Psychotherapy and Alcoholics Anonymous - An Integrated Approach

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Psychotherapy and Alcoholics Anonymous: An Integrated Approach
William A. Knack
State University of New York, College at Old Westbury

This article provides a rationale for, and a method of, combining a nonprofessional self-help addiction recovery program, Alcoholics Anonymous (AA), and a professional treatment approach, psychotherapy. The two approaches share a common goal, target similar issues, and work toward similar outcomes. A psychotherapy approach that integrates the two approaches can be quite powerful. Treating a patient in psychotherapy who is also working in the AA program without a good understanding of AA can result in the two approaches working at cross-purposes, diminishing the effectiveness of both interventions. After a brief discussion of psychotherapy integration, the AA program is examined in detail, focusing on the philosophy and change strategies that are compatible with psychodynamic and cognitive– behavioral models of psychotherapy. A method for integrating these techniques into a psychotherapy directed at treating addiction is presented. Guidelines are provided to manage the implementation of this integrated approach throughout the process of recovery.
Keywords: Alcoholics Anonymous, psychotherapy, alcoholism, 12-step programs, psychotherapy integration

The rationale for integrating the Alcoholics Anonymous (AA) 12-step approach and psychotherapy is based upon the prevalence of alcohol problems and alcoholism and the utilization and effectiveness of the AA program. More than 30% of Americans have met the criteria for an alcohol-use disorder at some time in their lives (Hasin, Stinson, Ogburn, & Grant, 2007). AA is an international program with 97,000 AA groups (AA World Services, 1999). A total of 1.7 million members attend yearly (AA World Services, 1990). Morgenstern, Bux, Labouvie, Blanchard, and
I recognize the contributions of Jack Craig, and of Lori Bohm and Catherine Stuart for their counsel, encouragement, and support. Correspondence concerning this article should be addressed to William A. Knack, Department of Psychology, State University of New York, College at Old Westbury, P. O. Box 210, Old Westbury, NY 11568-0210. E-mail: [email protected] 86
Journal of Psychotherapy Integration 2009, Vol. 19, No. 1, 86 –109 © 2009 American Psychological Association 1053-0479/09/$12.00 DOI: 10.1037/a0015447

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Morgan (2002) stated the following: “Studies have generally found that 12-step approaches yield equivalent outcomes to such science based treatments as cognitive– behavioral treatment (CBT). In some cases, 12-step treatment yielded superior results . . . [in the treatment of alcohol and cocaine dependence].” Humphreys and Moos (2007) conducted a study comparing cognitive– behavior therapy (CBT) with AA participation and found that the AA group achieved higher abstinence rates and used less clinical services than the CBT group. Forty-seven percent of active AA members have been sober between 1 and 5 years. Another 26% have been sober between 1 and 5 years. Forty percent of newcomers who stay active for 1 year stay sober for a second year (AA World Services, 1990). Numerous studies indicate that AA members who work the program have a greater likelihood of staying sober (Emrick, Tonigan, Montgomery, & Little, 1993). At the same time, 60% drop out in the first year. This suggests that maintaining AA involvement is predictive of sobriety. Consequently, an important goal of psychotherapy should be to encourage and maintain AA involvement. This approach has been called 12-step facilitation (Nowinski, 1996). However, simply supporting a psychotherapy patient’s participation in AA fails to result in a unified treatment approach if the two models of change are not working together in a coordinated manner. Failing to fully understand the message and methods of the AA program can result in the perception of incompatibility and/or result in the two approaches working at cross-purposes. To achieve this level of consistency in the treatment approach, the two models must be integrated. Additionally, participation in the AA program and integrating AA with psychotherapy can be reciprocally beneficial, enhancing the effectiveness of both the psychotherapy and the AA experience.

PSYCHOTHERAPY AND PSYCHOTHERAPY INTEGRATION Over the past 120 years, many schools of psychotherapy have evolved. These include the classical psychoanalytic, object-relational, interpersonal, behavioral, cognitive, and family systems schools or approaches. Although there are significant differences between the philosophy, techniques, and implementation of these approaches, there are also many similarities. Frank (1961) asserted that these common factors may be more powerful in achieving behavior change than the unique factors associated with any one approach. The following commonalities among the most frequently practiced approaches to psychotherapy were identified: in each approach, (a) There is a trained socially sanctioned healer, (b) The patient is schooled in the model, (c) There is a formal change process, (d) An understanding of

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both the problem and of the cure is achieved, (e) The patient is remoralized, and (f) There is an expectation of improvement and consequently the experience of hope. The identification of common factors among seemingly disparate models of treatment, related to successful outcomes along with the development of professional organizations and journals, has facilitated the integration of different treatment approaches (Gold, 1996; Norcross & Goldfried, 1992; Stricker & Gold, 1993). Early attempts at integrating psychotherapeutic approaches include an integration of psychoanalysis and behavior therapy (Wachtel, 1977) and a multimodal approach advocated by Lazarus (1989, 1992). Gold (1996) summarized three approaches to psychotherapy integration. These are (a) technical eclecticism, in which two or more techniques from different systems are applied systematically and sequentially; (b) the common-factors approach, in which common factors in all psychotherapies are emphasized and relied upon; and (c) theoretical integration, in which seemingly incompatible philosophical differences are united, and behavior is explained in terms of interactions. The AA program and psychotherapy can be integrated using each of these three approaches. To understand this, it is first necessary to identify the key points of the AA program.

