Mental Health, Relapse & Suicide
In today’s day and age the 12-step model has become widely accepted. Accepted as a free, readily available, relapse prevention model for many types of issues from alcohol and other drug use to codependent patterns, to gambling, sex, and more.
Turn on a movie or a show about drinking and it is inevitable that some variant of a 12-step program is on display.
What happens when people go to 12-step programs and have mental health issues?
This is the secret that no one wants to talk about.
Mental health issues are not readily treated by a peer based recovery group, and suicide becomes the capital S word that no one dare talk about.
Let’s go to Jane-
Jane is an avid 12-stepper. One night Jane hears a group member share about depression and suicidal thoughts. Jane says “thank you for your share.”
She thinks to say hi to this group member prior to leaving for the evening.
The next morning that member had completed suicide.
The famous last words of the group as a whole “keep coming back.”
Let’s go to John,
John is a prominent person in his field. He has the perfect life- 2 kids and a beautiful wife.
He comes and comes, he shares all of his struggles and woes. He works every step like his life depends on it; because well it does (as he is told over and over again.)
John has a relapse, John’s career is being closely monitored at this time due to his use at work.
John’s relapse results in a terrible mistake.
John shares this in a meeting and his feelings of shame as well. John goes home, gets drunk and completes suicide.
Let’s talk about Priscilla.
Priscilla was the trophy wife, she married and settled down and had a family.
She diligently worked to raise those kids, but her depression and substance use lost them to her.
She came to meetings, and shared and shared. “Keep coming back, don’t go away.”
She struggled to quit for one day, ten days, 100 days. She joined a crew and bought people things, she became a part of.
Then she relapsed, she relapsed and struggled and sank into a depression that was too difficult to overcome.
1,000 eyes watched in horror as she spiraled into the abyss.
She took some pills and never came back.
Let’s talk about Elizabeth
So much potential in this gal. Her entire identity was wrapped up in the idea of sobriety “I don’t have another recovery in me.”
Meeting after meeting she shared this mantra, “I have another relapse, but not another recovery.”
Everyone applauded the dedication to her 12-step program.
She relapsed after 6 months of repeating this mantra, her husband left, and shortly thereafter she completed suicide.
Few Mental Health Facts
When you think about suicide and the fact that 22% of suicide completions are from opiate/ prescription overdoses, and 20% of suicides involve alcohol or other drugs.
Then compound on that the idea that increasing misuse of substances is a major factor in suicide the problem becomes systemic.
Substance use disorder is very common among depressed people, bipolar people, borderline personality.
As well as other significant mental health diagnoses that place someone at risk. At risk for suicide completion, chronic suicidal ideation, and other self harm behaviors.
So with all this information, one might say that there is an underground crisis occurring.
People don’t talk about this in a meeting, or there is a potential for shaming.
Bill Wilson, one of the founders of AA struggled with depression his entire life.
He fought and fought the demons of sadness, and hopelessness.
He tried LSD to soothe his weary mind.
Bill‘s Mental Health
The AA community ridiculed him, they accused him of living outside the values of the program.
He, a beacon of recovery, had to hide the genuine part of himself because psychotropic medication was not allowed in sobriety.
We go to the present where the message is relatively unchanged- mind or mood altering substances are a big red flag for relapse.
Ask & Say
Have depression? (they ask)
– Just eat clean, go for a walk, write about it, and “Call your sponsor”. (they say)
Want to kill yourself? (they ask)
– Share about it in a meeting. (they say)
So you go ahead and share about it in a meeting, and you still feel bad?
Pray about it; because yeah that cures everything. (they say)
Are You a Chronic, relapsing, IV heroin user?
– Don’t touch that suboxone. (they say)
Despite over a decade of research suggesting that suboxone use over a period of 9-18 months significantly reduces relapse long-term, yes long-term.
Extended suboxone prevents people from dying of a drug overdose. It enables them to enter into recovery, and deal with what brought them there to begin with.
No, this too is a relapse or never being in recovery to being with. (they say)
The Dirty Little Secret
The dirty little secret is that 12-step programs do not encourage mental health, at least not being very mentally healthy.
They say work the steps and everything will change.
What if instead you work the steps, and you get worse?
So you work them again and the depression remains.
So you seek outside help and the groups tells you to not talk about that, because therapy is a dirty word.
What Then? Therapy has not been enough, 12-steps leave you longing…. so is there an alternative?
John goes to a psychiatrist, they prescribe something for his depression and anxiety.
John tells one of his peers he’s working on depression with this medication.
Rather than being met with support John hears 10 stories of all the times everyone else got off medication successfully, and how they are really in recovery now.
John takes the medicine for a few months and feels no better so he tries again.
Eventually after 4 medication attempts, and minimal support from his 12-step program he stops.
Soon John relapses and we are back to the suicide of John.
Q & A
So why then is mental health such a dirty word?
Why do 12-step members condone medication?
The answers are complex.
In reality many people are on psychotropic medications in the rooms, but very few discuss this fact.
Often those who do, present as unstable and with lower levels of functioning.
Go back to the case of chronic, medication resistant depression.
There are about 3-4 categories of approved medications to treat depression dopamine stimulators, SSRIS, MAOIs, and SNRIs available today.
