Mental health and recovery from addiction - the chicken or the egg?

www.comas.org.uk www.serenitycafe.org.uk

IntroductionThis paper was developed because many people involved in the Serenity Cafe have experienced mental ill health and periods of mental and emotional vulnerability during their recovery from addiction. We were interested to explore their experiences and we were helped to do so with a grant from the Choose Life programme of the City of Edinburgh Council and Edinburgh Community Health Partnership. The findings are based on individual interviews and group discussions within the Serenity Cafe, and a specific focus group of individuals in recovery with experience of mental ill health .

We hope that these findings will:

Help health professionals to understand the perspective of people in recovery from addiction, which our findings suggest is particular to recovery from addiction rather than generally linked to recovery from mental illness or addiction.

Help people in recovery build their understanding of the relationship between addiction, mental health and recovery, and how their self management can be strengthened through shared experience.

Recovery Recovery is a term now used in a range of different sectors to describe a process of enabling an individual to have the best life possible and to be active in managing their day to day experience of illness, through developing their own personal understanding of how illness affects them and taking a ‘whole life’ perspective, and through engagement with services on their own terms. The concept of recovery, and its values and principles, has much to offer whether a person is recovering from mental illness or recovering from addiction. However, in the Serenity Cafe, people have chosen to identify with recovery from addiction, and approaches and services which focus on recovery from addiction, rather than recovery from mental illness, even though some have a diagnosed mental illness and have previous experience of mental health services and support groups.

People involved in the Serenity Cafe feel it is important to recognise that recovery from addiction, and the language of recovery, has been used by people addicted to alcohol and drugs for over half a century in Scotland. Although many people recover from addiction without using mutual aid groups (AA, NA or CA) to help their self management, these groups pioneered a network of people supporting each other to recovery which formed the basis of many modern approaches to treatment, and which has created a thriving ‘recovery community’ throughout Edinburgh, the UK and internationally. Throughout this paper we use the term ‘recovery’ to describe recovery from addiction, and the ‘recovery community’ to describe the network of people who self identify with this process, with great respect for those involved in the mental health recovery movement.

However, although there is an understanding of ‘recovery’ within the recovery community, people involved in this study experienced varying attitudes and understanding towards mental illness, some of which made experience of mental health problems whilst recovering from addiction an additional challenge for them.

“You know, I’ve suffered more from anxiety since being clean and sober than I can ever remember being [in 40 years of addiction]”

“It’s difficult in early recovery, to figure out what’s, because you’re experiencing life for the first time without putting substances in your system”

“I struggled, I actually shut down and stopped talking to people in recovery about my other [mental] illness”

The Sereni ty Caf é a i ms to pr ov i de a h ub in Ed i nbur gh fo r t he reco ver y commun ity , bu i l d i ng soc i a l netw orks , c r eating perso na l deve l op men t opp ort uni ties and su ppo rting co l lectiv e actio n fo r peop le reco ver i ng f ro m addi ctio n to d rug s and a l coh ol , he l p i ng to s t r en gthen lo ng term r ec ov er y and enabl i ng p eo pl e to rega in a po s i tiv e and fu l fi l l ed l i fe . The S er en it y Cafe w as estab l i shed in 2 00 9 in Ed i nbu rgh by peo pl e recov er i ng f r om addi ctio n, wi th th e supp or t o f c ommuni ty d ev e lo pment agency Co mas. I n 2 01 0 the Sereni ty Café wo n the Commun ity Actio n Awar d of the SCVO Sco ttish Char i ty Awar ds . The Sereni ty Ca fé uses an actio n research appr oach h el p i ng p eo pl e i n reco ver y to shar e th ei r exper i ences and exper tise . Th i s pap er i s o ne of a ser ies exp l or in g d i fferent aspects of r eco v er y .

Mental health and recovery from addiction – the chicken or the egg?Insights from people in recovery from addiction on their experiences of mental health and mental health services

Mental health in recovery


All of the people involved in this study recognised that their mental health and addiction were inextricably linked. Regardless if which came first, ultimately both needed to be addressed together.