THE PROGRAM OF AA AA was founded in 1935 by William Wilson, a stockbroker, and Robert Smith, a surgeon. According to the originators, the program was established because medicine and psychotherapy had little to offer the addict in the way of treatment. AA was formed when two alcoholics struggling to get sober and stay sober themselves found that they could achieve and maintain sobriety by helping others to do so. Thus, while the motivation for helping others is self-centered, the result is altruistic in that others receive help. AA grew to the scale of a social movement. It has been an international organization since 1940. Although the goal of successful participation in the AA program is abstinence, abstinence without a corresponding change in character or personality is viewed as unstable. Alcoholism is conceptualized as a problem that is “90% thinking and 10% drinking.” The idea that one will not remain sober “without undergoing a profound personality change” (AA World Services, 1967, p. 1) is certainly consistent with psychodynamic approaches to the psychotherapy of alcoholism, which is discussed in detail later. A good description of the application of the AA program can be found in a section of Alcoholics Anonymous (AA World Services, 1939) titled

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“How It Works.” This section and other portions of the text are paraphrased and summarized here: The AA program consists of people in recovery helping themselves by helping one another. It is described as a program for people who want it, not for all who need it. It is stated that, “If you want what we have, do what we do,” and “it works if you work it.” The only requirement for membership is a desire to stop drinking. Honesty, openness, and willingness to follow the program are necessary for success. There is recognition that there are those who will not be successful. Typically, it is those individuals who are not willing or capable of following the program. As people recover in AA, they work toward progress, not perfection. Three pertinent ideas are emphasized: (a) They were alcoholic and could not manage their lives (this is to say that there is recognition and acceptance that they cannot drink in a controlled and safe manner, and there have been significant negative consequences of their drinking); (b) They could not stop drinking on their own; and (c) The way to gain control is to surrender to a “higher power.” This is one of the great paradoxes: By admitting and accepting a lack of control or powerlessness, one gains control. To surrender is to accept that one cannot manage his drinking on his own. One then “turns it over” or looks to someone or something else for guidance, direction, and support. This someone or something else is referred to as a higher power. For some, the higher power is a sponsor who has been successful in recovery. For many, the higher power is the group. For others, the higher power is a deity. These three ideas have been summarized in the following way: “I cannot do this alone. Something or someone else can. I will ask for help and follow direction.” Following directions requires following the program, which means taking certain steps. Following the steps results in a realization of “The Promises,” which are the positive changes achieved by the individuals who follow the steps. It is asserted that only Step 1 (accepting that one cannot drink) must be done perfectly. The remaining 11 steps are works in progress over the course of one’s life. The 12 steps and promises are presented in Appendix 1.

COMMON FACTORS: AA AND PSYCHOTHERAPY A review of how AA operates and of common curative factors in psychotherapy suggests a number of similarities. It can be argued that the AA group as a whole and the AA sponsor in particular constitute “a trained socially sanctioned healer.” The social sanction is implicit in the social recognition and utilization of the AA program. The AA program

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is most frequently a major component of inpatient and outpatient treatment programs. Judges frequently mandate defendants with alcohol and drug problems to attend AA. Physicians, psychologists, and other mental health professionals routinely refer patients to AA. The government has supported the incorporation of AA groups in prison treatment programs. This suggests that the AA approach has both social recognition and social sanction. Psychotherapists, patients, AA sponsors, and “sponsees” are all trained in their respective models of treatment. Psychotherapists attend formal professional training programs in schools that are freestanding or university based. Many therapists have learned much about the practice of psychotherapy as a function of having been patients themselves. As practicing therapists, we certainly learn from our patients. Psychotherapy patients are “schooled” in different ways. Sometimes this schooling occurs as a function of the experiential process. They learn the model as they progress through the treatment process. In some approaches, there are reading and homework assignments. In other approaches, the therapist may be more directly instructional. The training in AA that the healers (both sponsors and the AA group as a whole) receive occurs in the process of joining AA and being “schooled in the model” in a manner similar to the schooling that psychotherapy patients receive. There are formal “training” experiences in AA. There are AA meetings specifically devoted to schooling in the model. There are “Big Book Meetings,” in which the handbook of AA is read and discussed. There are also “Step Meetings,” in which each of the 12 Steps is read and discussed. AA groups offer a regular succession of these meetings. A sponsor is someone who has sufficiently learned the steps and their application so that he or she can guide a more junior member through them. The role is very much a teacher/therapist role in which the student is taught, in part, by modeling. Sponsor/sponsee interactions can also be rather Socratic in nature. Sponsors often direct sponsees to read specific literature to inform a discussion to follow. As one works through the 12 Steps, the literature is regularly used to direct, guide, reinforce, or challenge behavior. AA groups have requirements for being a sponsor, such as having completed at least 1 year of sobriety and having worked through all 12 steps. Thus, the group “socially sanctions” the sponsor. The change process in AA is quite formal. Members begin as newcomers. From the beginning, it is communicated that they need to learn how to get sober and remain so. The message is sent: “If you want what we’ve got, do what we do.” Newcomers are encouraged to attend meetings, pick a home group, get involved and give service, get a sponsor, and begin working the steps. Each day in early sobriety is recognized. Recognition is then provided for 90 days and then yearly intervals. As newcomers work

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through each step with their sponsors, they are also encouraged to share their experiences related to each step in the larger group setting. They receive feedback from the group as to how well they are doing. The sponsor determines when a step has been successfully completed and then places the sponsee on the next step. There are certain meetings that members are not allowed to lead unless they have completed all 12 steps. As a function of the process described here, an understanding of both the problem and the cure is achieved. Members attempt to achieve progress, not perfection. They see around them others who have been successful, as well as those who have relapsed and come back and are enjoying a new success. Members experience an increase in self-esteem, agency, and personal value. They are “remoralized.” There is an expectation of continued improvement and, consequently, the experience of hope. This change process parallels the change process in psychotherapy described by Frank (1961). The psychotherapeutic process, or “talking cure,” is a verbal treatment that promotes behavior change by facilitating the development of introspection and insight, motivating effort and persistence and often providing a corrective emotional experience and/or teaching skills depending upon the specific model of psychotherapy. The AA program and psychotherapy share these common processes, target similar issues, and pursue similar resolutions.