Then we get into alternative treatments- ECT and Esketamine are both FDA approved alternatives to medication used over a short period of time (6mos-1year.)
A conundrum we face with many of these treatments-
Wellbutrin is a typical dopamine stimulating drug, and has a history of abuse in the correctional setting.
ECT requires anesthetic aka some form of IV pain and benzodiazepine drug, and Ketamine has a history of abuse in the club world.
What Do We Do?
So what do we do with people who struggle with substance abuse and mental health issues.
We cover our ears and shut out the grim reality. The reality that suicide involves substance use. And that substance users are 4 times more likely than the general population to complete suicide. Just as the trans community is a much higher risk.
Why do we have to make mental health care a dirty word in the 12-step community?
Let’s Take Laura-
Laura’s a prominent 12-step attender, a professional, and advocate in her field.
She suffers from mental health issues. She went off of her medicine and ended up on the rinse repeat for psychiatric hospitalizations.
Then came the isolation, and eventual loss of self.
The first words out of her mouth on her third hospitalization “At least I didn’t relapse.”
The 12-step community says this is just a sign. A sign that one is spiritually bereft, but can we as a society chalk it up to that?
If there were 8 treatments for cancer and 2 of them involved using a mood altering drug and all 6 of the other treatments weren’t cutting it.
Wouldn’t you encourage the person with cancer to try everything?
Wouldn’t the 12-step community stand up and say “we support you overcoming cancer.”
So maybe the secret is that too many members live in this unfulfilled grey area, where they aren’t drinking anymore, but they aren’t quite happy.
That’s called anhedonia and many people experience it right away in their program.
So when does mental health stop being an outside issue, a dirty word?
When the treatment involves medication that is not understood by the general lay person.
When a member has an opinion on that specific medicine because they feel being sober means more than what the medical field does.
When being clean means living a life of misery. In misery because in order to be clean you have to not take psychotropic medication.
Depression is just a segment of the mental health spectrum one will see in a 12-step community. However the sicker you are the less you are encouraged to participate.
Un-Qualified & Un-Licenced
12-step members are not trained in mental health treatment, but feel they can pass whatever judgement they like for their own end. “No cross talk, Jane.”
Except in the case of telling a newcomer how sharing suicidal thoughts is an outside issue and talking about mental health should be done someplace else.
Getting into recovery is depressing, finding an alternative to use is hard.
It’s not easy to stop, and it doesn’t always feel great or welcome.
So instead of saying “don’t do that you won’t be sober,” the 12-step community should embrace all members.
Shame Based Has To Go
In order to stay relevant and retain members these 12-step communities will need to embrace what changes are coming, treating mental illness is no longer prayed away.
Some people don’t respond to first line medications, and alternatives are available.
Instead of a shame based approach to mental health, the recovery community must embrace the idea that recovery is not a one size fits all.
Instead of making mental health the dirty secret, recovery communities must accept the idea that recovery goes far beyond a drink or a drug.
Recovery touches every part of that individuals life, mental health matters, and the end goal is to learn a new way to live and lose the desire to use.
The New Frontier
It’s no longer necessary to live in the time of Bill W, where it was required to suffer in sadness.
Times have changed, medicine has changed. It’s a new frontier.
It’s time to accept that mental health and recovery are inseparable.
Without some kind of zeitgeist change in the recovery community AA, and other 12-step modalities will fall to the wayside.
The community must band together to save itself from antiquated beliefs that mental health is an outside issue.
Mental health care is only an outside issue until it’s brought into the rooms.
Band together and support the still suffering person, without that the program fails its members.
Needs of Your Community
If a community is only as strong as it’s weakest link, then why would one of the most fragile, weak communities continue maintaining behaviors?
So, as one fellow 12-stepper to another. Please do not ignore the needs of your community.
Rise up and support those who are suffering in silence.
If someone shares that they are at the end of the road, embrace them, encourage them, and help them find the road to a genuine, true, lasting recovery.
This includes mental health care.
Sponsors & Meetings
Sponsors aren’t therapist, meetings aren’t therapy, but as one loving, kind person to another why can’t we help them find their way?
Suicide does not have to be a dirty word.
It is only through understanding and application that we recover.
Written by Sarah Zubrin MA, MFT, LAC Chief Clinical Officer of Mile High Continuing Care
Sarah is a Licensed Addictions Counselor, with a Master’s Degree in Marriage and Family Therapy.
As a Colorado native you can find her outside of work rock climbing, hiking, skiing, camping, and walking her dogs. Sarah has been working in the mental health field for over a decade and has extensive experience in the co-occurring field.
She has many years of experience working with at-risk adolescents, young adults, adults, and their families in both outpatient and residential settings. Recently she has been working as a clinical supervisor for addiction counselors in training and working clinically in the full continuum of care.
Sarah has a deep level of compassion and passion for the recovery community and believes that recovery is possible for every client that walks through the doors.
With a truly integrated approach to treatment co-occurring disorders are addressed simultaneously.
She also believes fully that working with families to help change the family culture is an essential part of the process. She works both individually and in groups to help every client develop sustainable long-term recovery skills.