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D ouble T rouble R ecovery SELF HELP FOR THE DUALLY DIAGNOSED. Presenter: Howard Vogel 2005. Acknowledgements. Thanks to all of the consumers who are made this presentation possible by sharing their experiences, And thanks to the service providers for their cooperation. . Background.

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  • Thanks to all of the consumers who are made this presentation possible by sharing their experiences,
  • And thanks to the service providers for their cooperation.
  • High prevalence of comorbidity with many far-reaching treatment implications:
  • More severe and chronic than single, “pure” psychiatric disorders
  • Associated with a variety of negative consequences including clinically, therapeutically, psychologically as well as socially and economically.
  • Predictor of negative treatment outcomes for drug users.


  • Interaction between street drugs and medication.
self help programs
Self-Help Programs
  • A group of individuals who share a common problem behavior.
  • They learn to accept their problem, share their experiences, strengths, and hopes.
  • Only requirement for attending is the desire to abstain from the problem behavior.
  • No “professional” involvement.
  • Most are based on some adaptation of the 12-step model.
self help programs continued
Self-Help Programs (continued)
  • Recognized as a potentially cost-effective treatment modality.
  • Often included in aftercare planning and used as a complement to formal treatment.
  • Little research on self-help.
  • Conducted with AA groups.
  • Evidence that involvement self-help group has a positive effect on recovery.
how self help works
How Self-Help Works
  • Self-help contributes to the reduction of mental health symptoms in five ways:
  • 1. Provides a social network based on commonly shared experience.
  • 2. Facilitates move from help-recipient to helper
  • 3. Specific ways of coping based on experience are shared.
  • 4. Those who cope successfully serve as role models.
  • 5. Provides meaningful structure which is self-generated rather than imposed from the outside.
traditional self help and the dually diagnosed
Traditional Self-Help and the Dually-Diagnosed
  • “ONE DISEASE-ONE RECOVERY.” Recovery needs which fall within that single parameter are ignored, misunderstood, or stigmatized.
  • MISGUIDED ADVICE ABOUT MENTAL DISORDERS AND MEDICATION can lead to non-compliance with medication, increased psychiatric symptoms, and substance abuse relapse.
traditional self help and the dually diagnosed8
Traditional Self-Help and the Dually-Diagnosed
  • Lack of identification =



  • Individuals with dual recovery needs cannot typically find the HONESTY, ACCEPTANCE, EMOTIONAL SUPPORT AND SHARED EXPERIENCES which are critical elements of mutual aid process in traditional self-help groups
A fellowship of men and women who share their experience, strength, and hope with each other so they may solve their common problems and help others to recover from their particular addiction(s) and mental disorders.
  • A mutual aid program adapted from 12 step programs
  • Primary purpose is to maintain freedom from addiction(s) and to maintain well-being.
  • DTR also addresses the problems and benefits of psychiatric medication, thus recognizing that for many, having addiction and mental disorders represents Double Trouble in Recovery.
No dues or fees for DTR membership; DTR is self-supporting through members’ own contributions.
  • Not affiliated with any sect, denomination, political group, organization or institution.
  • From the first group in NYC in 1989, DTR is now a nationwide movement. Currently, there are over 100 DTR groups in the US, 40+ in NYC alone.
  • An average of 15 new groups start each year.
A 3.5 year effectiveness study.
  • Funded by the National Institute on Drug Abuse (NIDA).
  • Using a 12-month prospective longitudinal cohort of 310 members in 25 peer-led DTR groups in NYC.
  • Semi-structured interview protocol
Male 72%
  • Median Age 39 years (SD+8.6)
  • African-American 58%
  • Hispanic 16%
  • Caucasian 25%
  • Other 1%
  • Primary Income:
    • Government Assistance 95%
    • Job 3%
    • Other 2%
Less than grad/GED 41%
  • HS grad/GED 32%
  • Some college or more 27%
  • Living Arrangements:
  • Own apt/house 21%
  • Community residence/Apt program 52%
  • SRO 16%
  • W/friends/relatives 11%
Ever physically abused 48%
  • Ever sexually abused 36%
  • Legal status:
  • No involvement 91%
  • Probation/parole/pending 7%
  • Seropositive for HIV 6%
Age 1st emotional/MH problems 18 yrs*
  • Age 1st sought/received help for MH 22 yrs*
  • Age 1st diagnosed 30 yrs*
    • Schizophrenia 43%
    • Unipolar (major) depression 26%
    • Bipolar Disorder 25%
    • Schizoaffective 7%
    • Mood Disorder 5%
    • PTSD 5%


Symptoms past year 70%
  • Emotional/mental health past month:
    • Very Troubled 10%
    • Moderately 28%
    • Somewhat Troubled 38%
    • Not at all 24%
Ever hospitalized for MH 89%
  • Ever in outpatient treatment 97%
  • Ever on medication for MH 100%
  • Median age started medication 24 yrs*
  • Currently in outpatient MH/MICA 91%
  • Length of current enrollment 8 mos.
  • Currently taking medications for MH 92%


