"There is a principle which is a bar against all information, wlikh is /.'roof against ill arguments and which atpuot fail to keep p man in everlasting ignorance - that principle is contempt prior to investigation." - Herbert Spencer
Psychiatry does not know enough about Alcoholics Anonymous (AA) and the other 12-step programs that have developed from it. Current psychiatric training, which requires the inclusion of some training in working with "self-help" programs, will improve this situation of relative ignorance. This article outlines some of the knowledge and skill that will help psychiatrists use AA and other 12-step programs in the treatment of alcoholism and other drug addictions.*
The first step in our cognitive restructuring is the recognition that AA, the original 12-step program, is a treatment system tor alcoholism that aids normal growth and development. This system was developed by a group of chronic "low bottom" alcoholics, including some physicians, who had been treated unsuccessfully by medicine, psychiatry, and psychoanalysis.
One historic stimulus to the development of AA was .lung's acknowledgement to his alcoholic patient, Rowland H, who relapsed after an apparently successful analysis, that there was nothing more medicine or psychiatry could do for him.1 Jung suggested that he might be helped by a conversion experience. Rowland returned to the US, joined the Oxford group, maintained sobriety, and shared his experience with Ebby T, who also joined the Oxford group. In November 1934, Ebby visited his friend Bill W, who was impressed by Ebby's sobriety but not his religion. The following month, Bill W entered Towns hospital for the fourth and last time as a patient. While detoxifying in the hospital he had a spiritual experience that arose from his despair and depression.
Following discharge, Bill W attempted to help other alcoholics. After many failures he shared his frustration with Dr. Silkworth, his physician. At this point a second medical stimulus to the formation of AA was provided. Silkworth said, in part, "For God's sake, stop preaching. Tell them about the obsession and the physical sensitivity they are developing - say it's lethal as cancer. - A drunk must be led, not pushed."Hp2i7) ln May 1935/ Bill W, recognizing his own need to talk to another alcoholic, met Dr. Bob 5, a surgeon in Akron, Ohio. The two became cofounders of AA.
It took over three years of shared experience to develop the 12 steps and the Big Book, entitled Alcoholics Anonymous. Members from the Akron, Cleveland, and New York groups all contributed. While the Big Book was written by Bill W, he often commented that he felt more like an umpire than an author.2|Plsll) It was in this process that AA separated itself from the Oxford group and any association with religion. The spiritual nature of the program is so persona] and accepting of any or no experience that atheists and agnostics can easily participate. It took another 15 years for the 12 Traditions to be developed, and much longer for the 12 Concepts and 6 Warranties, which arc sometimes referred to as the "constitution" of AA.
The outcome of this lengthy process was a program that is still the most effective method for maintaining sobriety. Vaillant, in a prospective 30-year follow-up of 110 alcoholics, found that the number of AA visits made by these men explained 28% of the clinical outcome. 3 The usually important variables of stable adjustment, married, employed, and never detoxeii explained only 7% of the clinical outcome. Medical or psychiatric treatment did not explain any of the clinical outcome.
The development of the Minnesota model of treatment, combining professional treatment with AA, resulted in improvements in treatment effectiveness. A recent prospective study of employed alcoholics found that treatment plus AA was more effective than AA alone in helping employed alcohol abusers attain and continue abstinence.4 This study confirms the value of combining professional treatment with AA.
With roots in medicine, psychoanalysis, and religion, AA is compatible with psychiatric treatment. Given its demonstrated effectiveness in the treatment of alcoholism, it is even more important for psychiatrists to have a working knowledge of what happens in AA than to know about surgery, obstetrics, and other disciplines in which we all received training. The big difference is that AA is not under professional control. It is protected by a set of traditions that have maintained the organization and its program successfully for over 55 years. AA works best in conjunction with psychiatric treatment when we are knowledgeable about and supportive of our patients' experiences in that program, and exercise care with our prescriptions.
WHAT AA IS AND IS NOT
The sole purpose of AA is to help alcoholics attain and maintain sobriety. This singleness of purpose needs to be understood by psychiatry. It means that our patients will experience no conflict with the program of AA as long as they do not drink. The only requirement for membership is a desire to stop drinking. A good description of AA can be found in an earlier issue of this journal.5
We need to understand that AA does not:
* Solicit members. It is a program of attraction, not promotion. This means we need to help our alcoholic patients make the initial contact with AA.
* Charge dues or fees. In an era of rising health care costs, AA provides a notable exception in providing treatment with no monetary cost. It does, however, for many, require considerable time and effort to be effective.