THEORETICAL INTEGRATION Bandura (1978) presented and discussed a causal model of human behavior termed reciprocal determinism. This model is best summarized by the formula B f (P 4 3 E): Behavior is a function of an interaction between the person and the environment. The person consists of both biological and psychological components. Psychological processes include perception and the analysis and organization of information from the environment. The environment can be categorized as familial, social and cultural, recent and remote. Opazo (1997) formulated a supraparadigmatic integrative model that is based upon six parameters of the psychological system. The parameters of biological, environmental, behavioral, cognitive, affective, unconscious, and systemic are organized around the self. The self system integrates influences from these parameters by translating the experience of the parameter giving it meaning. These parameters interact in a reciprocal or circular fashion so that cause and effect can be difficult to determine. Guajardo, Bagladi, and Kushner (2004, p. 41) stated that this model provides “a complete source of potential etiologies” (of addiction) and their interaction.

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The originators of the program of AA described the alcoholism that they were attempting to address as a mental, spiritual, and physical disease. These three categories are described as subsuming biological, environmental, behavioral, cognitive, affective, and family system components, as well as a spiritual component. Although the term unconscious is not used to communicate the same meaning as Opazo’s utilization of the term, there is reference to goal-directed motivations, thoughts, feelings, and behaviors, the origin of which is unknown. Thus, AA philosophy is consistent with these aspects of the supraparadigmatic model as the structures and practices of AA address issues in the six parameters of the psychological system. Hopson and Beaird-Spiller (1995) conducted a study to examine the psychological needs addressed by the AA program. The program directly addresses many of the psychological needs of recovering alcoholics and other addicts. For example, speaking about one’s experience provides an opportunity to use language to represent the self and express feelings. It can help establish and consolidate a sense of self. As one patient stated, “When I had to tell the story of me in 30 minutes, I realized that I felt things that I was not aware of and how the things that have happened to me have made me who I am.” Attending meetings regularly can restore a sense of agency, a sense that there is something that one can do, as well as facilitating self-regulation and establishing regularity. Another patient stated, “This I can do. I can go to meetings. It helped them. It can help me . . . just being on a schedule makes my life feel so ordered and in control.” Additionally, the emphasis on fellowship can establish or restore a sense of relatedness to others. The sponsor system can restore a relationship with self and others and build self-acceptance and trust. Unconditional acceptance contributes to selfacceptance. Many patients have described their experience of the fellowship of AA and their relationship with their sponsor and other members as a reconnection with people. For others, these relationships may represent their first real interpersonal connections. One patient expressed the following, “As I came to know other people better, I came to know myself better. While we are not all exactly the same, we are more similar than we are different. I have a much better sense of who I am, and I do not feel so different and alone anymore.” Many of the sayings that are utilized in AA are verbal/cognitive devices or tools designed to address issues central in addiction. Sayings such as “Keep coming back” reinforce a sense of agency (that one can do something to help one’s self) and reinforce a sense of connectedness to others. Other sayings directly address some of the personality deficits often observed in alcoholics and other addicts. “One day at a time,” “Don’t drink now,” and “Wait a minute” can help restore a sense of temporality. “This

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too shall pass,” “Easy does it,” and “HALT” (hungry, angry, lonely, and tired) can help build tolerance of affect, regulate affect, and modulate feeling states. The meaning and utilization of these verbal/cognitive tools or devices will be discussed further later. Hopson and Beaird-Spiller (1995) also found the first three steps to be associated with psychological factors important in addiction. Step 1 (powerlessness) was found to be associated with the acknowledgment of a loss of agency. Step 2 (the belief that something greater than oneself can help) was viewed as compensating for a lack of internal structure. Step 3 (turning it over) was associated with relief from the effort of carrying the weight of strong feelings without assistance and the presumption of agency. These first three steps have been critical for patients in psychotherapy particularly, but not only, in early recovery. The recognition of powerlessness or of the loss of agency provides a reason to do something different in that whatever the patient has been doing has not worked. The second step offers hope in that it is communicated that there is something more powerful than the self that can work. This is demonstrated by the presence of an organization of people who have successfully achieved what the patient could not achieve relying exclusively on his or her own resources. In the third step, the patient “makes a decision” to rely upon others for help. Often, for the patient in psychotherapy, there is an increased reliance on the therapeutic process and an increase in the experience of hope. The AA program and the majority of the psychotherapeutic approaches to the treatment of addiction share the common goal of abstinence. The reality that alcoholics cannot learn to drink in a controlled manner is well established (Wallace, 1993, 1990). They also share similar target issues. These target issues include motivating the patient for change, facilitating the patient’s development of a sense of self, improving selfesteem and self-care, developing the ability to manage and tolerate affect and self-soothe, and building mutually satisfying relationships with others. The desired resolutions of these issues are similar in both AA and psychotherapy. Constructing a treatment that is integrated results in addressing these issues in at least three arenas: in psychotherapy, in AA, and in the patient’s daily life. This integration can potentiate progress in a reciprocal manner. A good understanding of the psychological function of AA practices and precepts allows the therapist to support, use, and incorporate into the psychotherapy those aspects of the AA program that facilitate progress and are consistent with the model of psychotherapy that is being practiced. At the same time, doing so supports and enhances the patients’ work in AA, which is clearly associated with success in recovery. Such a unified approach can be very powerful.

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THE PSYCHOLOGICAL FUNCTION OF AA PRACTICES AND PRECEPTS FROM A PSYCHODYNAMIC PERSPECTIVE From a psychodynamic perspective, addiction has been viewed as representing attempts at self-care and self-soothing (Khantzian, 1980; Kohut, 1977; Krystal, 1975, 1978), affect tolerance (Krystal, 1978; Krystal & Raskin, 1970), and a way of managing affect by changing painful psychic states, such as emptiness and deadness (McDougal, 1982, 1989). Compulsive substance use has also been discussed as a remedy for narcissistic injury and internal fragmentation (Kohut, 1977; Wurmser, 1974, 1984), helplessness and rage (Dodes, 2002; Wurmser, 1984), self– object differentiation (Krystal, 1978), and negotiating separation and connectedness (Kernberg, 1975; Krystal, 1975, 1978). Additionally, addictive behavior has also been described as a compromise accomplished by way of a displacement of action warding off other perceived dangerous behavior (Dodes, 2002) and as an attempt at medicating a harsh superego (Kernberg, 1975; Wurmser, 1984). These psychodynamic factors in addiction are directly addressed by aspects of the structure and practice of AA beyond those reported by Hopson and Beaird-Spiller (1995).

