Why Don't You Just Get Over It? The Secret Heart of Dual Diagnosis

Trigger Warning: references to corporal punishment.

I used to think I inherited my father’s rage. I used to think alcoholism “ran in the family.” I used to think I had a self-destructive streak that compelled me to snatch failure from the jaws of victory at every turn with my drinking, self-sabotage, and misanthropy. I used to say, “I don’t burn my bridges behind me. I burn my bridges before I get to them.”

The fact was, I had a giant, sucking sinkhole in the middle of my soul that demanded I fill it with alcohol. I called it “the Black Hole.” I’m going to talk about that black hole.

When I sobered up in 1977, there was no such thing as dual diagnosis. Depression was dismissed as a “sincere form of self-pity.” Listen to the opening words of “How It Works”, chapter 5 of the “Big Book,” Alcoholics Anonymous:

Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault. They seem to have been born that way…

There are those, too, who suffer from grave emotional and mental disorders, but many of them do recover if they have the capacity to be honest.

Such a patronizing and simplistic view of alcoholism and mental illness, written by a stockbroker in 1939, this is still read at thousands of meetings around the world every day, word for word.

Once, during my first year, I was speaking in a meeting in the basement of the Alano Club, trying to work out something about my self-image, and Don, who enjoyed putting people in their places, stood up and said, “Self-image, schmelf-image! You’re an ALCOHOLIC!”

Long and short of it, I didn’t start working on my major depressive disorder until I’d been sober for over 20 years. That phase of my recovery started in 1998 when I went to intensive outpatient treatment for two months. There, I learned my rage and depression stemmed from the fact that I grew up without any sense of safety. For now, suffice to say, the family cover story, as I have come to understand it, was that “Doug had two major accidents a year through the age of six.” Or at least that’s what Dad blurted out to my second wife the first time they met.

After years of talk therapy along with a succession of dozens of medications, I emerged from my depression with a speed that can only be described as glacial. At times, I was taking three prescription medications at once, including a massive dosage of a drug originally developed for seizures, plus a fourth prescription drug for sleep—all under supervision, mind you. I also practiced coping skills like bicycling, writing poetry, and meditation. The drugs were intended to get me to a baseline where I could hope to practice the coping skills.

I’m 46 years sober now and it’s only been in the last several years that I’ve realized I’m a trauma survivor, and that’s the central fact of my symptomology, not my alcoholism, not my depression, not my genes. I don’t have a monster inside me, I have a five-year-old boy. My rage and depression are an inevitable consequence of growing up without a sense of safety, and without healthy attachment bonds with my caregivers (a raging, domineering father and an emotionally exhausted mother, God bless her). My alcohol and marijuana use were my attempt to self-medicate my overwhelming emptiness, lack of self-esteem, lack of agency, and anhedonia (inability to experience pleasure or satisfaction).

So for all these years, I’ve had it exactly backwards. For 20 years, I managed my alcoholism in isolation (as a moral issue!) despite having untreated major depression. And then for another 20-plus years I’ve been working on my depression, also in isolation, as though it were a genetic disorder. That’s forty-some years spent, as the old joke goes, looking for my wallet under a street lamp a block away from where I dropped it because the light’s better there!

What I’m learning today from trauma experts like Gabor Maté and Bessel Van der Kolk is that every slap in the face, every spanking with a belt, every tongue-scrubbing with Ivory soap, every “major accident,” literally rewired my developing 2-3-4-5-year-old brain with the soul sickness that screams, “If the two people who are my whole world, on whom I utterly depend not only for shelter and sustenance but for safety and my sense of myself, don’t love me, how can I possibly be lovable?”

So, that’s where we have to start, with the trauma, not the depression, not the substances of abuse. Because both addiction and mood disorders are really just defense mechanisms, and treating them with medication in isolation from a person’s story is like putting a broken leg in a cast without setting the bone first.

Complex PTSD (the result of developmental trauma) is not just analogous to surviving a plane crash—it is substantially the same thing. If I found a passenger moaning amid the smoking wreckage of an airplane, would I turn up my nose and say, “That’s just attention-seeking behavior?” Would I tell them, “You made your own bed when you bought the plane ticket?” Of course not. And yet it is so seductively easy for even well-meaning people who haven’t been there to dismiss trauma-related behaviors with judgmental microaggressions like acting out, manipulative, needy, or anti-social.

As a peer supporter in mental health and addiction, what can I do with this information? What I can (and must) do here and now is 1) take universal precautions and assume every person I serve is a trauma survivor, and 2) treat them with the same compassion and respect I would unhesitatingly accord a plane crash victim.

And that, in a nutshell, is Trauma Informed Care.

FURTHER STUDY:

Khantzian, Edward. (2003). The self-medication hypothesis revisited: The dually diagnosed patient. Primary Psychiatry. 10.53-54.

The Wisdom of Trauma (2021 film) Directors: Maurizio Benazzo, Zaya Benazzo. Starring Dr. Gabor Maté.

https://www.documentarymania.com/player.php?title=The+Wisdom+of+Trauma

Webinar: WHAT DOES BECOMING TRAUMA-INFORMED MEAN FOR NON-CLINICAL STAFF?

(Karen Johnson LCSW, Director of Trauma-Informed Services, National Council for Behavioral Health)

https://www.relias.com/resource/becoming-trauma-informed-non-clinical-staff? Retrieved 9/25/2023.

Westberg, Douglas. (2021). Reclaiming Our Story. Mental Health and Addiction Association of Oregon.

https://www.mhaoforegon.org/blog/2021/8/13/reclaiming-our-story