Age 1st used drugs/alcohol 14 yrs.
  • 1st Substance used:
    • Alcohol 65%
    • Marijuana 23%
    • Heroin 4%
    • Crack/cocaine 3%
  • Why started: Peer pressure/to fit in 63%
  • Primary substance (lifetime):
    • Crack/cocaine 42%
    • Alcohol 34%
    • Heroin 11%
    • Marijuana 10%
    • Other 3%
Past year any drug/alcohol 47%
  • Any drugs 36%
  • Any alcohol 34%
  • Past month any drug/alcohol 9%
  • Any drugs 5%
  • Any alcohol 6%
Age 1st D&A treatment 28 yrs.*
  • Ever hospitalized for D&A 75%
  • Ever in outpatient for D&A 96%
  • Currently in outpatient for D&A 77%
  • Length of current enrollment 8 mos.*


“Overall, what has caused you the most problems?”
    • Substance abuse 29% − Mental Health 17%
    • Both Equally 49% − Not sure 6%
  • “When you have symptoms, how much do you feel like using?”
    • Very much 44% −A little 14%
    • Moderately 17% −Not at all 25%
  • When/if using...
    • Symptoms get worse 69%
    • Symptoms get better 16%
    • Symptoms stay the same 15%
“Overall, what has caused you the most problems?”
    • 1-3 months 12%
    • 4-12 months 25%
    • 1 year or more 64%
  • “When/If you have symptoms, how much do you feel like using?”
    • Through a therapist 41%
    • Through a friend/assoc 19%
    • At drug treatment prog. 16%
  • “When/If using...
    • Twice a week or more 37%
    • Once a week 60%
    • Less than once a week 3%
Length of attendance:
    • 1-3 months
    • 4-12 months
    • 1 year or more
  • Frequency of attendance
    • Twice a week or more 7%
    • Once a week 60%
    • Less than once a week 3%
  • “How did you first hear about DTR?” (Top 3)
    • Through a therapist 41%
    • Through a friend/assoc 19%
    • At a drug treatment prog. 16%
Importance of DTR in recovery
    • Very important 85%
    • Moderately 13%
    • A little/not at all 3%
  • Importance of other DTR members in recovery
    • Very important 79%
    • Moderately 15%
    • A little/not at all 6%
Currently attending Alcoholics Anonymous 73%
    • Currently attending Narcotics Anonymous 64%
    • Speak about MH in AA or NA 49%
  • Reasons for attending other 12-step groups (Top 2)
    • To stay clean and sober/deal w/drug issues 51%
    • To hear other’s stories 18%
  • Reasons for not attending other 12-step meetings (Top 2)
    • DTR meets my needs, don’t miss groups. 32%
    • Don’t feel accepted/comfortable. 17%
“Why do you come to DTR?”
    • To identify with, relate to other dually diagnosed people 38%
    • To stay clean and sober 22%
    • For help, support, acceptance, understanding, and respect 20%
  • “How has coming to DTR affected your life and your recovery?”
    • Give me hope, support, encouragement, a new outlook on life 20%
    • Better understanding of self, issues, dual-diagnosis 20%
    • I don’t use, I stay clean and sober, I am restored to sanity 19%
“How would your life be different now if you hadn’t come to DTR?”
    • I would be using/getting high 32%
    • I would be confused, lonely, searching for help 16%
  • “Overall, what has changed in your life since you started attending DTR?”
    • Greater self-esteem, respect, acceptance, understand for self and others 21%
  • Goals and hopes for the next year:
    • Vocational/job mentions???? 47%
    • Housing 30%
    • Stay clean and sober 29%
    • Educational 20%
As part of it’s effort to educate about dual diagnosis, DTR organized dialogues where consumers and service providers exchange ideas and concerns outside of the therapeutic environment.
  • One question is: “What has been your most difficult struggle in your recovery from dual-diagnosis?”
  • Proceeds from ten dialogues held in New York State in 1996 and 1997 representing over 200 participants were combined to eliminate redundancy.
  • The resulting list of 36 items was incorporated into the baseline questionnaire of the study. Specifically, the question was: “Following are issues and situations that people may struggle with during their experience dealing with these issues in recovery.”
  • The answer categories were on a 4 point Likert-type scale: Very difficult to deal with/to do, moderately difficult, a little difficult to deal with, and not at all difficult.
Working, finding/keeping job:
    • Very difficult 46%
  • Dealing with feelings

(anger, pain, shame, guilt) 46%

  • Fear of picking up 44%
  • Having money problems 41%
  • Dealing with inner conflicts 39%
Accepting a Higher Power
  • Very Difficult 13%
  • Following a program such as the 12-steps 16%
  • Not being accepted at other 12-step groups 19%
  • Being open minded, listening 20%
  • Asking/accepting help and support 22%
Interest in self-help is growing rapidly in the context of managed care health service delivery
  • The single focus (one disease-one recovery) of traditional self-help groups is an important part of their appeal to members. However, it often falls short of meeting the needs of those with multiple recovery needs
  • Self-help groups designed to embrace the dually-diagnosed, such as DTR, provides a safe forum where the combination of mutual support and acceptance, honesty, and role modeling creates a feeling of self-confidence and empowerment that is helpful in the struggle for staying clean and taking one’s medications
  • DTR members credit DTR for giving them the ability to stay on the path of their double recovery. “For me, coming to DTR was like coming home.”