In sum, it was hypothesized that higher levels of perceived support and more participation in 12-step mutual aid groups would be associated with more successful recovery (less mental health symptoms and substance use) and with higher levels of personal well-being. The hypothesized associations among support, dual recovery and well-being were confirmed. The hypothesized associations between participation in 12-step mutual aid and dual recovery were confirmed for dual recovery groups (DTR) but not for traditional 12-step groups. Participation in specialized mutual aid was associated with recovery status indirectly by contributing to perceived levels of support. Personal well-being was directly associated with participation in DTR, and spiritual and steady partner support. The associations were generally moderate, perhaps, in part, because of the skewed distribution of some of the variables (e.g., substance use past month). However, these results are encouraging.
Participants generally reported high levels of support from various sources; in particular, they reported receiving the highest levels of support from both DTR peers and treatment providers. Increases in the number of supportive relationships have been shown to improve quality of life in individuals with mental health disorders (Rosenfield & Wenzel, 1997
). In the present study, the various sources of support could intervene at different levels, forming a protective network around participants. For example, DTR peers could share their experiences and coping strategies while treatment providers could offer clinical interventions (such as individual counseling or medication).
Participant’s reports of multiple supportive relationships also offered an interpretation for the finding that having a greater number of supportive people was associated with more mental health distress in the past year. While this association seems counterintuitive, an explanation can be proposed for this sample. The majority of study participants lived in settings where various supportive resources are available (community residence, treatment programs, self-help groups). It may be that the number of people offering support increased when the individual was showing signs of mental health distress. According to this interpretation, participants would receive support from several people or sources in their everyday lives, and the number of supports would increase when participants were not feeling well. For example, treatment providers and peers would perceive that more support was needed and would rally around the individual through the crisis and for some tune afterwards. The number of sources of support could thus follow rather than precede the crisis. This interpretation is strengthened by the fact that the association between number of supportive people and mental health disappeared when the time frame for mental health symptoms was the past month. Moreover, this interpretation does not contradict or negate the authors’ overall conclusion that support enhances the likelihood of recovery; rather, it suggests that recovery from mental health may be associated with having a supportive network that is sensitive to one’s need for support at a given moment in time.
The study findings indicate that extent of support is associated with better mental health. Perceived extent of support can be thought of as answering the question: “Am I getting the support that I need?” allowing for the fact that need for support varies. While perceived extent is not the equivalent of satisfaction with levels of support, it can reasonably be interpreted as a measure of the match between need for support and support received. (A large discrepancy between support needed and support received would likely result in low perceived extent of support.) Thus, taken together, the findings suggest that extent of support, that is, support received that matches need, is associated with better mental health.
The association between support and substance use was more straightforward: higher levels of support derived from a greater number of people or sources were associated with less substance use. That support was differently associated with recovery from mental health disorders and addiction suggests that the processes underlying the two recoveries and the role of support networks in each may also be different. It may be that in the case of mental disorders, an imminent crisis is preceded by visible warning signs (e.g., isolation, reported by many DTR members as preceding the recurrence of symptoms) that allow members of one’s support group to rally around the individual and “cushion the fall”; in the case of addiction, perhaps because of the strong role of denial, a slip or relapse is not preceded by signs that can be as easily interpreted by members of the support network because the nature of addiction is such that the individual will conceal urges, at least in the early stages of recovery. Empirical investigation of these questions can contribute greatly to understanding the course of the two disorders, particularly in treating dually-diagnosed individuals.
The association between importance of spiritual support and well-being underscores the role of spirituality in the recovery process and calls attention to the need to incorporate spirituality in addiction treatment (for discussion, seeGoldfarb, Galanter, McDowell, Lifshutz & Dermatis, 1996
). A previous study reported that dually-diagnosed clients view spirituality as crucial to their recovery, and that staff underestimated both clients’ level of spirituality and the importance they placed on such issues (McDowell, Galanter, Goldfarb & Lifshutz, 1996
). In the present sample, levels of perceived spiritual support were generally high, which may be expected for individuals who attend 12-step fellowship meetings where spirituality is viewed as the path to recovery.