Self medication for copingSome began using substances to blot out their mental ‘unease’ or as a coping mechanism for problems such as bereavement, abuse or trauma; others only felt at socially at ease when they had used substances. “I always felt that there was something wrong with me as well. The thing, whether it was mental health, I always thought there was always something. I mean the alcoholism side, there’s the hole in your soul, and then there’s the other side, aye, I always thought I was mad”.“I suppose any kind of mood altering substance for me gave me some control over my emotional state”.However, some people also found that the lifestyle of an addict in itself created mental health problems. Addiction forced people to live a lifestyle which brought shame and guilt, for which they used substances to mask the pain and to cope. Others were in dangerous situations and one or two people have since worked with professionals who suggested they were experiencing post-traumatic stress disorder because of this.“There was a hell of a lot of violence, people getting killed in fact, and I was really in the thick of it – madly, madly paranoid and I treated my paranoia with more cocaine. I had a breakdown and a suicide attempt”.

Using labelsPeople had different experiences relating to the value of being able to identify as having mental health problems. Some people found that being able to adopt a label of being mentally ill helped them to avoid confronting their addiction. “I quite liked seeing psychiatrists and going to see shrinks and mental health professionals...’cos I knew I wasn’t right but I thought they were all full of shit and I thought they were pretty stupid really not to be able to see what I was doing...... I thought the most any mental health professional could do for me was scratch the surface. They would never get anything outta me ‘cos I had this huge defence up for my addictions”.Others found that being given a ‘diagnosis’ of a mental condition was liberating, providing the opportunity to seek specific information and achieve some understanding of it, and feel relief to know there was a reason for behaviour they couldn’t control, such as ADHD.However, many people with a diagnosed condition felt this needed to be re-assessed in recovery, to understand how much the mental health problems were really associated with long term substance use, and how much mental health problems were a fundamental part of someone which they would learn to self manage without using substances to mask the experience.“I went to do my interview for[addiction] treatment, they were very much like ‘ok, doctors in mental health will initially diagnose depression, schizophrenia, ADHD, everything, before they’ll do alcoholism. Actually, what you might be suffering from is just alcoholism”.

Life without a substance as a coping mechanismAfter becoming abstinent in recovery, many people face a long and daunting period of mental and emotional fragility. After years of extreme substance use, many people are advised by peers in recovery to expect life to be difficult at first.“I remember ...in early recovery thinking I’m going to need to be sectioned, I can’t leave the house, I can’t have a conversation with anybody. What’s going on? And she was like ‘its early recovery, give it time’”Most of the people involved in this study regularly experience opportunities in the recovery community, through mutual aid groups, to share their thoughts and feelings and to hear from others. Whilst this can be experienced as helpful, it is sometimes extremely difficult for people to begin to express themselves after years of ‘covering up’ with substances.

It’s “It’s from my childhood, all the things that come back to haunt me. Big time”

The genie out of the bottleMost people felt they needed more than mutual aid groups could provide, to restore their mental health, but many found accessing counselling, a CPN or other service difficult. Some felt that time-limited addiction treatment programmes, with limited aftercare, left people particularly vulnerable.“treatment actually brings up a lot of emotions in people ... you’re forced to share all this stuff in group and then there you go, bang, twelve weeks, off into the [mutual aid network]. You can’t sit in a [AA] meeting and go to someone...you know? So I do believe that something should be put in place for...more than just the aftercare”.

Which came first – addiction or mental ill-health?“the drugs

came for me later than the madness”

“For me, the mental health and recovery from addiction, in my experience, it’s very much like the chicken and the egg, you know, what came first? The mental health or addiction?.... my using alcohol self medicated a lot of stuff from my past but I also believe I was an alcoholic so it’s very difficult, it was very difficult for me to see what came first”

“The doctor (GP), he did perceive it as two different things, it’s the alcohol that’s causing this and I’m saying ‘no, it’s not.’ To me, it was complimentar



Experience of services The people involved in this study experienced mental health services at different stages of their active addiction and into their recovery. The majority of people did not find that mental health professionals were helpful in identifying their addiction or prompting them to consider addressing the addiction in order to improve their mental health.

