abuse, only one study (Najavits et al, 1997) has addressed the issue with any real effort and only one publication (Najavits, 2002) covers the subject in any depth. In one journal, Najavits specifically explores the issue of counselor training. The effort, however, was in a very limited context. The article “Training Clinicians in the Seeking Safety Treatment Protocol for Traumatic Stress Disorder and Substance Abuse” (Najavits, 2000), clearly focuses on the specific treatment procedures outlined by Najavits in her own publication. She indicates that research on substance abuse treatment over the past decade has confirmed that clinicians differing widely in their impact on outcomes. The differences in outcomes are identified as severe; studies such as Christensen and Jacobson (1994), Najavits and Weiss (1994), Najavits, Crits-Christoph, and Dierberger (2000) all identify the best-case role of the clinician as “life-saving” versus the worst case scenario being a “damaging” role (Najavits, 2000, p. 3)

The findings of these two research efforts revealed a significant reduction in PTSD and substance abuse symptoms after a 24-session cognitive-behavioral group therapy specifically designed for a population of women with dual-diagnosis PTSD and substance abuse issues (Najavits et al, 1997).

Najavits (1997) and other studies such as Gatz et al (2005) paved the way for many in terms of grants and funding to implement programs in substance abuse treatment centers with a PTSD focus. However, there is not an immediate or large shift in treatment for substance abuse treatment centers.

Although early research on PTSD and substance abuse focused almost exclusively on male combat veterans whose substance abuse was connected to war trauma (Keane and Wolfe, 1990), research has expanded its focus to now include review of the clinical profile of women with PTSD and substance abuse issues (Najavits et al, 1997). Evidence indicates that women typically have different profiles from men (Najavits et al, 1997).

The combination of PTSD and substance abuse is more common among women than it is among men (Najavits et al, 1997). Two studies are cited by Najavits et al (1997) for having compared women and men with dual diagnosis PTSD and substance abuse. The findings indicated that women have more than two to nearly four times the rate of PTSD, with 43% of women versus 12% of men (Brown, Recupero, and Stout, 1995), and 30% of women versus 15% of men (Najavits et al, 1995) reported by the two studies respectively.

Other interesting findings presented by Najavits et al (1997) that warrant review here, were the range of life problems associated with women with dual diagnosis PTSD and substance abuse. Findings from several studies found that dual diagnosis PTSD and substance abuse victims have higher rates of a whole range of issues, including mood and anxiety disorders (Najavits et al, 1995; Brady et al, 1994; Kofoed et al, 1993), medical problems (Najavits et al, 1995), psychological symptoms (Najavits et al, 1995), inpatient admissions (Brown et al, 1995), and interpersonal problems (Najavits et al, 1995). They also demonstrated lower global level of functioning (Najavits et al, 1995), compliance with aftercare (Brady et al, 1994), and motivation for treatment (Najavits et al, 1995). Additionally, women with PTSD and substance abuse issues also report a range of co-occurring life problems such as homelessness (Smith, North, and Spitznagel, 1993; Paone, Chavkin, Willets, et al, 1992), loss of child custody (Fullilove, Kinscherff, and Fenton, 1992), maltreatment of their children (Famularo et al , 1992), and instance of battered woman syndrome (Levit, 1991).

According to the National Institute for Drug Abuse [NIDA] (2000), while men are more likely to have the opportunity to use drugs, men and women are equally likely to develop an addiction. Women and men do, however, differ in their vulnerability. While men are more likely to abuse marijuana and alcohol, women are more likely to become addicted or dependent on depressants and sedatives. Men and women are equally likely to become addicted to or dependent on cocaine, heroin, hallucinogens, tobacco, and inhalants. Women are more likely to look to depress sleeplessness and anxiety with sedatives.

Of course, women are also more likely to be exposed to certain kinds of trauma (NIDA, 2000) and are at greater risk of revictimization in the context of substance abuse combined with PTSD.