ESTABLISHING, CONSOLIDATING, AND MAINTAINING A SENSE OF SELF Krystal (1978) discussed the difficulty that addicts have with regard to self-definition and self-object differentiation. Wurmser (1974, 1984) and Kohut (1977) described the internal fragmentation often experienced by compulsive drug users. Hopson and Beaird-Spiller (1995) noted that there are aspects of the AA experience that facilitate the development of, and consolidation of, a sense of self. Encouraging patients to “work” the aspects of the AA program that directly address these issues provides the patient with support and facilitates the psychotherapeutic process. At both open and closed AA meetings, members “tell their story.” This story is most often a life history organized around the development of compulsive alcohol use. They share their experience, strength, and hope by telling the group “what it was like, what happened, and what it is like now.” These life stories often begin at birth and describe early childhood experiences in the family of origin that shaped the feelings, attitudes, and beliefs that precipitated and maintained drinking behavior. The role that these attitudes, beliefs, and feelings played in the development of alcoholic drinking and behavioral problems is discussed. There is usually an emphasis on how these attitudes, beliefs, and feelings changed as a function of

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abstinence and recovery. Members become more aware of what is unique about them and what they have in common with others. Self-object differentiation is enhanced. Those group members who listen to the story are encouraged to “identify, don’t compare,” facilitating an interpersonal connection directly challenging the sense of alienation, separation, and disconnectedness discussed by Krystal (1975, 1978) and Kernberg (1975). Introspection and the consolidation of the self are further enhanced in the process of completing the fourth step, which requires that a searching and fearless moral inventory is completed. This requires self-examination of positive and negative traits and behaviors or actions. When this step is done honestly and thoroughly, the self view is rather complete and the self-representation is quite real. The fourth step usually results in a written document which, in the fifth step, is shared with another person. This person is often, but not always, the sponsor. In sharing with another person “the exact nature of our wrongs” as they exist alongside positive traits and attributes, an honest presentation of the self is offered to another human being. If the person to whom the self-disclosure is made is chosen correctly, the response is not punishment or condemnation. What is communicated is unconditional acceptance and the reality that one does not have to continue on as before. Change is possible and evident in the members of AA. The absence of a punishing response and the message that one’s shortcomings are simply human directly challenges the harsh superego observed in many alcoholics and other addicts (Wurmser, 1984; Kernberg, 1975). This process also facilitates the development of more true and intimate relationships with others in general, further diminishing the sense of alienation and aloneness.

ESTABLISHING A SENSE OF RELATEDNESS TO OTHERS The process described thus far results in a clearer, more complete, and stronger sense of self and self-acceptance. At the same time, a more complete and more accurate view of others is being established. This generates much grist for the psychotherapeutic mill. The AA emphasis on fellowship and regular meeting attendance (“keep coming back”) facilitates the development of interpersonal relationships. The interpersonal relationship between sponsor and sponsee, particularly after the fifth step has been completed, can serve as a bridge to more meaningful interpersonal relationships with others. Because AA meets as a group, over time, social anxieties often decrease. Through the process of telling one’s story and listening to the stories of others, one becomes known to others and knows others. In this way, group members know a great deal about one another, even without direct individual interpersonal interactions. Eventu-

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ally, interpersonal connections are established. AA members are encouraged to call their sponsor and at least one other alcoholic daily. All group members can receive calls from other alcoholics who may need help or who are simply following the suggestion that they make the call. Over time, newcomers find that they have something to offer to more recent newcomers. Self-esteem and self-worth increases with the realization that one has something to offer that someone else wants or needs. As one patient said in session:
At the meeting the other week, this new guy Ted came up to me. He’s been sober 6 days. He asked me how long I have been sober. I was embarrassed to answer because I don’t have much time. But I told him that I’m sober 2 months. You know what he said to me? “Two months! God, how did you do that? I don’t think I can make it another night.” So I told him what I do and that he can do the same thing. If it worked for me, it could work for him. I felt useful. I felt great! We talk all the time now.

SELF-CARE AND SELF-SOOTHING DEFICITS Khantzian (1980) highlighted the self-care deficits often observed in alcoholics and other addicts. Khantzian uses the term self-care to describe the addict’s inability to recognize the signs of danger and deterioration associated with compulsive drug use. When these signs are not recognized, the anxiety that would normally motivate change behavior is not experienced, and the alcoholic does not act in the service of self-protection and self-care. In AA, this is labeled denial. It is not thought of as an ego deficit but as a defense. Regardless of the etiology of this self-care problem, AA directly addresses it in a manner that can be quite effective. In the process of telling one’s story, the progression of negative consequences and the unmanageability of life associated with alcoholic drinking become inarguably clear. Working on Step 1 involves the reconstruction the sequence of events of life conflict and associating these events with alcohol use. The goal is to “Tie the drinking to the trouble in your life.” Working on Step 8 involves constructing a list of all the people that you have had a negative impact on as a direct result of drinking and of the attitudes and beliefs that support addictive behavior, such as entitlement. Completing such a list further clarifies the relationship between addictive behavior and conflict and pain. The resulting increased awareness and understanding is then used to help the recovering AA member to “think the drink through.” When they experience the impulse to drink, they are encouraged to put the negative consequences in front of the thoughts about drinking. This involves looking at where drinking has led them in the past and where it will lead them if they drink again, before they take a drink.

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Many addicts evidence what Kohut (1977, 1993) identified as deficits in the ability to self-soothe. This ability is typically learned in interaction with parents who soothe their child by reflecting the child’s goodness and power and by providing a sense of calm, safety, and protection. The child may feel good enough and powerful on his own, or he may merge with the allpowerful parent to establish a sense of goodness, power, and security. Many alcoholics and other addicts never internalize this healthy grandiosity or the capacity to self-soothe, so they look outside themselves to an ego-enhancing and calming, soothing substance. Kohut (1977, 1993) maintained that reparative experiences later in life can correct these deficits if the individual is involved in higher-quality interpersonal relationships with others who possess the missing abilities. Participation in AA can be such a reparative experience. Self-acceptance and a healthy grandiosity are supported by the corrective emotional experience that the AA member has with the unconditionally accepting sponsor and with the group, both of which mirror the member’s positive qualities and accomplishments. In working Steps 2 and 3, members are encouraged to recognize that something greater than themselves (the higher power or the “idealized parental image”) can restore them. Members are encouraged to turn it over to (or merge with) the all-powerful entity. In this way, the powerless become empowered, and a sense of protection and serenity is achieved.