The active addict using mental health servicesMost people take personal responsibility for mental health services being ineffective in getting to the root of the relationship between their mental health and their addiction. “In addiction, for me, I was never 100% honest with any professional I worked with. ... now getting into recovery I realise I wasn’t honest. So it’s like, yes, I believe they could do more, but we also have to take responsibility for how much we really share. ‘Cos for years, I would be on anti-depressants and all that....” “No, I never got anything for alcoholism..... [were you honest with them?] Not at first. When I was getting drink and going to the [mental] hospital, well I wasn’t honest with them. When I was in my wheelchair and going down to the pub I wasn’t honest with them”Some felt that the challenge of enabling professionals to address issues beyond their specialism is just as relevant to addiction services. Once identified as an addict, many people were routed into addiction services which focused on their drug use rather than their mental illness.However, some people could identify GPs, CPNs and other professionals who had been the key to addressing their addiction and their mental health problems.

The journey through services to recoverySome people felt that professionals who took a simple and direct approach to identifying an addiction and its relationship with mental ill-health provided the stepping stone into their recovery. When professionals ignore addiction it’s a very long road to realising recovery for both mental health and addiction.“I had a CPN...for 5 years and none of them ever said. Every week I went they would say ‘well, maybe try and go to the pub and only drink one or two this weekend, okay, and then I’d go back and say ‘well that worked (!), then I drank 3, 4, 5, 6, and ended up in the cells! They never actually said ‘do you think you have a drink problem?’”Many of the alcoholics in this study experienced several detoxes, regarding it as a ‘5000 mile service’ or ‘bi-annual break’ after which they relapsed very quickly (some within hours), returning home to the same environment with no skills to manage their addiction on a long term basis.“You got out, they gave you your Antabuse. ... you’ve got to go see your dedicated alcohol counsellor, but it was 6 weeks before you saw them. I think I lasted the six weeks but two days after I was back on the drink again. I couldn’t hold it, I just couldn’t hold”.All of the people involved in this study were profoundly grateful for the chances they were given and which finally led to their recovery.

The recovering addict using mental health servicesA number of people involved in this study had begun a relationship with a CPN or psychotherapist before treatment for addiction, which they were able to continue on leaving treatment (rather than being ‘crossed off their client list’ because they had accessed another service), and which they found invaluable to cope with their vulnerability during early recovery. “I’m very grateful ... I had a therapist before I went into [treatment programme] and I still see the therapist now, coming out, and I don’t know, I can’t say that if I didn’t have that, that I’d still be clean and sober”Some people feel that mental distress or crises are relapse triggers for people recovering from addiction. In order to find a coping mechanism in abstinence, people may need ongoing, timely access to services “I was diagnosed with depression just a couple of weeks ago again, and I think it’s with all the fear in my life from my illness I had there, not long ago in December. I find it hard, the fear and it always comes back, it’s like scared to tell anybody until I saw a CPN again”

“I would bullshit and lie to get people of the track, I’d talk about other things that were happening in my life... it was a crutch to lean on....these people think I’ve got this condition .... Deep down I knew it was a lot of shit, I knew I had to get clean If I wanted any chance but I never really wanted to”.

“I’d always make sure I was looking fairly sharp ... there was no way I was gonna go in to see a professional of any sort, and let them see the real me. I would always make sure my clothes were clean and ironed, I’d had a shave and I was in pretty good shape at that point and then after I went straight round the pub”

“They never actually said ‘do you think you have a drink problem?’ Once they had given me a diagnosis of mental health, they kind of focused on that. We’ve given her a diagnosis, so this must be it. The alcohol, when the medication starts working, she’ll stop drinking”.



A number of individuals involved in the Serenity Cafe have attempted suicide or used self harm to manage their difficult emotions during their active addiction. However, for some, thoughts about suicide or self harm did not stop in early recovery.