* Control or follow up on members. No membership records are kept. This means that our only source of information about our patient's progress in the program will be from the patient or immediate family.
* Provide housing, meals, or transportation. Occasionally other AA members may provide these, but in every instance it is an individual act of charity and not part of AA's program.
* Provide medical, psychiatric, or nursing care. While not providing professional care, AA is very supportive of it. When our patients are on psychiatric medications, it is useful to refer them to the pamphlet, The AA Member - Medications and Otiier D rugs.4
* Join councils or social agencies. While we may be enthusiastic about the good that could be done if AA supported worthwhile causes, this will not happen. AA's singleness of purpose in helping the alcoholic is protected by its tradition of nonalliance and nonaf filiation. This also means that no treatment program or professional can claim a special alliance or relationship with AA. Groups holding AA meetings in hospitals, churches, or other institutions are only cooperating to make AA available to alcoholics and are not connected in any official way to those institutions.
* Accept money from nonmembers. AA operates on the principle of self-support and accepts no outside money Even though we may wish to contribute to this program it will not be accepted.
How AA Works
Although psychiatry has always been friendly with AA, inviting Bill W to address the American Psychiatric Association in ?948, the relationship has been a distant one. Little was written about AA in our professional literature, despite Bill Ws invitation to us to "be our partners, physicians wielding well your invisible scalpels, workers all, in our common cause."" Fortunately, interest has been increasing.
A study in the mid-1980s found that psychiatrists were significantly (/x.OOl) more likely to refer alcoholic patients to AA than were internists or surgeons/ Brickman was one of the first to recommend combining AA with the psychotherapy or psychoanalysis of alcoholic patients. 8 Recently Khantzian and Mack provided strong theoretical backing for considering AA a specific treatment.4 They describe AA as a "sophisticated psychosocial form of treatment that addresses human psychological vulnerabilities that alcoholics and others share related to problems of self-regulation."
The therapeutic aspects of AA emphasized by Khantzian and Mack are:
* The instillation of hope through contact with others.
* The encouragement of openness and self-disclosure.
* Repeated emphasis on shared experiences, developing a network of stable individual and group relationships.
* A focus on abstinence and loss of control over the use of alcohol.
* An insistence that one cannot get better on one's own.
* A spiritual dimension that helps move a person from self-centereclness toward a capacity for both humility and object love.
The above factors contribute to a positive shift in ego defense mechanisms and characterologic change. This brief summary docs not reflect the richness of the authors' discussion.
There are three major elements to AA's program of recovery.
AA meetings provide the usual context within which an alcoholic works his or her program. They are extremely variable. If patients do not like a particular meeting we can safely encourage them to try some others until they find one in which they are comfortable. Some examples of the range of meetings is as follows.
Open - for anyone who wants to know more about Alcoholics Anonymous.
Closed - for those who have a desire to stop drinking.
Speaker - where one or more AA members share their experience, strength, and hope with regard to alcoholism and their progress in sobriety.
Discussion - where a subject or subjects pertaining to sobriety are chosen and discussed.
Big Book study - where sections of the Big Book are read, discussed, and studied.
Step study - where one of the 12 steps is chosen for study and application.
Women, gay/lesbian, etc. - for individuals who have trouble participating in mixed or regular meetings. These meetings, while controversial and not considered by some to be regular AA meetings, can be an excellent way to introduce individuals who have or who experience barriers to participation in general AA meetings, e.g., alcoholic physicians.
We can reassure our patients that they will be welcomed at meetings. Newcomers are considered the most important people at any AA meeting.
Patient resistance is usually highest when we first make the diagnosis and referral. There are many ways to deal with this resistance. One of the most effective was described by Sisson and Mallams.111 They randomly assigned newly diagnosed alcoholics to two referral methods. In the first group, they used the "standard" method of recommending AA and providing a phone number. In the second group, they called AA while the patient was in the office and put the patient on the phone with an AA member who offered to take them to a meeting. None of the first group went to a meeting, but all of the second group did.
Also useful in countering patient resistance is emphasis on acceptance, safety, and learning. The degree of honest acceptance seen and experienced at AA meetings is phenomenal. No matter how unkempt, unusual, or distressed the individual is, she or he is greeted with genuine warmth. People who are shunned in churches, classrooms, or other tolerant settings are welcomed at AA meetings. The principle of anonymity provides a degree of safety for participants similar to that found in professional's offices. It is not unusual to have the following statement read or posted: "Whom you see here, What you hear here, Let it stay here." Breaches of someone else's anonymity or confidentiality are extremely rare. Meetings are also excellent places to learn about the varieties of alcoholic experience and the many routes to sobriety. It often helps to recommend that the patients sit with an open mind, reflecting on their own issues with their ears open. They will often hear what they need to hear. Meetings can also be an excellent stimulus for psychotherapy sessions.