BUILDING AFFECT TOLERANCE AND MANAGING AFFECT AND BEHAVIOR Several researchers have recognized the difficulty that addicts have in tolerating and managing emotions and behavior. Krystal and Raskin (1970; see also Krystal, 1978) discussed this difficulty with the tolerance of strong emotional experiences and the impulse to medicate them. McDougal (1982, 1989) examined the use of substances to change painful affective states such as emptiness and deadness. Dodes (2002) and Wurmser (1984) highlighted the compulsive drug user’s vulnerability to narcissistic injury. A lack of tolerance for the accompanying experience of anger and rage, as well as the need to medicate it, is identified as an important precipitant of compulsive use. Additionally, unwanted impulses and behaviors are often medicated with substances decreasing the likelihood of occurrence. Dodes (2002) described the action of addictive behavior itself as a displacement of other perceived dangerous or otherwise unwanted behavior. The practice in AA of putting one’s experience into words and honestly sharing thoughts and feelings with a sponsor and with the group

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allows some discharge of affect and communicates the member’s needs and conflicts to others. The atmosphere of unconditional acceptance facilitates this. Psychological and emotional pain is shared. Support is offered in return. Acronyms such as HOPE (hold on, pain ends) and sayings such as “this too shall pass” communicate the temporality of pain and distress. Specific strategies are suggested, such as “move a muscle, change a thought.” Prevention strategies are also offered, such as teaching the person in recovery to be aware of HALT (hungry, angry, lonely, tired) states. These states are presented as setting the recovering addict up for relapse or any other undesired behavior. AA members who are struggling with anger, resentment, and depression are often encouraged to “make a gratitude list.” This strategy is similar to, but not exactly the same as, positive reframing. Step 10 also directly addresses the experience of resentment and anger as these emotions frequently precipitate relapse. The message in Step 10 is that anger, no matter how justified it may be, can be hurtful to the person that is experiencing it and must be managed. The message is not that anger is necessarily bad but that emotional experience must be balanced and unbridled anger is destructive. AA members are encouraged to express what they are thinking and feeling so that the thoughts and feelings are subject to the scrutiny of others. They are encouraged to look for and to examine their particular vulnerabilities that contribute to their experience of hurt and anger. Individual motives can be checked. Support is offered. Ultimately, individuals are encouraged to take responsibility for what they do, regardless of how justified the anger may be. AA strategies similar to positive reframing are suggested in these situations as well. Narcissism plays a major role as a risk factor for substance use and as a moderator variable related to relapse. Dodes (2002) stated that all addictions are displaced efforts to repair underlying narcissistic injuries. Addiction is often driven by the rage associated with the narcissistic injury (Wurmser, 1974, 1984). In the service of supporting pathological narcissism, substance abuse may be a defensive/compensatory strategy to maintain and enhance self-esteem and cohesion of the self (Kohut, 1977, 1993). Patton, Connor, and Scott (1982) stated that by ingesting alcohol and other drugs, the narcissistically impaired person may acquire the confidence so painfully lacking, addressing a deficit in what Kohut called the grandiose self, or the substance may be used to calm and protect himself or herself addressing a deficit in the omnipotent idealized parental image. Active participation in the program of AA directly addresses many of the issues and conflicts revolving around pathological narcissism by providing a reparative experience. The communication of unconditional acceptance and the expectation of, and tolerance of, normal human failings

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helps to address self-criticism and perfectionism. AA members are taught that they are intrinsically of value and that they do not have to be perfect or “better than.” The goal is to be “right-sized.” Being right-sized means having an accurate self-appraisal that is neither self-deprecating nor selfaggrandizing. Honest and accurate self-disclosure submits the selfappraisal to examination and feedback is offered. The issue of narcissistic grandiosity and self-focus is approached with the AA program’s emphasis on humility. It is explained that to be humble is “not to think less of yourself, but to think of yourself less.” Opportunities for positive mirroring exist at the initial contact with AA, and the “goodness” of the individual is reinforced throughout. A sense of agency and power is instilled. The message is sent: “It works if you work it, so work it you’re worth it.” An omnipotent idealized object is offered for merger as the higher power: the group and sponsor. With an internalized sense of goodness and power and in response to normal human failures of largely competent and dependable group members, the recovering AA member develops additional competencies. Self-esteem is supported by real-world accomplishments. Members can now see themselves as of value to others as well. Narcissistic supplies are accrued, and self-esteem and independence are increased.

AA AND CBT The AA program is essentially a cognitive– behavioral program. It facilitates changing one’s perception or understanding, resulting in change in emotional experience and behavior. Morgenstern et al. (2002, p. 665) reported findings that “overall, supported the role of 12-step cognitions in mediating outcomes in 12-step treatment.” The AA program maintains that alcoholism is 10% drinking and 90% thinking. To get sober and stay sober, one must change one’s “stinking thinking.” The cognitive changes that are sought are all along the lines discussed earlier in detail. The cognitive psychotherapist can utilize or reinforce select components of the AA approach that are consistent with any particular treatment goal. For example, if the patient’s unrealistic belief that she cannot live without drinking is the focus of treatment, helping her to see that others who have felt as she does are now living happily in sobriety can be enormously helpful. Encouraging them to attend AA Speaker’s Meetings allows them to hear the stories of people who felt as they do who have learned to live a sober life. Utilizing the saying “If you want what we have, do what we do” not only communicates that a life without alcohol is possible but also suggests a strategy for change.