SuicideSome people’s thoughts about suicide were strongly linked to a sense of hopelessness and self disgust at their addiction, they felt that suicide was the only way of escaping their addiction. A small number of people now feel that if their recovery fails and they relapse, they may attempt suicide again rather than live in active addiction.“I think I would possibly go over to suicide rather than I would go over to drink or drugs but that’s how I feel...... it was when I was back up here and I was drug and alcohol free in my life and I felt terrible. It was like I was holding my hands up to my whole family and I was saying ‘my life’s been a complete lie, I mean, I just felt so low like, you know? And I decided .... if it doesn’t change I’m going to do myself in. And I had no doubt where I was going to do it, how I was going do it”Some people suggest that professionals are unaware of the ongoing battle and emotional rollercoaster people live with even when they have been in recovery for a period of time.“I present on the outside, you know, this kind of confident kind of..but I still have periods where I feel suicidal in recovery, I want to self harm because of my emotion and I can say that to my psychiatrist and she will look at me and say ‘but everything is going great for you’, you know, in recovery. And it’s like will you listen to me, do you know what I mean”?Others lacked coping mechanisms and attempted suicide as a response to crises in their lives.“It was a nothing occasion. I remember thinking everything’s gone, it’s all finished like, you know, and then I was just so down, I thought ‘f**k it’, sorry about the language but that’s just how I felt. I didn’t have a big understanding about it, I didn’t sit and write or talk about my feelings, I just thought f**k it like, you know? That’s the most medical explanation I can give you ‘f**k this’, you know, that’s it. And I woke up surrounded by the pill packets, and I was still here”.Other people describe using their knowledge of drugs to make very calculated attempts to die by overdose and now feel very lucky to have survived. Some feel they have moved on from the self-loathing that led to their suicide attempt, through working hard at recovery and at rebuilding their lives.“I do now have mornings when I get up and say to myself ‘you’re alright, you’re not a bad person’”

Self harmOften people began their addiction to substances as a pursuit of fun and happiness, for many combined with a deep need to escape from negative emotions and unease. However, all of the participants felt that eventually, their addiction became a form of self harm and part of a vicious cycle of substance dependence. People continued to use substances way beyond getting any positive benefit from them and were then knowingly harming their health, whilst continuing to use substances to blot out the shame. However, they see this cycle as ‘self harm’ in retrospect, they were not consciously self harming at the time. Three people involved in this study were sectioned for their safety during periods of mental distress in their active addiction, but either used substances within institutions (having these smuggled in) or immediately on discharge.Some did self harm in other ways, including cutting, or outrageous risk taking within very dangerous criminal environments. Some people describe the dissonance between the unreality of the “war zone” they were living in, compared to the ordered, professional lives of the people in services they spoke to.“I was living a mad life and I went to see her and she was ... glowing, beautiful and she was well educated and all that and I thought ‘what the f**k are you gonna talk to me about?’ you know what I mean, you ain’t got a f**kin’ hope of getting anythin’ outta me, you’re just too f**kin’ soft”For others, the loss of careers and the loss of esteem within their family gave them an acute sense of isolation for which self harm provided a release.“I needed wrapping up, I was always close to self harm. I was afraid of life and needed to be enveloped”.Most people involved in this study recognise that during their active addiction their lifestyle required them to be manipulative and to hide, which ultimately made it difficult for some professionals to see their turmoil, particularly for those who were ‘functioning’ alcoholics or addicts. “I’ve never been scruffy... I’ve always worked, you know, so I’ve never had to brush myself up to go see a doctor or whatever, I was always pretty smart and ‘cos you’re like that they think you’re OK.”

Suicide and self harm“It’s traumatic when you stop. It is when you stop, when you get clean and sober and you look back and see the things you’ve done and you begin to realize who you are and it doesn’t fit with what you’ve done and the way you’ve lived your life. It’s very, very common to get depressed then. It’s quite logical to get depressed”.

