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How do the Twelve Steps of Alcoholics Anonymous really work for those with co-occuring addiction and mental health disorders? In this beautifully written recovery handbook, New York Times best-selling author Marya Hornbacher uses true stories of recovery-her own and others'-to guide readers through the maze of issues that make "working the Steps" uniquely challenging for people with co-occurring disorders. At first, many of those with mental health disorders and addiction feel adrift with little support in a ...
How do the Twelve Steps of Alcoholics Anonymous really work for those with co-occuring addiction and mental health disorders? In this beautifully written recovery handbook, New York Times best-selling author Marya Hornbacher uses true stories of recovery-her own and others'-to guide readers through the maze of issues that make "working the Steps" uniquely challenging for people with co-occurring disorders. At first, many of those with mental health disorders and addiction feel adrift with little support in a program that seems to discourage talk about emotional problems, and the therapy and medication they require. But Hornbacher shows how, wisely navigated, the Twelve Steps can offer insight, spiritual sustenance, and practical guidance for those who truly must approach sanity and sobriety one day at a time.
The Twelve Steps and Mental Illness
I don't know which was the stranger, more terrifying moment: the moment when a psychiatrist told me I had a mental illness, or the moment I realized I was an alcoholic, through and through. I remember both moments clearly: my stomach dropped, the room seemed suddenly cold, and I wanted to run for the door. When it came time for me to face facts, I didn't do it. Not that first time. The fear that accompanied those simple facts—that I have a mental illness, that I am an alcoholic—was so overwhelming that I did what fear told me to do: I hid.
Addicts are good at hiding—for a while. We've turned it into an art form. We hide from our families, our friends, our employers; some of us feel we are hiding from God. We are capable of believing the ridiculous notion that no one can see what's really going on. No one really knows how sad and sick and dependent we are. People with mental illness often share this skill at hiding. The world we live in tells us that mental illness is something to be ashamed of, and heaven knows we feel that shame—and we do all we can to hide our illness from that judging world, from our fellows, and often from ourselves.
So by the time the mentally ill addict or alcoholic has reached a place of complete defeat—by the time we realize that our lives have become unmanageable—we are living under so many layers of shame, deception, denial, and fear, that it seems at first impossible to dig ourselves out. We are used to the dark, lonely place where we've lived for so long. We're used to the company of our substance of choice, the comfort of our habitual terror, the pain of our mental illness. These things are more familiar than what the twelve steps promise: a life in a community of people like ourselves, but who have found a better way to live. To the practicing addict with mental illness, a life up there in the light seems almost as frightening as a life down here in our own private hell.
But we must reach for that life if we want to survive.
Addicts, mentally ill or not, must all come to a turning point where they recognize that there is no future ahead on the road they're walking, and realize that it's time for them to turn down a new road. That moment of realization is rarely a calm one. It often takes hitting the wall pretty hard—often more than once—before we see the futility of trying to live the way we were. From the Twelve Steps and Twelve Traditions: 'We perceive that only through utter defeat are we able to take our first steps toward liberation and strength.'
And that is where we're headed, when we set out with Step One: toward liberation and strength. It's a paradox that we triumph through surrender; but it is true. It is true of addiction, and it is true of mental illness: the way out is through.
When I first came into the program, I found the idea of admitting defeat insane. I already felt defeated, by my illness, by my addiction, by my entire life. Why were these people asking me to go one step further and admit complete defeat—admit, in short, that I was wholly and completely powerless? I insisted that I would get sober anyway, whether I admitted powerlessness or not. Couldn't I just hang onto some sense of control over my life? I told my sponsor she didn't understand mental illness—if she understood the horrible feeling of being literally out of control of your own mind, she would never try to make me feel even less power than I already did.
I believed, at first, that Step One would be impossible for me. I believed my mental illness would make it too painful. I believed it would be too excruciating, too terrifying, to admit total powerlessness over my addiction and over my life, when I already felt so terribly helpless as it was.
But I have come to see this differently. I have come to see the first step as one that my metal illness allows me to understand with particular clarity. I began to apply what I know about mental illness to what I was learning about addiction; and I began to listen to what I was being told about how addiction could be overcome.
Who knows better than we do a true sense of helplessness over the body and mind? Our mental illnesses do not define us, but they are part of the very bodies we live in and part of the very makeup of our minds. My mental illness is inscribed on my genes and expressed in my very thoughts—it's that close to me. Working the twelve steps, I began to learn that addiction is an illness of body and mind as well. It is an allergy of the body that manifests itself as an obsession of the mind. It is passed through families in the genes, just as mental illness is. People who suffer from addiction are physically different from people who do not; our bodies respond to certain substances and behaviors differently than do healthy, non-addicted bodies.
