Double Trouble in Recovery (DTR) is a mutual aid program adapted from the 12 step method of AA, which specifically embraces those who have a dual diagnosis of substance abuse/dependency and psychiatric disability. The fellowship was spearheaded in New York State by the first author in 1989 out of his own experiences in dual recovery. Having attended traditional 12-step meetings for his addictions, he found that existing groups were not suitable for those with added psychiatric disabilities who have problems unaddressed and often stigmatized in traditional 12-step programs (e.g., psychiatric symptoms, faking medications, dealing with medication side effects). DTR developed as a grassroots initiative, from one individual to one group and growing; over the years and throughout its growth, it has kept and promises to keep this grassroots bend with which consumers feel at ease, thus reinforcing (or perhaps contributing to) the benefits of the fellowship. DTR was developed and functions today with minimal involvement from the professional community. All DTR groups are lead by recovering individuals, even where groups are held in institutional settings.
From the first group formed in New York City in 1989, DTR has grown and spread nationwide by word of mouth, and recommendations from social workers and therapists, as well as through conferences and workshops. Currently, there are over 100 DTR groups in the US (47 in New York City). New DTR groups are being started constantly, some as a consumers’ initiative, others at the behest of professionals who feel that mutual help fellowships are a useful addition to formal treatment, especially for the hard-to-engage population of the dually diagnosed. In the last 3 years, there has been on average at least one new DTR group started each month. This rate of expansion promises to continue or even increase, particularly since large managed-care companies nationwide are expressing interest in adding a self-help component to the menu of services offered to their client companies. DTR, Inc., a small nonprofit organization, supports this growth by training consumers as group facilitators on how to start a DTR group, and by providing ongoing support to existing groups.
DTR is not the only self-help dual-recovery program; other organizations with similar goals include Dual Recovery Anonymous (DRA) and Dual Disorders Anonymous, At this writing however, the authors have been unable to locate an organization with ongoing group meetings in the New York area (where the need is so great) other than DTR. Experience tells us that it is difficult to maintain such specialized fellowships, perhaps more so than for those with a single diagnosis focus; mundane issues such as funding and organization must be addressed and can become insurmountable obstacles for a fellowship of individuals whose own existence is often at risk, dealing not only with psychiatric disabilities and chemical dependency but also with community residence living, entitlements and so on. There are also a few dual-diagnosis meetings conducted under the auspices of Alcoholics Anonymous, most often in halfway houses, according to AA (Alcoholics Anonymous General Services, March 25, 1997, personal communication), these meetings are not considered “groups” and are excluded from the meeting list, as their purpose is perceived to depart from AA’s primary goal of sobriety; some states do include such meetings on their list however. As to empirical findings on the effectiveness of self-help for the dually diagnosed, a literature search of the social sciences databases proved fruitless.
While no outcome data on DTR are yet available, two preliminary studies were conducted in preparation for a full-scale evaluation- (A 3½-year, NIDA-funded longitudinal study began in early 1998.)
This study was designed to obtain background information about DTR members, including sociodemographics, psychiatric and substance use history, and treatment experiences. The instrument was a two-page anonymous, structured, self-administered questionnaire. A sample (N = 52) was obtained by recruiting participants at four DTR meetings in New York City in June–September 1996. Three were established 5, 3, and 2.5 years ago; the fourth had started one month previously. The four sites, in the aggregate, were designated as approximately representative of the overall DTR membership by DTR’s executive director. By observation, 90% or more of the attendees at each group completed the questionnaire, suggesting that this sample was representative of the population from which it was drawn.
DTR members are predominantly male (73%) and ethnically diverse: African American (45%), Hispanic (22%), non-Hispanic white (33%). Members’ ages range from 22 to 67 (median = 42). Sixteen percent of the sample graduated from college, 28% attended college but did not graduate, 22% graduated high school or the equivalent, while 34% did not. Forty-four percent are currently employed (22% full-time, 22% part-time), 16% are disabled, and 37% are not employed.
- Ever used: DTR’s members’ experience with drugs is extensive: 58% have used cocaine, 50% crack, 31% heroin, 81% alcohol, 37% non-prescribed pills to get high, 31% methamphetamines, 65% marijuana, 13% street methadone; 17% have been IV drug users.
- Past year use: Recent use is very limited; in the past year, 6% have used cocaine, 2% crack, 4% heroin, 10% alcohol, 2% non-prescribed pills to get high, 2% methamphetamines, 2% smoked marijuana, 4% street methadone, and 2% injection. 3)
Treatment history: 46% have been in alcohol treatment or detox, 33% in drug detox (7 days or less), 31% in drug rehab (short-term), 46% in a drug-free outpatient program, 15% in a methadone maintenance program, 37% in a residential or therapeutic community; 54% have attended traditional 12-step meetings. Currently, 2% are attending a drug-free outpatient program and 2% are in methadone maintenance.
- Diagnosis: All DTR members surveyed reported at least one psychiatric diagnosis: 44% have a diagnosis of schizophrenia, 46% unipolar depression, 21% bipolar disorder, 10% anxiety disorder/phobia, and 6% post-traumatic stress (nearly half of members have multiple diagnoses).
- Medications: 76% are currently taking prescribed medication for their psychiatric illness.
