Effectiveness of Dual Focus Mutual Aid for Co-Occurring Substance Use and Mental Health Disorders: A Review and Synthesis of the “Double Trouble” in Recovery Evaluation

Abstract

Over 5 million adults in the United States have a co-occurring substance use disorder and serious psychological distress. Mutual aid (self-help) can usefully complement treatment, but people with co-occurring substance use and psychiatric disorders often encounter a lack of empathy and acceptance in traditional mutual aid groups. Double Trouble in Recovery (DTR) is a dual focus fellowship whose mission is to bring the benefits of mutual aid to persons recovering from co-occurring disorders. An evaluation of DTR was conducted by interviewing 310 persons attending 24 DTR meetings in New York City (NYC) in 1998 and following them up for 2 years, in 1999 and 2000. The evaluation produced 13 articles in 12 peer-reviewed journals, the main results of which are summarized here. The sample's characteristics were as follows: mean age, 40 years; women, 28%; black, 59%; white, 25%; Hispanic, 14%; never married, 63%; live in supported community residence, 53%; high school graduate or GED, 60%; arrested as adult, 63%; diagnoses of: schizophrenia, 39%; major depression, 21%; or bipolar disorder, 20%; currently prescribed psychiatric medication, 92%; primary substance used, current or past: cocaine/crack, 42%; alcohol 34%; or heroin, 11%. Overall, the findings indicate that DTR participation has both direct and indirect effects on several important components of recovery: drug/alcohol abstinence, psychiatric medication adherence, self-efficacy for recovery, and quality of life. The study also identified several “common” therapeutic factors (e.g., internal motivation and social support) and unique mutual aid processes (helper-therapy and reciprocal learning) that mediate the influence of DTR participation on recovery. For clinicians, these results underline the importance of fostering stable affiliation with specialized dual focus 12-step groups for their patients with co-occurring disorders, as part of a comprehensive recovery-oriented treatment approach.

Keywords:

• co-occurring disorders
• mutual aid
• self-help
• DTR
• recovery
• substance use
• 12-step
• addiction
• mental illness

Acknowledgments

This research was supported by grant no. R01 DA11240 (S. Magura, Principal Investigator) from the National Institute on Drug Abuse. The study was conducted at National Development and Research Institutes, Inc., N.Y. The cooperation of the members of DTR and of the many organizations where the meetings were held is gratefully acknowledged. The following made substantial scientific contributions to the study in various roles, as reflected in the authorship of the study's articles (in alphabetical order): Charles Cleland, Edward L. Knight, Alexandre B. Laudet, Daniel Mahmood, Andrew Rosenblum, and Howard S. Vogel.

Notes

¹ The National Survey on Drug Use and Health (NSDUH) is a nationwide U.S. survey involving interviews with approximately 70,000 randomly selected individuals aged 12 and above. It provides national- and state-level estimates of the past month, past year, and lifetime use of tobacco products, alcohol, illicit drugs, and nonmedical use of prescription drugs.

² The DTR program is detailed later.

³ Treatment can be briefly and usefully defined as a planned, goal-directed change process, of necessary quality, appropriateness, and conditions (endogenous and exogenous), which is bounded (culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutual-help based (AA, NA, etc.), and self-help (natural recovery) models. There are no unique models or techniques used with substance users—of whatever types—and non-substance users. In the West, with the relatively new ideology of “harm reduction” and even the newer quality of life (QOL) treatment-driven model there are now a new set of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Editor's note.

⁴ The National Institute of Mental Health Epidemiologic Catchment Area Program interviewed 20,291 persons to determine the prevalence of comorbid alcohol, other drug, and mental disorders in the United States total community and institutional population.

⁵ A diagnostic process, in simplistic terms, permits the collection of necessary and relevant data/information in order to facilitate decision-making. From a medical-treatment perspective a useful diagnosis “offers,” minimally, three critical and necessary types of information: etiology, process, and prognosis, which are not always known. The relatively recent substance use disorder related nosology of “dual diagnosis” is inadvertently misleading in that any substance user, of whatever type can be “tagged”/diagnosed in each area of his/her life: medically, psychiatrically, socially, gender identification, educationally, spiritually, morally, IQ, SES, ethnically, racially, legal-status, etc. depending upon the criteria used (whatever their underpinnings and validity) and the needs of the categorizers. Neither “substance use disorder” nor dual diagnosis, or any of their variations offer, etiological, process, and prognostic information which can be used for effective treatment planning, implementation, and evaluation of heterogeneous drug users. “Dual diagnosis,” as an ongoing useful tool for a range of substance use(r) intervention stakeholders and gatekeepers, can be usefully explored in the vast labeling theory literature. To paraphrase the General Semanticists: the map = = the territory; the substance use disorder and/or the “dually diagnosed” = = the substance user PERSON. Editor's note.

⁶ The journal's style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor's note.

⁷ The reader is referred to Sir Bradford Hill's nine criteriafor assessing causality which were created in 1965 to help assist researchers and clinicians determine if risk factors were causesof a particular disease or outcomeor merely associated. The nine criteria include: strength of association, consistency between studies, temporality, biological gradient, biological plausibility, coherence, specificity, experimental evidence, and analogy. These are defined later (Hill, 1965).