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One particular area of concern in the treatment of addiction is generating and maintaining motivation. As Nowinski (1996) highlighted, motivation sustaining active effort in recovery is often a problem for patients in psychotherapy, as well as for those utilizing AA. Prochaska and DiClemente (1982) addressed the issue of motivation for change. They present change as occurring through a process of stages. Stage 1 is referred to as precontemplation. During this stage, the patient does not believe a problem exists. In Stage 2 (contemplation), the patient considers the existence of a problem but remains ambivalent. In Stage 3 (preparation), the patient prepares to change but still retains some ambivalence. In Stage 4, the patient takes action. He or she begins to change, but ambivalence can still be a problem. Stage 5 is described as maintenance, and the goal is to maintain change and prevent relapse. Stage 6 is defined by relapse or completion/termination. Expanding upon this change model, Bishop (2001) delineated three types of patients from a clinical perspective. Type I patients are Stage 1 patients. They are not volitional. They were probably sent to therapy and do not think they have a problem. The task here is combating denial. Type II patients are Stage 2 and 3 patients. They think they may have a problem, but they are not sure if they want to do anything about it. They need to examine the consequences of their drinking and explore options. Type III patients are Stage 4 and 5 patients. They want help and want to change. The task is to maintain progress or start again. From a cognitive– behavioral perspective, Bishop recommended applying the ABCs (activating event, beliefs, consequences) and pursued hidden irrational beliefs to help patients manage their behavior by understanding the chain of events and altering their perceptions. The program of AA has much to offer all three types of patients identified by Bishop (see Table 1). A review of the function of the 12 steps specifically with regard to motivation for change suggests the following: Type I patient issues are addressed by the first step. In Step 1, acceptance of the need for change and the need for the maintenance of change is recognized and promoted. Step 1 is worked throughout the entire span of recovery. The issues that characterize Type II patients are addressed by Steps 1, 2, and 3. In Step 2, there is the recognition that help is available and change is possible. In Step 3, a willingness to change is reflected in deciding to rely upon and follow the program. Type III patient issues are addressed by Steps 4 through 12. In Step 4, one identifies one’s own role in having made negative choices and dysfunctional behaviors. This helps identify behaviors in need of change. As these behaviors are shared with another person in Step 5, they are recorded, so to speak and open to scrutiny, and change strategies are further developed. In Steps 6 and 7, a conscious commitment to change is made. In my psychotherapeutic work with people in recovery who are also in AA, I have

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Table 1. Bishop’s Patient Typology and the Corresponding Alcoholics Anonymous (AA) Practice That Can Support, Motivate, and Maintain Change Patient typology and the necessary psychotherapeutic intervention Type 1: The patient is not volitional. He was probably sent to therapy and does not think he has a problem. The task here is combating denial. These are precontemplation patients. Type 2: The patient thinks he may have a problem, but he is not sure if he wants to do anything about it. He needs to examine the consequences of his drinking and explore options. These are contemplation and preparation patients. Type 3: The patient wants help and wants to change. The task is to maintain progress or start again. These are action and maintenance patients. AA practice that can support the necessary psychotherapeutic intervention Step 1: The trouble in, and the unmanageability of, life is accepted as a direct consequence of drinking. This is actively reinforced in early recovery. AA sayings such as, “if nothing changes, nothing changes” addresses the issue of needing to do something, and “change or die” highlights the possible tragic consequences of failing to change. In addition to Step 1 (which is worked throughout recovery), Step 2 highlights that an intervention can be effective and that there is hope if one will follow Step 3 and accept direction and guidance. The statement “If you want what we have, then do what we do” can provide a positive motivation. Steps 4, 5, 8, and 9 involve “cleaning house” and starting to “clear away the wreckage of the past.” Beginning to feel better about oneself and recognizing growth and change is motivational. Steps 6 and 7 involve examining one’s resistance to change and securing a commitment to further change. Step 10 is about maintaining change on a daily basis, and Step 12 focuses on “practicing these principles in all our affairs” or ongoing maintenance.

found that the working though of Steps 6 and 7 can result in a renewed commitment to change and significantly accelerates the psychotherapy. When a psychotherapy has stalled, I have at times recommended that the patient revisit Steps 6 and 7 with his or her sponsor. This usually results in the clear identification of the resistance. One patient, a recovering alcoholic who suffered from work inhibition, correctly identified his powerful fear of criticism and rejection as a resistance to enacting some of the change strategies that he consciously accepted when he reworked the sixth step. When he identified and experienced his fear, the focus of the psychotherapy shifted and he ultimately committed to and engaged in behavioral change. Steps 8 and 9 involve an active demonstration of the willingness to live differently. In the act of recognizing that one has done some wrong and had a negative impact on others, the need for change and the desire to change is enhanced. The act of taking responsibility for one’s past behavior and attempting to make amends is a very necessary and significant change for

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the majority of people in recovery. AA members working the ninth step feel awkward and different. Clearly, these are new behaviors for most. The actions taken in this step proclaim a very loud assertion to oneself and to the outside world that the patient wants to change, is changing, or has changed. It is a display of the internalization of change. Steps 10, 11, and 12 are maintenance of change steps. It is said in AA that one works through Steps 1 through 9 to be able to live in Steps 10, 11, and 12.

PSYCHOTHERAPY AND AA INTEGRATION BY STAGE OF RECOVERY Brown (1995) described recovery from alcoholism as proceeding through several stages. These stages are labeled drinking, transition, early recovery, and ongoing recovery. The patient’s treatment needs are different during each of these stages. Yalisove (1992) further clarified the course of therapy, the goal of therapy, and role of the therapist during each stage. During the drinking stage of early recovery, the patient is intoxicated, unstable, and desperate. His or her contact with the therapist or with AA may have been coerced. Because the patient’s judgment is drug affected, the therapist must function as an auxiliary ego. The therapeutic task during this stage is to accomplish a level of care assessment, to manage the crisis, and to provide for the patient’s immediate safety. This crisis needs to be managed, and the patient may need to be referred to a higher level of care (Yalisove, 1992). During this stage, AA can be enormously helpful. AA members can offer 24-hr support. They will be physically present with the individual and will watch and safeguard them. They willingly transport people to hospitals, detoxification units, or and rehabilitation centers. This early connection with AA can be quite enduring and can result in a sense of gratitude and hope. When the therapist has a role in this early connection, the “positive transference” is shared. During the transition stage, the patient’s abstinence is unstable. In early transition, he or she may be confused and quite labile. With episodes of abstinence and/or periods of abstinence that are longer, there may be some cognitive clearing but periods of confusion and mood labiality persist. The therapeutic task during this stage is to further assess the addiction, establish the need for abstinence, maintain a stable abstinence, and promote the acceptance of addiction. The structure and rules of treatment need to be established. A behavioral focus during this stage is often helpful. Any steps toward progress must be reinforced, and reversals or relapses must have appropriate consequences. The role of the therapist continues as an auxiliary ego, a teacher, and supporter of progress. It is important to