“I’ve been in recovery 18 months and I still feel suicidal at times, and I still feel like self-harming at times, and that’s because of my feelings and how I feel, but I also have to figure out.... at first they didn’t know what was going on with me, then they give me this diagnosis and it was all “great, now we know what’s wrong with you”, then I get into recovery [from addiction] and I still see a psychiatrist every week but it’s now about the alcoholism, I’m not getting support for the



Self help and peer support People in recovery for addiction who have been through residential or quasi-residential treatment services are profoundly grateful for the opportunity to get clean and sober, to make a break from the ties associated with their addiction and to gain some skills to sustain their abstinence. Some people have been through several treatment regimes before “getting it” [sustained abstinence]. However, there are many people who have achieved abstinence without the support of treatment services. The role of peer support, and the long term self management required after treatment or getting clean and sober in other ways, is therefore important to understand. Peer supportThe Serenity Cafe provides a network for people in recovery from addiction through which they can find peer support. Some people attend an ‘aftercare’ group at a treatment centre. Many people also use mutual aid groups (AA, NA and CA) of which there are over 100 meetings every week in Edinburgh alone. However, people experiencing mental health problems in recovery from addiction had mixed experiences of peer support within such settings in relation to their mental health.The benefits include having an outlet for thoughts and feelings with people who can identify with your experience, and having access to others’ wisdom that comes from experience.“The peer support is very, very good. Obviously there’s the self help meetings, the fellowships, but you just do a share, you don’t get feedback so I find the aftercare at the treatment centre I was in very, very helpful. I’ve not been able to go to it for twelve weeks because I’ve been doing a course at college, and I really needed it. Luckily, I do have a lot of friends I can phone up and that I talk to at the Serenity Cafe and after [mutual aid] meetings”. “I’ve got a fantastic sponsor that I can talk to about stuff like that. ...because everything in my life isn’t addiction, do you know what I mean? Everything I suffer from is not in addiction; it will not be cured by the Twelve Steps or the Fellowship. For alcoholism, on a day to day basis, I work the program but that’s not all the parts of me, do you know what I mean?”However, some people have experienced difficulties in sharing their experience of mental health problems within settings focusing on recovery from addiction. Some of this is based on the general ignorance and stigma associated with mental health which can be found in many community settings, and some is based on a specific peer pressure, occasionally found in some mutual aid settings, not to use prescribed medication for other illnesses as if this threatens someone’s abstinence. Although this is not the ‘official’ position of mutual aid groups, the people involved in this study have occasionally experienced this. Many acknowledge that in early recovery there is inevitably mental and emotional turbulence which some feel need not be rushed to a formal diagnosis of mental illness.“I very rarely say about my other [mental] illness, because I did it early on in recovery and I was given some very dangerous advice, in relation to medication. And, I think it’s ‘cos it’s hard for me to understand so it’s hard for me to expect anyone else to understand. I went through a period in early recovery where I started to listen to people about medication and I came off my [mental health] medication and it was the worst thing I could have ever have done”“...some people suffer it and some people say ‘well that’s just the illness in early recovery’, and some suffer it more than others and it shouldn’t be underestimated. My feeling is that some people may actually suffer from depression when getting into recovery and medication will help the depression”.Some people feel that, although peer support is important and useful, it cannot substitute for professional help, which brings with it specialist knowledge and a binding professional-patient confidentiality, rather than ‘group sharing’ in aftercare and mutual aid groups which although confidential, is not necessarily as intimate as some people require.“I can’t tell everybody in AA about my life, it’s like if you’re talking to somebody professional, it doesn’t go back to anybody”.

Self helpFor people involved in this study, the main approach to self help was reading more about their mental illness to gain greater personal insight into their experiences. “I’m reading all the books and I’ve got to work on that part in my recovery as well. Very much, mental health and addiction”

“I believe everybody goes through a stage where they’re depressed in recovery. Guilt, shame, anxiety, I used alcohol to cover all my feelings for so many years but I think there’s a difference between depression in early recovery, and clinical depression and I think each individual, I think sometimes the fellowships put everybody in these little circles of... and that can be quite dangerous. We may both be in early recovery suffering from depression. Yours actually might lead to clinical depression and if we’re both being given a suggestion of ‘well that’s just early recovery’, well I personally think that’s really dangerous sometimes...”

