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May 2016

Mainstreaming COD into AA/NA; Hong Kong

savvy & stump the shrink

I received a question that arose from a recent workshop I did on Co-Occurring Mental and Substance Use Disorders (COD). This month I am combining SAVVY with a STUMP THE SHRINK question. This centers on “mainstreaming” people with co-occurring disorders to use Alcoholics Anonymous (AA) and Narcotic Anonymous (NA) as support groups even though they have mental health issues in addition to alcohol or other drug issues. 

Hi David: I have been a subscriber of your newsletter for several years and have been to a few of your presentations. I recently attended the conference in Portland. I have been in the field of Substance Use Disorders (SUD) treatment for many years. I know the tremendous value of AA/NA but one of my greatest challenges has been mainstreaming. Can you tell me more about how this is accomplished? How about a few “Tips”?” — Amy, MS, LADC, CCS 


Why consider “mainstreaming” people with COD into AA/NA? 

Firstly, I am using the term “mainstreaming” as is done in the education field. Previously students with special learning needs were kept separate from the mainstream of regular classes. Mainstreaming combines those with special needs with all students. Here are reasons to consider introducing AA/NA to people with COD:

  • Everyone needs as much support and recovery groups as possible. In many areas, AA and NA are the most available and accessible groups.
  • Correctly prepared, people with COD can receive the help they deserve and need at 12-Step groups, while still respecting the mission of each group.
  • Even if AA and NA members consider themselves single-focused on addiction (alcohol or other drugs), some actually have mental health issues themselves. They could benefit from mingling with people identified as dealing with COD.


Issues to address when preparing people with COD to attend AA/NA 

Introducing 12-Step groups to anyone should be much more than referring them with an admonition: “You should go to 90 meetings in 90 days.” But if you consider mainstreaming in COD treatment, it takes even more preparation for those with addiction and mental illness:

  • Is the person sufficiently stable in their mental illness to use good judgment about when and what to speak about at a 12-Step group? – If the client is too unstable in their psychosis, personality, bipolar or mood disorder then this is not the time to be mainstreamed.
  • Have you identified which AA/NA groups in the area are open to welcoming people with COD? – You wouldn’t want to set a person up for being confronted by an “old-timer” who is a purist.
  • Has your client had previous positive or negative experiences with AA/NA? – If positive, can your client re-kindle those skills and resources (getting a sponsor and names and numbers; returning to a home group etc.)? If negative, can they be coached through how to deal with any anxieties or negativity they still harbor?


Note the AA-approved literature: “The AA Member – Medications and Other Drugs” 

Some “old-timer” at an AA meeting may tell a client: “You shouldn’t be taking those drugs from those psychiatrists”; “You’re chewing your booze and should stop those medications” or words to that effect. Note the balanced approach in the following excerpts: 

Because of the difficulties that many alcoholics have with drugs, some members have taken the position that no one in A.A. should take any medication. While this position has undoubtedly prevented relapses for some, it has meant disaster for others…..

It becomes clear that just as it is wrong to enable or support any alcoholic to become re- addicted to any drug, it’s equally wrong to deprive any alcoholic of medication, which can alleviate or control other disabling physical and/or emotional problems.” (Page 6, revised 2011 edition).

You can read the whole pamphlet at:

Disclaimer: I am not a member of AA/NA or any other 12-Step group, though I have attended open meetings to learn more. I have great respect for the power of mutual help groups and 12-Step groups in particular, having seen thousands moved and changed by the fellowship of AA, NA and other groups. My experience comes from working with patients and clients who have taught me about 12-Step groups. However if I have misrepresented meetings you attend that may be more open to COD, let me know and teach me.


Not all people with COD have the same co-occurring mental health issues, therefore different issues must be addressed when considering mainstreaming in AA/NA. 


Diagnosis-specific suggestions when linking people to AA/NA 

Here are a few common diagnoses and mental health issues which require different preparation for people you try to mainstream in AA/NA: 

1. Schizoid or socially-avoidant people

Usually when you link a person to AA/NA, you advise something like: “Go early, sit up front, stay late, talk to people, get involved.” For the more avoidant, schizoid or shy person fearful of even getting to a meeting, you might say the opposite:

  • “Go late, sit at the back, leave early, don’t talk to anyone or get involved, but go. Don’t not go.”
  • “Once you feel a bit more comfortable, go a minute early, sit in the second back row, stay a minute longer but don’t talk to anyone.”
  • “When you feel more comfortable, go a few minutes early, third back row, stay few minutes longer, smile and say ‘hi” to someone but don’t talk.”
  • “Then arrive on time, stay after and start talking to someone.”

The idea: Ease into attending meetings at a pace that feels safe and in control. Be sure to go, rather than avoid meetings and staying stuck. 