- Treatment history: 63% have been in an inpatient psychiatric treatment program, 56% in an outpatient program, 60% in individual counseling or therapy; 48% have attended group counseling or therapy. Currently, 12% are attending an outpatient psychiatric treatment program, 13% are receiving individual counseling, and 13% are in group counseling.
- Attendance: DTR attendance among study participants ranges from less than 1 month to over 2 years (median=18 months): 10% have been attending less than 1 month, 16% 1 to 3 months, 12% 4 to 6 months, 10% 7 months to 1 year, 33% 1 to 2 years, and 18% over 2 years. The majority of members attend very regularly: 43% more than once a week, 43% once a week, 4% once every other week. 10% once a month or less. Of those attending for a year or more, 90% are attending a meeting at least once a week. The data suggest an association between DTR attendance and medication status: of those not currently taking medication. 83% attend at least one DTR meeting a week and 73% have been coming for a year or more. The most common routes to DTR are through a therapist or social worker (49%) or a friend or associate (31%); 12% of participants heard about DTR in the community, and 8% at another 12-step meeting— 70% of members surveyed attend a traditional 12-step meeting (AA or NA) at least once a week.
- Members’ views about DTR: participants were asked so express their degree of agreement with 13 statements designed to assess their experience with DTR as well as with other 12-steps groups (see ).
Members’ Opinions about DTR and Other 12-Step Programs
The second study was qualitative and designed to supplement and elucidate the information obtained in Study One. It consisted of a semi-structured ethnographic interview focusing on members’ experiences with DTR including what was happening in their lives when they first attended a DTR meeting, comparisons with other 12-steps groups they may attend, what they derive from DTR attendance, and a history of their psychiatric disabilities and substance use from initiation to present.
Eight DTR members were interviewed: six men and two women, all minority members, ranging in age from 29 to 42 years. This is a convenience sample of volunteers obtained at one meeting. While the details vary, all recounted similar histories, which we have organized by common themes:
“I had no childhood.” Members recount growing up in a neglectful, dysfunctional family, often with one alcoholic parent or guardian; most report first experimenting with alcohol and drugs (from marijuana to heroin) often because of peer and parental pressure (alcoholic parent forcing child to drink) and experiencing psychiatric symptoms (ranging from hearing voices to major depression and suicidal ideations) in early adolescence. About half underwent psychiatric care including medications, although medication was usually discontinued almost immediately due to unpleasant side effects and to the feeling that medications were not necessary and that drugs were better.
“I felt normal for the first time.” The result of using drugs and/or alcohol was a feeling of confidence and “belonging” which led to increased substance use, often of multiple substances such as marijuana and alcohol, LSD and alcohol, or heroin and cocaine or crack. That in turn brought about increased psychiatric symptoms that were disregarded, as individuals were by then caught up in a drug lifestyle including crime, incarcerations, and homelessness. While some members have an extensive history of drug abuse treatment going back to adolescence, the majority of those interviewed did not come to formal treatment until “hitting bottom” (i.e., experiencing some turning point such as having drug-induced seizures, passing out and being robbed in the middle of winter, or attempting suicide). Death felt close at hand, and the individual grasped at treatment as the fast hope.
“My new life.” It is no coincidence that many DTR members refer to the date they “turned around” as their birth date. Most of those interviewed had their turning point about 3 years ago, on the heels of some 20 or more years of substance use and psychiatric disabilities going unchecked. Treatment usually began in a hospital inpatient psychiatric program, from where comorbidity often directed members to a program for substance abusers with a mental health disorder (MICA). For two members, treatment started in a substance abuse program; while they had experienced psychiatric symptoms since early adolescence, no psychiatric diagnosis had ever been made until recently.
Fellowship as “safety net.” It is at that point that those interviewed came to hear about DTR and began attending— some while still in an inpatient unit, others after having moved on to an outpatient program. Most had had superficial experience with AA and/or NA but typically did not feel connected and thus did not share, or shared only about their substance use, which bothered them. Coming to DTR, members felt relieved and exhilarated by being with others who had had the same experiences with drugs, psychiatric symptoms, and medication, and could freely discuss it in a nonjudgmental, supportive atmosphere. For the first time, they report, they feel they can be themselves, be accepted, and trust others; this is in the context of a history where they felt no one could be trusted, be it psychiatrist, drug counselor or peers at 12-step meetings. These members report that DTR allows them to feel more comfortable seeking help for both their addiction and their psychiatric illness; it gives them a more positive attitude toward medication and provides them with a safety net: “When you’re walking a tight rope, if you know there is a safety net under you, you don’t think about falling; DTR is my safety net.”
“My rock of Gibraltar.” Because DTR is a true mutual-help group, members are invited early on to take an active role in the group, be it by “qualifying” (being the main speaker at a meeting and speaking of one’s experiences in front of the entire group), by making a presentation about DTR at another facility, or by becoming a group facilitator (“chairman” in AA parlance, that is, leading the group protocol, opening, closing, etc.) As described by members, the combination of sharing with others who have had similar experiences (mutual support), seeing chose who are further along in their recovery (role models), and becoming a helper to other newer members (as opposed to being a stigmatized service recipient) brings about a new feeling of self-confidence and empowerment (self-efficacy), which facilitates the struggle for staying clean and taking one’s medications. Thus, DTR members credit DTR for giving them the ability to stay on the path of their double recovery: “if it was not for DTR, I would be back in the hospital or using; it’s my rock of Gibraltar.”