Following the Twelve Steps can be uniquely challenging for people with co-occurring mental health and substance use disorders. From mixed messages about medication and treatment, to dealing with emotions that arise from working the Steps, Marya Hornbacher provides practical guidance for approaching sanity and sobriety.

We admitted we were powerless over alcohol--that our lives had become unmanageable.

Step One
Acceptance

I don't know which was the stranger, more terrifying moment: the moment when a psychiatrist told me I had a mental illness, or the moment I realized I was an alcoholic, through and through. I remember both moments clearly: my stomach dropped, the room seemed cold, and I wanted to run for the door. When it came time for me to face facts, I didn't do it. Not that first time. The fear that accompanied those simple facts--that I have a mental illness, that I am an alcoholic--was so overwhelming that I did what fear told me to do: I hid.

 Addicts are good at hiding--for a while. We've turned it into an art form. We hide from our families, our friends, our employers; some of us feel we are hiding from God. We are capable of believing the ridiculous notion that no one can see what's really going on. No one really knows how sad and sick and dependent we are. People with mental illness often share this skill at hiding. The world we live in tells us that mental illness is something to be ashamed of, and heaven knows we feel that shame--and we do all we can to hide our illness from that judging world, from our fellows, and often from ourselves.

So by the time we addicts or alcoholics with mental illness have reached a place of complete defeat--by the time we realize that our lives have become unmanageable--we are living under so many layers of shame, deception, denial, and fear that it seems at first impossible to dig ourselves out. We are used to the dark, lonely place where we've lived for so long. We're used to the company of our substance of choice, the comfort of our habitual terror, the pain of our mental illness. These things are more familiar than what the Twelve Steps promise: a life in a community of people who have found a better way to live. To the practicing addict with mental illness, a life up there in the light seems almost as frightening as a life down here in her own private hell.

 But we must reach for that life if we want to survive.

Addicts, mentally ill or not, must all come to a turning point where they recognize that there is no future ahead on the road they're walking, and realize that it's time for them to turn down a new road. That moment of realization is rarely a calm one. It often takes hitting the wall pretty hard--often more than once--before we see the futility of trying to live the way we were. From the Twelve Steps and Twelve Traditions: "We perceive that only through utter defeat are we able to take our first steps toward liberation and strength."

And that is where we're headed when we set out with Step One: toward liberation and strength.

When I first came into the program, I found the idea of admitting defeat insane. I already felt defeated, by my illness, by my addiction, by my entire life. Why were these people asking me to go one step further and admit complete defeat--admit, in short, that I was wholly and completely powerless? I insisted that I would get sober anyway, whether I admitted powerlessness or not. Couldn't I just hang on to some sense of control over my life? The answer my sponsor gave me was a resounding no.

When I was first faced with the need to admit powerlessness, I told my sponsor she didn't understand mental illness--if she understood the horrible feeling of being literally out of control of one's own mind, she would never try to make me feel even less power than I already did. I believed, at first, that Step One would be impossible for me. I believed my mental illness would make it too painful. I believed it would be too excruciating, too terrifying, to admit total powerlessness over my addiction and over my life when I already felt so terribly helpless.

But I have come to see this differently. I have come to see the First Step as one that my mental illness allows me to understand with particular clarity. I began to apply what I know about mental illness to what I was learning about addiction, and I began to listen to what I was being told about how addiction could be overcome.

Who knows better than we do a true sense of helplessness over the body and mind? Our mental illnesses do not define us, but they are part of the very bodies we live in and part of the very makeup of our minds. My mental illness is inscribed on my genes and expressed in my very thoughts-it's that close to me. Working the Twelve Steps, I began to learn that addiction is an illness of body and mind as well. It is defined as a mental illness in the Diagnostic and Statistical Manual of Mental Disorders, a compendium of psychiatric diagnoses that lists and defines them. It is an allergy of the body that manifests itself as an obsession of the mind. It is passed through families in the genes, just as other mental illnesses are. People who suffer from addiction are physically different from people who do not; our bodies respond to certain substances and behaviors differently than do healthy, nonaddicted bodies.

Excerpted from Sane: Mental Illness, Addiction, and the 12 Steps by Marya Hornbacher. In addition to her international best seller, Madness: A Bipolar Life, Marya Hornbacher is the author of Wasted: A Memoir of Anorexia and Bulimia, a novel The Center of Winter, and her newest book Waiting: A Nonbeliever's Higher Power.

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A calm mind fosters clear seeing, which is another way of saying that if we practice mindfulness, we will have less self-deception. We learn to be honest, and delusions fall away. When we sit in meditation, we observe our mind, watching the thoughts pass through, all the mental traffic honking, swerving, and cutting in. We practice holding "bare attention" toward the thoughts and feelings that arise, accepting them with kindness and non-judgment.

 --from Mindfulness and the 12 Steps