2. People with Borderline Personality Disorder

To a newcomer, a welcoming AA member may say something like: “Glad you are here, welcome. Here’s my name and number, call me anytime.” A person with Borderline Personality Disorder (BPD) or psychodynamics may have poor boundary issues and end up sapping the energy and goodwill of the AA member. When they call their sponsor, they may get voice mail or an answering machine. To ensure there is a sponsor ready to listen, you may need to advise such a client to be working with three sponsors:

  • Sponsor #1, who is burning out, drained by the many calls that seemingly never satisfy the endless needs for nurturance and support.
  • Sponsor #2 with whom the client is actively working, who still has energy to help; and has not yet been impacted by all the calls for nurturance and support.
  • Sponsor #3 is still fresh and doesn’t know the client well yet. They offer their name and number for help 24 hours a day, 7 days a week; “call me anytime” unaware of what may lay ahead.

With these 3 sponsors, the client is taking responsibility to always have someone available to whom s/he can reach out. 

3. Women (and men) who too quickly fall into counterproductive relationships

Kristen McGuiness wrote about “The 13th Step: People Who Prey on Newcomers” (2011) and spoke about “thirteenth stepping” when someone with more than a year of sober time hits on a person with less than a year: “Some AA members try to get fresh recruits on their backs before they’re on their feet.” Read more at:

  • Even though it may feel good to be wanted, wooed and dated, early sobriety is no time for launching into romantic or sexual relationships.
  • You will want help women and men recognize this vulnerability in themselves. Help them practice how to respond to a 13th stepper coming onto them. Too late to be thinking about what to say in the heat of the moment; use assertiveness training to learn how to say “no”.
  • A woman might want to go to more Women’s AA meetings.
  • At regular meetings, have a female on each arm to guard against temptations to “hook up.”
  • If in doubt as to whether advances from an AA member are innocent or sinister, share the concern with a trusted ally, sponsor or person of the same gender.


Coaching tips for people with COD when they attend AA/NA 

Teach these skills to your clients:

  • To identify those people at a meeting who are more open to talking about COD – listen for a speaker who mentions mental health issues and not just addiction. Approach them privately. If an AA/NA member is more welcoming and understanding about mental health issues, ask that person about other members who are similar.
  • To handle an AA/NA member who may confront them for being at the meeting because they have mental illness not just addiction.
  • To respect the others’ opinion and not be defensive or antagonistic.
  • To reassure the member that they are not there to disrupt the meeting and have the same needs for recovery support as everyone.
  • To express that they will be careful not to detract from the main mission of the meeting.
  • To recognize the similarities with other speakers even if the speaker does not drink or drug the same as they do. For example, someone may talk about alcohol, though your client has a benzodiazepine problem.
  • Note the effects of addiction on family, friends and work; and how they are similar to your client’s family, friends and work problems, even though the drug or substance used is different.


Hong Kong is in my top ten list of favorite places to visit and people-watch and culture-watch. This month was my sixth trip, reviving nostalgic memories of a visit as a pre-teen with my parents, brother and sister, to ensuing trips as an adult for work and play. 

These are a few of my favorite things: the trains, food and shopping.

TRAINS: The fast, efficient, accessible Mass Transit Railway (MTR) system is truly a rapid transit system. Lighted arrows show you the direction the train is headed. Flashing lights alert you about the next stop and even which side of the train the doors will open.

Missed the train?  No problem. Another one will arrive in five minutes or less. 

I know other countries have similarly efficient rapid transit. How is it the USA seems so far behind similarly wealthy and populous countries?   

FOOD:  Then there’s my favorite desert – not too sweet, uniquely Asian and still searching to find it in the USA – fresh mango, sago and black jelly pieces (that’s it on the end at the far right of the photo) for $39 Hong Kong dollars, about $5 US.  I relished eating my first on within two hours of arriving in Hong Kong.

SHOPPING: Of course there’s the shopping. Whether you want the look alike fake name brand bags or clothes, or the real (and expensive) item, it is all there. You can wander for hours up long, crowded streets with zillions of vendors; or stroll in air-conditioned luxury shopping malls. 

How can you resist mixed silk and wool suits for $130? Not the real thing from Italy, but looks pretty good nevertheless. The label didn’t say Messina “Made in Italy” but Messina “Made by Italy” – they couldn’t even get the English right in the fake label. Imagine that, I have a suit made by Italy! But hey, it had “Messina” and “Italy” in the label so that sounds good. I bought it anyway!

There are many tourist sites too numerous to mention. I’ll end by sharing my experience in an authentic and well-regarded Beijing restaurant. Their specialty is tasty Peking Duck and unique handmade noodles. Feet away from our table was the talented chef demonstrating his special noodle-making skills, tossing and flinging it all in the air with twists and turns. You weren’t there, but you can see it on YouTube!  

I hope I am asked back to Hong Kong to train more health-care professionals seeking addiction counseling certification. If you are looking for a place to visit, you know where I would recommend.

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