All these things are true of the body of someone with mental illness: it too is a physical disease that manifests as a disorder of mind. The brain is a complicated organ, and we are only just beginning to understand it. But one thing is clear: many people who deal with mental illness also deal with addiction. And while that can at times seem like kind of a bum deal, it also offers those of us who have mental illness and addiction some wonderful opportunities.
The twelve steps, it is often said, are a program for living. They are not just a way of keeping the plug in the jug. And the first step—admitting we are powerless, and that our lives are out of control—is how we make a beginning on that new way of living.
It's important to remember that the first step isn't taken for its own sake—we aren't admitting powerlessness as an end in itself. The first step is not there just to make us feel terrified and out of control. It's there to get us started on our way through the rest of the steps, to get us started on this journey to a new life. It's there to help us let go of our vise-grip on the delusions that keep us sick. Picture Step One as the moment when you open your hands and let all the deceptions, denial, shame, and fear drop to the ground. Then walk away.
The same things that keep us trapped in active addictions prevent us from dealing in a healthy way with our mental illness. We tell ourselves: it isn't that bad. No one can tell. It isn't hurting anyone but me. Everyone's making a big deal out of nothing. Or we tell ourselves: it's hopeless. No one can help me. There's no point in trying. I'm going to die this way, and there's no way out. Or, we tell ourselves: If I just ignore it, it will go away. If I just pretend this isn't happening, maybe it will stop.
These are delusions, and they are fatal. Until we honestly face our mental illness, and do all we can to treat and manage it, we will continue to be limited and harmed by it; until we honestly face our addiction, and do all we can to recover from it, we will continue to live in this hell of isolation, smashed dreams, hopelessness, and despair. We cannot choose one or the other—we can't say, I will deal with my mental illness but continue in my addiction; and we can't say, I will sober up but continue to ignore my mental illness. To try to choose is foolish. They must both be dealt with—dealt with head-on, and at once.
The first time I went to a twelve-step meeting, I was badly hung over and several days off the medications I needed. I remember sitting in the meeting room, staring at the signs with the Twelve Steps that hung on the wall. It was blindingly sunny, I felt like the floor was swimming, and I was peering at the words. I could not make head or tail of what they said. I mean, I could read them—I just couldn't make sense of what they meant. I read through them several times, and finally gave up and just focused on the first step.
Admitted we were powerless over alcohol—well, I wasn't so sure about that. Sure, I drank a lot. Too much. I knew that. But powerless? It seemed like an awfully strong word.
…and that our lives had become unmanageable. Now, that I could get behind. No question was my life unmanageable. My life was a raging mess. Everyone I knew had a theory about why it was such a mess—I drank too much, I needed more therapy, I worked too hard, I didn't sleep enough, I kept going off my meds. And I had a theory, too: I was just a screw-up, had always been a screw-up, and would always be a screw-up, no matter what I did.
So, sitting in that meeting room, I couldn't quite explain why I was hit with the realization that those steps on the wall were a lifeboat, and I was sinking, and I needed to hang on for dear life.
You know what? I didn't. I walked out of the meeting and went home and took my meds with a beer. I did what I always did—I hid.
My life wasn't really unmanageable, I decided. And I certainly wasn't powerless over alcohol.
Fast-forward just a few months: I'm sitting in a snowbank on the sidewalk of a wide, dirty, empty street. It's maybe 7 o'clock in the morning. The sun's just coming up, and I'm out of booze. I'm peering into the mouth of the bottle, as if I'll find some more in there if I look real hard. I'm trying to stand up, but am too drunk to get out of the snowbank. Freezing cold, wet and filthy, I realize the liquor store won't open for another three hours. I start to cry.
I am powerless over alcohol. And my life has become seriously unmanageable.
In other words: a new beginning.
Every addict wants the magic bullet, the moment of revelation where we said, 'Aha!' and it all came clear. Sadly, few of us have such a moment. My snowbank realization that I was pretty well done for if I didn't get some help was followed by months and months of fighting. Fighting other people, fighting the program, fighting myself. Fighting, first and foremost, the first step. Fighting the idea that I was powerless, that alcohol and mental illness were bigger than I was, that I needed to take action to recover if I wanted to survive. Waiting around for salvation just wasn't going to cut it anymore. Waiting for it to all go away overnight wasn't one of my options. I had to act, and fast.
But the simple fact that I could act—that there was something that could be done if I chose to do it, there was a way out of the hell in which I was living—was a revelation. For so long, I had believed that there was no hope for me. No hope for a mentally ill alcoholic who couldn't seem to get either her mental illness or her alcoholism under control. I was a crazy drunk, and there was nothing I could do, nothing that could be done for me. Helpless and hopeless, I had given up all faith in the world, and had lost all faith in myself.