“ I just don’t want to speak to people, I have that on occasion like, you know? ..... I have a brilliant sponsor that I just use his life skills, what he understands about people, you know, I use him for that. ..... I go to [mutual aid] meetings and I listen. I find this [the focus group] very fascinating, you know like very



Messages for professionals In early recovery people need easy access to support for their mental health. On leaving

treatment they feel vulnerable and ‘raw’ from issues raised during treatment which short term treatment programmes cannot fully address. Many people in the Serenity Cafe have been fortunate in accessing counselling for past abuse and trauma through voluntary organisations, but waiting lists are of concern. Mental distress leaves people more vulnerable to relapse.

In abstinence, people have lost the coping mechanism they have used for many years – substances - and throughout their recovery may struggle to develop other coping skills. Professionals in universal services who know that someone is in recovery could help by being sensitive to this and helping them access support quickly when they need to.

Recovery from addiction isn’t always the answer to underlying mental illnesses by itself – although most people feel that underlying illnesses can’t be properly tackled without tackling the addiction. Professionals need to be willing to think beyond their own service specialism to help people effectively, or to collaborate with other professionals to help people.

Many of the people involved in this study felt that entering detox for alcoholism did not move them forward in their recovery. They feel more support is required to tackle the addiction and to plan for close support on discharge, with a more holistic understanding of the ‘recovery capital’ people need to sustain abstinence.

On discharge from any residential mental health service, an active addict is at risk of using substances very quickly, on top of any medication prescribed. People involved in this study feel it is important for mental health services to involve addiction services closely in treatment and discharge planning.

All of the people involved in this study are examples that recovery is possible. For many, the start of their recovery journey began when they met a professional who conveyed the belief that recovery is possible and shared hope for this person’s recovery, at the same time as having a realistic understanding of the nature of addiction.

Messages for people in recovery from addiction Peer support takes place in many different forms, from peer support integrated into

treatment services, in informal settings such as the Serenity Cafe, and through sponsorship in mutual aid groups. People’s mixed experiences in this study suggest that awareness raising and opportunities to learn more about mental health would be beneficial for people supporting others in recovery from addiction, who are experiencing mental health problems.

Mutual aid groups have guides for sponsors and area/regional committees to promote the development of mutual aid. These groups could help make sponsors more aware of sources of support in their areas for people experiencing mental health problems.

It would be helpful for everyone promoting and supporting recovery by any means to recognise that people may still need additional professional support for mental illness, and prescribed medication to address mental illness. Any peer pressure to stop medication against medical advice could be unhelpful. However, people may occasionally want help from their peers to self advocate for changes in the support they receive from mental health services, or to make mental health services understand the person’s experience of recovery from addiction better.

As a recovery community, helping to challenge misconceptions and stigma surrounding mental illness is an important task. All of us, at any time, may experience mental health problems which affect our lives and our recovery from addiction, no matter how long we have been abstinent. We all have in common the experience that early recovery is a very challenging time. Awareness and understanding is something we can offer others.

What now?“There is mental health issues with me and there always has been, and it’s part of my recovery process in dealing with them. But while I was drinking and using, I would never get anywhere near any of them. There was no chance of even knowing I had them or addressing them until I got clean and sober”.

“Recovery is experiencing peace in my head for the first time without the need to drug myself to get it”.

“Just surround myself with good people in recovery”.

“You have to work for personal growth. I was emotionally raw. I was nuts! The scariest part of my life was the Focus group led by Kane Duffy; paper reviewed by focus group participants and the Serenity Cafe steering group.Comas, 14 Montrose Terrace, Edinburgh, EH7 5DL [email protected]

Mental health and recovery from addiction - the chicken or the egg?

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