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provide guidance and direction and to promote a positive transference (Yalisove, 1992). The patient’s participation in AA during this phase of recovery/treatment is extremely important. During early transition, AA offers the patient a sponsor or a temporary sponsor for ego support. AA members will pick newcomers up and take them to meetings. Beginners’ Meetings tend to focus on the first three steps and emphasize what one must do to remain abstinent. They offer support and instruction and provide a sober support network. Step 1 reinforces the acceptance of powerlessness and unmanageability and reinforces the need for abstinence. Step 2 offers external support through the power of the group. A positive message and a sense of hope are communicated by sayings such as “it works if you work it.” During the later part of the transition phase, the patient who is also attending AA continues to practice Steps 1, 2, and 3 to maintain abstinence and accept direction. In doing so, the patient receives support in learning how to manage impulses and urges. Supportive relationships with a sponsor and group members continue to develop. According to Brown (1995), early recovery is characterized by a stable abstinence. During this phase, the patient needs to adapt to reality without the use of alcohol or other drugs or acting out. It is important for the patient, the therapist, and significant others in the patient’s life to recognize that symptoms of postacute withdrawal syndrome can persist for anywhere from 6 to 24 months after abstinence begins (Gorski & Miller, 1986; Kelly, 1994). This syndrome is characterized by cognitive problems as evidenced by the inability to concentrate, impairment of abstract reasoning, and rigid and repetitive thinking. There are also significant memory problems, emotional overreactions or numbness, sleep disturbances, physical coordination problems, and stress sensitivity. These symptoms usually peak during a 3- to 6-month period after abstinence begins. Therefore, lapses in judgment and impulse control are episodic and constitute significant relapse risks. The therapist’s role must remain rather supportive, parental, and instructional. The patient’s strengths and weaknesses must be continually assessed and monitored. In general, early recovery is not the time to address or uncover powerful and disturbing memories or emotions because the patient’s nervous system is only partially repaired and the tools for managing such an experience are not likely to be in place. The AA program has a great deal to offer the patient in early recovery, particularly with regard to practical coping tools and cognitive strategies. Working on Step 1 leads to accepting life on life’s terms, and Steps 2 and 3 help the individual to accept support from a sober support group. Steps 4 and 5 help address old behaviors and attitudes that can trigger relapse. The commitment to change is reviewed and reaffirmed in Steps 6 and 7. Steps 8 and 9 help to begin to solidify change and result in the individual’s

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heightened awareness of the progress that he or she has made. All of this facilitates the adjustment to reality without the use of medicating substances or behaviors by diminishing those factors that promote relapse and providing tools to manage the thoughts and feelings that occasioned addictive behavior in the past. In ongoing recovery, with a stable abstinence achieved, the psychotherapy treatment can now work on developing insight into the causes of addiction, psychological problems, and psychiatric and character disorders (Brown, 1995). The therapist’s role is more traditional. This type of psychodynamic exploration is not recommended in early recovery for the reasons stated earlier, but it is important that this work is accomplished in ongoing recovery to address any residual issues that will leave the patient vulnerable to relapse. When a patient has been successful in recovery for many years and then relapses, it is most often because this level of psychotherapy work has not been accomplished. The goal is to achieve selfknowledge and self-awareness, resolve conflict, and alleviate symptoms. In ongoing recovery, the patient in AA continues to work on “acceptance of life on life’s terms.” Having worked through Steps 1 through 9, the acceptance of the need for continued sobriety should be firmly rooted. It is likely that many of The Promises or positive outcomes of sobriety have been realized so that there are additional positive reasons to remain sober. Many core issues have been identified that can now be further examined with a patient who now has the ego strength to tolerate it. The patient is firmly connected to a sober support network and has developed many coping strategies to manage the threats to self-esteem and powerful emotions that a psychodynamic psychotherapy will generate. The therapist can have greater confidence in the patient’s ability to self-monitor and address his or her needs in healthy ways, including relying upon others for support and assistance.

PSYCHOTHERAPY AND AA: A BRIEF CASE STUDY ILLUSTRATION James was a 45-year-old, married father of one son. He sought treatment complaining of a persistent depression, marital problems, workaholism, and “a drinking problem.” He was quite accomplished in his field, having earned a doctorate in law and labor relations at an Ivy League university. He worked at a very intense high-pressured and high-profile position on issues that had important and serious consequences. He appeared visibly strained and depressed. James described a family of origin that was characterized by high expectations of achievement and low