The results indicate that participating in DTR contributes to dual recovery directly, in the case of substance use, and indirectly, in the case of mental health, by increasing the sources and extent of perceived support. While DTR participation was associated with less substance use, participation in other 12-step fellowships was not, but instead had a negative association with well-being, such that those who attended other 12-step fellowships had lower
levels of well-being. One possible interpretation of this result comes from participants’ reported reasons for attending or not attending such meetings. Reasons to attend traditional 12-step meetings generally centered around drugs and alcohol issues, while one of reasons for not attending was that no group other than DTR was necessary since participants were “not currently having cravings or slips.” Traditional 12-step fellowships are single problem-focused and members typically attend such meetings to deal with that specific issue. Thus it appears that DTR participants, many who feel uncomfortable at other 12-step fellowship meetings (Vogel et al., 1998
), attend these groups only when they are struggling with drug and alcohol issues and need to focus on that. According to this interpretation, decreased well-being and increased attendance at traditional 12-step groups would not be causally related, but rather would occur simultaneously as a result of a current struggle with addiction.
has described the conditions necessary to the process of recovery as abstinence, substitute dependencies, behavioral and medical consequences, enhanced hope and self-esteem, and social support in the form of unambivalent relationships. These factors may be even more crucial to recovery from co-occurring disorders than for overcoming “simple” addiction or mental disorder alone. As noted, dually-diagnosed individuals are faced not only with a double recovery challenge but may also lack some of the support resources available to those striving to recover from a single disorders. The isolation and ostracism associated with having a mental disorder may be compounded by low self-esteem and inadequate social skills, so that a dually-diagnosed person may not be able to reach out for support—indeed, may not feel worthy of it. This is consistent with the finding that two-thirds of DTR members reported starting to use drugs and alcohol in adolescence to fit in with and be accepted by peers, many adding that using substances made them feel normal for the first time (Vogel et al., 1998
A recent study of the issues challenging dually-diagnosed individuals in recovery found that dealing with emotions and feelings was reported as “very difficult” by the majority of subjects (Laudet, Magura, Vogel & Knight, 2000). The difficulty of dealing with feelings is understandable for individuals whose addiction is aggravated by mental disorders in which inappropriate affect regulation plays a large role. Dealing with feelings that may have been previously masked by active addiction and addressing feelings associated with entering recovery are crucial issues to work on in recovery. The importance of emotion management is heightened by the fact that how individuals deal with their feelings about the past (e.g., anger, shame, guilt, regret, sadness), the present (e.g., confusion, pain, isolation) and the future (e.g., fear, hopelessness) bears on their sobriety. In qualitative interviews, most subjects asked about slips and relapses to drug use mentioned an emotional cause: loneliness, isolation, and in particular, anger. To cope with these painful, sometimes new, and often confusing feelings, individuals need to explore and express their emotions. Clients with mental disorders function better in treatment climates that are supportive and encourage personal expression (Timko & Moos, 1998
). Personal disclosure, the sharing of one’s story, is one of the techniques used in group therapy offered at most treatment programs, as well as the hallmark of mutual aid groups. Personal disclosure is difficult and can only be therapeutic in a highly supportive environment where the individual feels that he/she will be accepted and loved, rather than judged, no matter what is disclosed. Unconditional acceptance and understanding are two of the key ingredients members find in self-help groups: personal disclosure among people who share your experience, understand it, and thus will accept you as one of their own.
Involvement in self-help has many recognized benefits, including validating one another’s experience, providing a structure for a new sense of self, and helping move from isolation and loneliness to empowerment and reconnection with ordinary life (Baxter & Diehl, 1998
). Further, self-help groups based on the 12-step program of recovery, such as DTR, go beyond “simple support” for achieving and maintaining abstinence, offering a forum for members to share information, coping strategies and life skills. For dually-diagnosed persons, the traditional “one-disease-one recovery” 12-step self-help group falls short of meeting their needs because it cannot afford them these benefits. Only a minority of the dually-diagnosed participate in substance use self-help groups, finding them alienating and unempathic (Noodrsy, Schwab, Fox & Drake, 1996
). This is also the experience of a substantial minority of participants in this study and present findings show no beneficial association between traditional 12-step attendance and dual recovery. In most cases, many of the critical ingredients of mutual aid, including identifying, bonding, and sharing coping strategies, are not available to dually-diagnosed persons in a traditional 12-step group (for discussion, Vogel et al., 1998
). In the cross-sectional analyses reported here, participation in DTR, a mutual aid group of dually-diagnosed individuals, is associated with recovery from both mental health disorders and substance use through members’ perceptions of support. Networking with other DTR members is correlated with greater perceived number of sources of support, and greater frequency of attendance is correlated with greater perceived extent of support.
All data presented here were based on self-report. Further, the findings were based on cross-sectional data; it is thus not possible to establish causation. Alternative interpretations (e.g., that individuals with less severe symptoms and/or substance addiction feel better, go to more meetings and thus receive more support) cannot presently be rejected. Later in the study, however, the analyses will be repeated using baseline data as predictors of one-year follow-up recovery status and personal well-being. Overall, the fact that the present findings are consistent with those of previous empirical studies of support and mutual aid is encouraging.