The twelve steps are a path up and out of that isolated, hopeless, helpless place. They are a series of actions I can take, and I take them in the company of others. They are hope when I am hopeless, and help when I think there is no help for me. The Big Book says that these steps can work, 'no matter how far down the scale we have gone.' Millions of recovering people can testify to the truth of that statement. And so, beginning wherever we are, knowing we are not alone, we take that first step: we admit that we are powerless, and that admission sets us free.
The admission of powerlessness lifts the burden of delusion we carry, the delusion that if we just try hard enough, we can master the substance that has us in its grip. Every addict has labored under this delusion—that we can, by force of will, gain control over the substance to which we're addicted, and that our failure to do that is simply more proof that we are failures as people. We who have a mental illness are already acquainted with this feeling of failure. How many times have we tried to control our mental illness—a physical disease—by 'pulling ourselves up by our bootstraps,' by 'positive thinking,' by trying to simply will our illness away? And how well has that worked? Neither mental illness nor addiction can be willed away; they both require serious action proportionate to the seriousness of the disease.
We must recognize that, as addicts, our bodies were constructed with a perverse will to self-destruct: we are chemically inclined to consume a substance that will ultimately consume us. The fact that we have a mental illness makes us doubly vulnerable to addiction. The Big Book has it right: 'The delusion we are like other people, or presently may be, has to be smashed.' When we admit that we are powerless—over the fact that we have a mental illness, and over the substance to which we have become addicted—we are prepared to take action that will put us back in charge of our lives.
For a long time, I grappled with the second part of the first step: 'our lives had become unmanageable.' I could concede that it was true—my life was clearly out of control. But that had always been the case. Was it because I was an addict, or because I had a mental illness? Before I got sober, I, like a lot of us, was pretty sure I drank to 'self-medicate.' I told myself I drank to deal with the pain of mental illness, and that if I wasn't mentally ill, I wouldn't have so much to drink about. This was one of many ways in which the old self-pity showed its face—the truth of the matter is that there are plenty of people who deal with their mental illness without getting smashed every night. Well, then (I said), maybe I'm really just an alcoholic, and not mentally ill at all. Maybe if I sober up, the mental illness will go away. Wishful thinking. The fact is that I am mentally ill and alcoholic. My life was unmanageable because I wasn't dealing with either.
And that's an important point: it wasn't that mental illness was making my life unmanageable, or that alcohol was. It was that I wasn't dealing with these things. Because life with a mental illness can be manageable; and millions of sober addicts will be glad to tell you that life after addiction is manageable as well. The key word, again, is action.
It may seem strange to speak of acceptance as action, but that's the action required to take Step One. The step requires radical acceptance. Acceptance of powerlessness; acceptance that our lives are truly and completely unmanageable; acceptance that we have reached a stage of complete defeat. Only when we accept these truths will we reach the willingness required to take the next eleven steps. Step One does not tell us we are failures; it shows us that the way we have been doing things has failed. Seeing clearly, we can assess the reality of our lives and situations, and accept that we need to live a new way. This new way of living exists, and can be obtained by working the steps.
It may be that the first step is particularly uncomfortable for someone with mental illness. I know that it was the hardest step for me to take. I wanted so badly to cling to the notion that I really was all right, that I really would get things under control if I just tried a little harder, that I wasn't powerless. The words 'complete defeat' made me feel sick. That was what I was so scared of—the idea that I had been defeated, by mental illness, by alcohol—and what I fought so hard against. I was willing to live in total denial, as long as I could cling to the delusion that I wasn't beaten yet. But that denial was killing me. That unwillingness to face facts, to accept reality, was a deadly form of fear, and had to be overcome.
This is what I didn't understand when I was fighting the first step: we are not being asked to stay in a place of complete defeat. We are being offered a way out. Step One divests us of the last of our delusions. It cleans the slate. It clears the fog before our eyes, and shows us a future we had not thought possible for ourselves.
Step 1 Acceptance 1
Step 2 Sanity 11
Step 3 Surrender 23
Step 4 Honesty 37
Step 5 Humility 51
Step 6 Willingness 63
Step 7 Transformation 75
Step 8 Responsibility 87
Step 9 Restitution 101
Step 10 Commitment 117
Step 11 Power 131
Step 12 Service 145
Epilogue: What It's Like Now 161
Appendix A The Twelve Steps of Alcoholics Anonymous 164
Appendix B Peer Support Group Resources 166
Posted November 6, 2010
Since I have a dual diagnosis, of severe clinical depression and alcoholism I found this book incredibly helpful for working the 12 steps with my Depressed Anonymous group.The book is an easy read with guidance paralleling the Big Book and clinical psychology for treating mental illness. I found this book to be inspiring and necessary to my recovery. I also believe that partners of dually diagnosed persons would benefit from reading this book as well.
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