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expressed emotion. He described his wife as rather narcissistic, selfinvolved, and ultimately passive. He expressed feeling as if he was “responsible for everything.” James worked frenetically and overcommitted himself. Consequently, he was always behind and “disappointing someone.” At the end of the day, he found it impossible to relax or sleep without drinking. He was a daily drinker who drank more heavily on the weekends. He clearly met the criteria for alcohol dependence. James began psychotherapy seeking relief from stress and depression. He recognized intellectually that he was drinking more than was good for him but did not see himself as alcoholic. He also failed to see that his depression and many of the conflicts at work and at home were directly related to his drinking as both a cause and a consequence. He needed to hear this to motivate him to do something about it and to commit to an ongoing treatment and change. However, the therapeutic alliance was new, and there was not likely to be a strong enough positive transference to tolerate a strong and persistent confrontation of the denial. In an effort to split the transference, I advised him to attend seven AA meetings so that he “could meet other people who also drank too much and see if he thought there were any similarities or differences and learn something about how they dealt with a drinking problem.” He accepted that this could be helpful even if he was not alcoholic. I specifically sent him to Open Speaker’s Meetings so that he could just sit and listen without having to speak himself. In psychotherapy, James reported that he felt that he could identify with some of what he heard “but not all of it.” This generated a fruitful discussion of his perception of similarities and differences between himself and other people with drinking problems. At this point, he concluded that although he was not an alcoholic, he liked some of these people and felt that he could learn from them. I sent him to attend a few Beginners’ Meetings at which he did not have to “admit that he was an alcoholic” but only that he had “a desire to stop drinking.” He attended these meetings, listened, and learned. He was not ready for a sponsor or even a temporary sponsor, but he left one of these meetings with a group membership list with 50 names and telephone numbers. As this was occurring, psychotherapy time was split between direct discussions about his drinking, which were often precipitated by experiences that he had at AA, and further assessing his depression and job and marital problems. After a month or so, he came into session and told me that he thought he was alcoholic “on top of everything else.” We agreed that he would continue in AA and get a sponsor and that we would work on “everything else.” In doing so, the relationship between “everything else” and his drinking became clear. Thus, the psychotherapy supported his AA participation, and his AA participation enhanced the psychotherapy. His commitment to change and

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his connection with me and with AA grew strong. He made a commitment to stop drinking. When he did so, he experienced withdrawal symptoms, which confirmed the diagnosis and enhanced his commitment to change. James’s transition to early recovery was characterized by a sense of accomplishment and three “slips,” or relapses. Although he heard the message from AA that relapse was part of the illness of alcoholism and that this simply confirmed his lack of control over drinking, his self-esteem was tenuous at best. He also evidenced the expected postacute withdrawal symptoms particularly with regard to exaggerated affect. AA members told him, “You’re right where you’re supposed to be,” helping to normalize the experience and letting him know that it will pass. In psychotherapy, he began to examine his negative self-view and negative expectations. He naturally began to review the history of these feelings, which led him to disclose several traumatic and painful childhood events. My response was empathic, validating, and supportive. At the same time, I had a discussion with him about putting a moratorium on this area of his experience until some future time when he would be better able to manage it. He agreed, and he was able to do so. The AA program helped him to keep his focus on the here and now and on the primary task of staying sober. As James achieved a stable abstinence, his fourth-, fifth-, eighth-, and ninth-step work generated much grist for the mill. This work in AA involves honest self-examination and enhanced his self-appraisal abilities. In psychotherapy, this fueled introspection and self-analysis. He had developed insight and was continuing to do so. Just after he celebrated 2 years of sobriety, we revisited the childhood trauma issues that had been disclosed earlier and “placed on hold.” James experienced the appropriate rage and sadness that he was barely able to manage. He used the tools of the program and expressed his feelings in meetings as well as in session. This resulted in a conflict between the message that he was receiving from me—that it was important for him to feel, express, and tolerate these emotions—and a message that he was getting from some in AA who were telling him that he should not allow these feelings because they could trigger a relapse. AA offered him strategies to avoid the experience of anger. I supported his utilizing these tools in his daily life while I continued to encourage his contacting and expressing his feelings in psychotherapy sessions. This integrated approach was quite helpful to him. The psychotherapy work proceeded with all of the necessary affect, but he had the tools and the personal assistance of AA members to detach from these emotions in his day-to-day life, function, and not drink. From this point forward, the psychotherapy proceeded in a more traditional manner but always with the awareness that this patient is an alcoholic in recovery and that, consequently, relapse is always a possibility that must be considered.

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CONCLUSION The utilization and effectiveness of AA identifies the program as a valuable asset in the treatment of addiction. Although the AA program and the professional treatment approach of psychotherapy grew out of different traditions, the two approaches share a common goal, target similar issues, and work toward similar outcomes. The two approaches can be integrated on theoretical and practical/clinical levels. A psychotherapy approach that integrates or unifies the two approaches can be quite powerful. Treating a patient in psychotherapy who is also working the AA program without a good understanding of AA can result in the two approaches working at cross-purposes, diminishing the effectiveness of both interventions. Given that addiction is an illness with a treatment success rate of approximately 40% across studies, it is necessary to utilize all available resources. In my clinical experience, the integrated approach described earlier increases treatment success and results in a more stable and durable recovery.

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APPENDIX 1

The 12 Steps and Promises of Alcoholics Anonymous
Step 1: We admitted that we were powerless over alcohol—that our lives had become unmanageable. Promise: We are going to know a new freedom and a new happiness. Step 2: Came to believe that a power greater than ourselves could restore us to sanity. Promise: We will not regret the past nor wish to shut the door on it. Step 3: Made a decision to turn our will and our lives over to the care of God as we understood Him. Promise: We will comprehend the word serenity and we will know peace. Step 4: Made a searching and fearless moral inventory of ourselves. Promise: No matter how far down the scale we have gone, we will see how our experience can benefit others. Step 5: Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. Promise: That feeling of uselessness and self-pity will disappear. Step 6: Were entirely ready to have God remove all these defects of character. Promise: We will lose interest in selfish things and gain interest in our fellows. Step 7: Humbly asked Him to remove our shortcomings. Promise: Self-seeking will slip away. Step 8: Made a list of all persons we had harmed and became willing to make amends to them all. Promise: Our whole attitude and outlook on life will change. Step 9: Made direct amends to such people wherever possible, except when to do so would injure them or others. Promise: Fear of people and of economic insecurity will slip away. Step 10: Continued to take personal inventory and, when we were wrong, promptly admitted it. Promise: We will intuitively know how to handle situations that used to baffle us. Step 11: Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. Promise: We will suddenly realize that God is doing for us what we could not do for ourselves. Step 12: Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs. Are these extravagant promises? We think not. They are being fulfilled among us—sometimes quickly, sometimes slowly. They will always materialize if we work for them.

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