Our patients are often terrified that they will be asked to speak at meetings. They can be assured that the statement "I pass" or a simple shake of their head will always be honored with no pressure. Sometimes psychiatric patients are told that they do not belong in closed meetings. This is usually because they have focused on problems other than alcohol. All objections can be met with the statement, "I want to stop drinking." When this is said, virtually every AA member will remember the singleness of purpose statement, "1 am responsible . . . When anyone, anywhere reaches out for help, I want the hand of AA always to be there. And for that: I am responsible." This statement could be thought of as the touchstone for the collective conscience of AA.
A useful metaphor for AA meetings is medication. To be effective they need to be taken daily in the first three months of sobriety. Most treatment programs now recommend 90 meetings in 90 days in recognition of the high risk of relapse in the first three months, and the need for an intensive experience to break through the defenses of denial, projection, and isolation.
Meetings introduce the alcoholic to other alcoholics in various stages of disease and recovery. This growing support system can be very effective in helping provide an experience of acceptance and belonging. AA began with one alcoholic talking to another. If your patient is not getting this experience, have her or ng to another. If your patient is not getting this experience, have her or him ask for a temporary contact or a 12-step visit. Hearing the story of someone their own age and sex can be very effective in decreasing resistance. Dr. Bob had planned to spend no more than 15 minutes with Bill W when they first met. That first contact lasted several hours.
Once a useful meeting is found, the psychiatrist should encourage Ih e patient to select a home group. Home groups serve several useful purposes. They provide a kind of extended family where the person feels at home. Members of the home group can provide the start of a phone list that the person can call when craving or other relapserelated issues arise. Calling on others for help has been associated with significantly (p><.05) reduced risk for relapse." Home groups assign responsibilities such as making coffee, setting up, greeting new arrivals, chairing meetings, cleaning up, etc. These activities provide the new member with an introduction to service, which is one of the major routes to both stable sobriety and character change.
One of the most important relationships in AA is that of a sponsor. The individual member picks his or her sponsor. The basis for this selection is usually someone who has the kind of sobriety the new member would like to have. The sponsor shares her or his experience and provides guidance in helping the new member develop an effective program of sobriety and work the steps. This mentor role is important to both parties. The sponsor has an experience of generativity while the new member has a role model to follow. Having a sponsor has also been significantly (p<.05) associated with a reduced risk of relapse.11
The fellowship of AA and relationships that form within it provide the background or context within which a program of recovery is worked. The 12 steps provide the core of this program. The 12 steps and 12 traditions of AA are included in this article. $ The modifications made by NA and CA have only to do with the nature of the addicting drugs. Each step presents a specific problem and each one can be assisted by the psychiatrist. In return, as the step is worked, it can facilitate psychiatric treatment.
Step one requires giving up denial. Resistance can be reduced by connecting adverse consequences in the person's life with use of alcohol. Working this step means becoming more comfortable with a new identity and being able to say, "My name is . . . , and I am an alcoholic." This step usually marks the beginning of sobriety. Its power is reflected in the saying, "For many years I was not an alcoholic, but 1 was drunk all the time. When 1 became an alcoholic, I stopped drinking, and haven't had a drink since."
Step two requires a belief that something greater than and different from self can be of help. The way in which this belief takes shape is left up to the individual. It basically requires an acknowledgement that "I cannot deal with this problem myself and need help from whatever it is that keeps me alive." As Khantzian and Mack put it, "the power and awe engendered by the outside universe and our humble place in it instill a sense of a force or power greater than ourselves."9 This common human experience can help reduce the resistance stemming from an unrealistic self-image that requires the person to solve every problem alone.
Step three is difficult in that it requires a conscious surrender of one's will and life to this Power. The biggest barrier is the primitive fantasy that God is humanly parental and punitive. In fact, this step is a decision to live without alcohol and to let go of the struggle, worry, and resentment that this decision entails. From a secular point of view, step three is similar to the meditational skill involved in opening and clearing one's mind, confident that the life force within us will maintain or enhance health without our conscious effort. For the many who have trouble with this process, the advice to trust their home group for guidance will be of help until they begin to experience some healthy inner control.
