What To Do When AA Isn't Working

By Jeff Forester 10/20/11

Some addicts believe that the 12 steps can solve all their problems. But they're designed to treat addiction—not depression, anxiety, and the like. So how do you know when you need a therapist, and what kind do you need?

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Bill Wilson and the early writers of the Big Book of Alcoholics Anonymous were very careful not to take a stand on medical matters or run at cross-purposes to the established medical society. Still, it would be decades before the medical community would embrace the disease model of alcoholism and accept the difficult truth that a group of erratic drunks had found a way to help people get and stay sober that had eluded science. 

They were also quick to recognize that addicts, for the most part, are pretty complicated folks, and despite its success at helping each other get sober, AA alone was often not enough to manage the host of complications the average alcoholic possesses. The reality is that after drunks and addicts get sober, they probably still have some pretty serious “issues” ranging the entire spectrum of mental health disorders. Simply put, addiction or alcoholism rarely occurs in isolation. Bill W. politely labels this smorgasbord of disorders “character defects.” Not coincidentally, half the steps—numbers four through 10—are pretty much designed to help the recovering person manage or even eradicate these persistent problems.  

Still, even Bill W. recognized that in many, or most, cases, the steps alone would not be enough to bring AA members back to full mental health. He chose his words carefully when he wrote that AA had “no opinion” on medical issues, pointedly urging members to seek “outside help” when necessary.

The reality is that after drunks and addicts get sober, they probably still have some pretty serious “issues” ranging the entire spectrum of mental health disorders. 

But how does a person in recovery know that it is time to seek “outside help” and what type of help should they seek?

Again Bill Wilson can be admired for his prescience. Research has proven that he had it right—that people with alcohol or other drug disorders often suffer from a bouquet of descriptive acronyms and psycho jargon that has replaced his placid “character defects”—“duel disorders,” “comorbid disorders,” “MICA” (mentally ill chemical abusers) and substance abusers with “SMI” (serious mental health illness), to name a few. The newest term is “co-occurring disorder.”  

The percentages are a bit daunting; about 16% of the US population suffers from substance abuse problems. In people with mental health disorders, the number is almost twice as high: 29%.  Forty-seven percent of schizophrenics and 56% of people with bipolar disorders have a substance abuse disorder. Almost 80% of alcoholics experience depression at some time in their lives, and 30% meet the diagnostic requirements for major depression. As many as one-third of people entering treatment for substance abuse issues meet the requirements for Post-Traumatic Stress Syndrome (PTSD).

Says Nino Del Pesco, a case manager with Ventura County Behavioral Health, “Co-occurring disorders are rampant with chemical dependency issues. A lot of people self-medicate because alcohol and drugs have similar effects to the medications used to treat many of these disorders.”

So the simple fact is that if you find yourself in a treatment center or sitting in the rooms of a 12-step program, chances are pretty good that your mental health problems might extend beyond an inability to quit using your drug of choice. Those in recovery are thus almost universally wise to seek some “outside help”—particularly when newly sober. 

The first, and increasingly most accessible, stop is a the general practitioner. Medical doctors are being given more and more training in diagnosing mental health disorders, which means that more and more of the burden is falling to them as insurance limitations narrow health care options. Family practitioners now have a host of mental health diagnostic tools they can give to accurately diagnose depression, anxiety disorders and others. A doc’s solution is often chemical (prescriptions for medications to combat anxiety or depression) or lifestyle (as in get plenty of exercise to help manage depression).  

Addicts are frustrating folks and often pose challenges when it comes to diagnosis and treatment. Co-occurring disorders overlaid on addiction can be difficult to diagnose when one problem masks or colors another, or when the recommended drug for one condition (say, Xanax for anxiety) might well trigger a relapse. 

According to Del Pesco, diagnosing someone is difficult until they have been sober for at least six months, when you can get a clearer picture of what they’re like. “For example, if they’re hearing voices,” Del Pesco asks, “is it because of meth or are they schizophrenic?”

Two sub-groups of mental health professionals that are particularly adept at untangling the tangle of addicts complicated psyches are licensed alcohol and drug counselors, or LADC’s, and licensed Marriage and Family Therapists, or LMFT’s.

LADC’s can be either psychiatrists or medical doctors with additional training in psychology and chemical dependency and abuse issues or they may by psychologists with masters or doctorates in these areas. A psychiatrist can write prescriptions for a patient while a psychologist cannot. LADC’s specialize in diagnosing mental health problems and then establishing a program to treat those disorders within the context of addiction by using a combination of drugs and talk therapy or cognitive behavioral work.  

In the rooms of AA, old timers often talk about how addiction is a “family disease.” By this they mean that the disease is played out in a social context and thus impacts not only the sufferer but also those within his or her community. As some say in the rooms, “Alcoholics don’t have relationships—they take hostages.” Enter the Licensed marriage and family therapist, or LMFT.

Says Kim Lundholm-Eades, a licensed marriage and family therapist and president of the Minnesota Association of Marriage and Family Therapists [MAMFT], “An MFT is trained specifically around relationships and to think about mental health problems in the context of systems—for example, family systems, or social systems like work relationships.” Lundholm-Eades, who worked at Hazelden for 16 years before opening her own private clinic called CenterLife Counseling, continues, “People don’t live in a vacuum; we have an impact on the systems around us.”

This is one reason why some marriages fail after the husband or wife gets sober and why many new to recovery lose old friends, jobs or communities that were in place while they were using. And it’s why people who are in relationships and new to recovery may be wise to seek out MFT support. 

Many of the mental health issues people in recovery must navigate are relationship issues. Managing relationships is key to long term recovery and again half the steps at least partially address the way the addict interacts with others. As a result, Marriage and Family therapists have become more and more involved and adept at treating addiction and alcohol related disorders and co-occurring disorders.

Lundholm-Eades is practical when it comes to treating addicts and their families. “I focus on good communication and conflict resolution skills first,” she says.

One of the many dangers of not managing co-occurring disorders, of course, is relapse. Active addiction amplifies the co-occurring disorders so that sobriety must indeed come first if the sufferer is going to have any hope of getting better. But the other side is that untreated depression, anxiety or mania can trigger relapse. 

The American Association of Marriage and Family Therapists has set up an online service for people in recovery to “seek outside help.” The TherapistLocator.net website is designed specifically to put those in need of services in touch with those who provide them.  

While getting outside help may be an important part of therapy, it is only a piece of the puzzle. “People in recovery are wise to have a support system,” says Lundholm-Eades. “But they should also look at the spiritual, physical and social aspects of their lives. To have a healthy recovery, all of these areas need support.”

Jeff Forester is writing an original screenplay for Lorenzo Di Bonaventura based on his award-winning book Forest for the Trees: How Humans Shaped the Northwoods. He’s written for The San Francisco Chronicle and Rolling Stone and has covered sober high schools and painkillers for The Fix.

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Jeff Forester is a writer in Minnesota. His book, Forest for the Trees: How Humans Shaped the North Woods, an ecological history of his state's famed Boundary Waters, came out in paperback in 2009. Jeff is the Executive Director of MN Lakes and Rivers Advocates MLR and you can follow him on Twitter.