Dual Diagnosis Anonymous is a new peer-led resource for people with co-existing mental health and addiction problems, as Dr Raffaella Milani explains. Coexisting substance misuse and mental health disorders (dual diagnosis) are the norm, rather than the exception. A report commissioned by the Department of Health and NTA in 2002 found that 75 per cent of users of drug services and 85 per cent of users of alcohol services were experiencing mental health problems, and 44 per cent of mental health service users either reported drug use or had used alcohol at hazardous or harmful levels in the past year (Weaver et al, 2002). The Prison Reform Trust’s 2010 Bromley Briefing reported that 75 per cent of all prisoners had a dual diagnosis, yet Lord Bradley’s 2009 review of people with mental health problems or learning disabilities in the criminal justice system stated that those needing to access services for both mental health and substance misuse/alcohol problems were disadvantaged by the system. Furthermore, the 2016 national confidential inquiry into suicide and homicide by people with mental illness found that over the last 20 years, alcohol/drug misuse and isolation have become increasingly common factors as antecedents of suicide; more than half of the patients who died by suicide had a history of alcohol or drug misuse, but only a minority of patients were in contact with substance misuse services. 'DDA offers an integrated approach to comorbidity.' Despite the high prevalence of people with dual diagnosis and the associated negative consequences on the physical, psychological and social domains, there is a clear gap in the service delivery for these clients. Recovery is a long-term process, and for people with comorbidity it is a lifelong commitment. Non-judgmental attitude, integrated care, and a social network that supports abstinence are three key elements of successful and sustainable recovery. Mutual aid groups such as AA have been playing an important role in supporting individuals in achieving and maintaining abstinence in the UK and around the world, and are an invaluable source of social capital for those who are most at risk of isolation. Since August 2016, a new peer-led resource has been made available in west London. It provides a non-judgmental, empathetic and welcoming environment where people with dual diagnosis can get their voice heard. Called Dual Diagnosis Anonymous (DDA), it is free, available in the community, does not require referral, there is no waiting list – and most importantly it adopts an integrated approach to comorbidity. The groups are facilitated with competence and compassion by John O'Donnell, a peer supporter with many years of experience in running groups. DDA-UK was founded by Daniel Ware and Alan Butler, with the support of the Ealing Councils' commissioners for addictions, Ealing Council commissioning for mental health and the clinical commissioning group. Daniel discovered DDA in 2014 on a research trip to Portland, USA, where he was studying approaches to homelessness and support. Having worked for the last 13 years in frontline homeless services in London, he was familiar with the lack of specific services and support for those with a dual diagnosis. ‘When I attended the US DDA meeting I was taken aback by the warmth, energy and positivity in the room,’ he says. ‘People were clearly in a supportive space which they could not find anywhere else.’ Daniel met DDA's founder Corbett Monica, a Vietnam vet and an experienced therapist, who was himself in recovery. It all started when two of Corbett's clients were politely asked not to return to a local AA meeting as they were ‘too unwell’. In response, Corbett gained permission from AA and devised the 12 steps ‘plus five’. The extra five steps related specifically to the mental health aspects of a dual diagnosis: acknowledging both illnesses, accepting help for both conditions, understanding the importance of a variety of interventions, combining illness self-management with peer supports and spirituality, and working the programme by helping others. The programme also includes the Dual Diagnosis Anonymous workbook, which guides the reader through the 12 plus five steps with explanations and well thought-through reflective exercises. The meeting consists of a regular AA-style gathering and an additional non-compulsory facilitated workshop to go through the workbook. The first time that I attended a DDA meeting I immediately sensed how people felt accepted and free to be themselves, whatever their mental health status at that moment in time. I was also surprised how diverse the group was, in terms of age, culture, gender, mental disorders and the addictive behaviours that members presented with. During the meeting there were moments of shared sadness but a lot of laughs too. As the co-founder and peer supporter Alan Butler explains, ‘When people attend meetings the first thing that becomes apparent is that they are hearing their own life experience echoed in the words of others. When you attend meetings you are advised to listen for the similarities – not the differences. In the traditional AA or NA fellowship people attempt to separate two inseparable conditions, for fear of judgment and not being accepted. Historically this is something dually diagnosed sufferers have been asked to do by the statutory services. 'There's a place and space where people can finally be heard.' ‘DDA offers a place and space where individuals with comorbidity can finally be heard by those who identify with similar experiences,’ he continued. They can talk of their personal struggles with addictive behaviours as well as of matters such as positive effects or side effects of medications, the hearing of voices, the clinical interventions, or their worries and anxieties. Identification is what keeps people attending self-help groups.’ The initial evaluation is very encouraging. One young DDA member who had been suffering from psychosis and cannabis misuse said that for the first time she could identify with other members in the group. She felt that cannabis was not considered to be problematic by members in traditional NA groups, while the DDA facilitator, other members and the workbook helped her understand how use could affect her mental health. ‘I found the workbook and the workshops very helpful, I understand better what happened to me and I feel free to talk about my medication and how I feel,’ she said. ‘I have been able to stay clean for several months and I am doing very well with my studies… The difference in age doesn’t bother me – I think that it’s helpful to confer with people who have more experience than me. I also find that the facilitator is very competent and helps me understand what I’m going through.’ There are five meetings happening in London every week and they are inclusive and open to anyone who is interested in being alcohol/drug free. Family members and professionals who want to familiarise themselves with the programme are welcome too. The goal and the challenge now is to make the programme sustainable throughout London and the UK in the next few years. Concluding with Alan’s words, ‘The fellowship of DDA is predicated upon hope – something that is voiced in the words penned by Fyodor Dostoevsky and adopted as our DDA motto: “To live without hope is to cease to live.”’ Find out more at www.ddauk.org/programs Dr Raffaella Milani is senior lecturer and course leader for substance use and misuse studies at the University of West London. More about the university’s courses here.