Step four is also difficult, but for very different reasons. Psychiatrists are familiar with resistance to searching and fearless associations in psychotherapy. Working this step usually triggers guilt, shame, grief, and other powerful negative emotions. It is unwise for anyone to do this step without a sponsor. Psychiatric support, without medication, caii also be useful. The benefits of self-knowledge and selfawareness that come from working this step can be extremely valuable and well worth the pain and effort. A useful conceptualization of this step is to view it as preparation for psychotherapy. In my experience, recovering alcoholics who have worked step four are more comfortable with and responsive to psychotherapy than those who have no experience with it. Working step four helps in the development of an observing ego.
Step five can also be viewed as a preparation for psychotherapy. It arouses social anxiety with anticipation of negative reactions from the person who hears the inventory. In many cases the anticipatory anxiety comes from the internal experience of superego discomfort. Sharing with another human being usually is a relief. Individuals willing to hear a fifth step never react in ? rejecting or punitive way. This may be a therapeutic experience, but it is not psychotherapy. Psychiatrists can readily encourage this step because it helps our patients learn to develop and enhance their social support system, which in tu rn can su stain the patien t in doing psychotherapeutic work.
Step six is derived from step four. Behaviors directly associated with the use of alcohol are usually stopped with abstinence. Other adverse behaviors related to the person's character remain. The readiness for change developed in step six is also useful preparation for psychotherapy- U is my impression that AA members describe experience with this step less often than they describe step four. There are two reasons for this. First, character problems are slow to change. Reviewing them often can be both discouraging and boring. Second, character problems are more egosyntonic than relationally syntonic. Self-awareness, without feedback from one's social support system, is much more difficult than selfawareness of ego dystonic behavior. Psychodynamic psychotherapy and psychoanalysis, both individual and group, interact in a positive way with steps six and seven.
Step seven is a fascinating but poorly understood step. It takes place internally and can only be inferred by external observation. The humility required for this step reawakens the experience of step one. The difference is that alcohol use may be easier to stop than are adverse characterologic behaviors. The successes experienced in working steps one and three prepare the alcoholic for the personal growth and development that can result from working steps six and seven. It should be noted that AA meetings put absolutely no pressure on the individual member to work these steps. Support is available but pressure usually comes only through individual relationships with sponsor, family, and close friends. The process of working through in psychotherapy complements the work in these steps. When change does occur in selfish, blaming, or other antisocial characterologic behaviors, it serves as a great source of hope for others. Our knowledge of the difficulty involved in effecting character change makes it easier to understand why many alcoholics remain for years actively working a program of recovery in AA.
Step eight develops from step four and puts the alcoholic in a state of preparation for relational repair. The wisdom of this preparation has been confirmed by research in behavioral change.12 Becoming willing ro make amends moves a person past resentment and blaming to a point of being mentally prepared to act. This step may also help the individual develop a capacity for empathy. From a psychological point of view, this awareness will reduce the likelihood of behavior that hurts others. Step eight is basic to developing relational skill that can assist and expedite the gains made in individual psychotherapy.
Step nine puts relational skill into practice. It is usually accompanied by anxiety, which can stem from all the punitive, rejecting fantasies of possible responses when amends are made. Support from sponsor, friends, and psychiatrist can help the recovering person make this important step. Damaged relationships can often be repaired by amends made in a safe, sensitive, and assertive way. It is hard to continue hating someone who acknowledges wrongdoing and offers to try to repair the damage. Skill in maintaining long-term relationships is, in part, based on the ability to recognize how we hurt others combined with efforts to apologize or make amends. From a psychotherapeutic point of view, the recovering person can be helped to learn the importance of' forgiving oneself, even though working this step does not result in being forgiven by the other person.
Step 10 specifies a continuing working of step four on a daily basis. As a recovery maintenance step, it is widely understood in the fellowship of AA to include a daily working of steps four through nine. This work acts as a continuing stimulus to both personal and relational growth and also development, including character change. Regularly working step H) resembles the ongoing application of the skills we and our patients learned in psychotherapy or psychoanalysis. Many AA and NA members view this step as critical for maintaining sobriety and keeping character defects in check. All of us in medicine and psychiatry would benefit from the second part of step TO by promptly admitting when we were wrong, especially to ou rselves.
Step 11 can be considered as a spiritual health step. It can also be viewed as a daily reworking of steps one through three, with echoes of steps five and seven, which attempt to use spiritual means to achieve intrapsychic change. The internal search for knowledge and power can result in a sense of purpose and meaning in one's life. This is often expressed in service to others and a growing development of altruism within the recovering alcoholic.
This spiritual part of the 12-step programs is the most controversial and the most misunderstood. The controversy for scientifically trained physicians has to do with whether there is such a thing as "spiritual." Since it cannot be measured, what possible association could it have with mental or physical health? Khantzian and Mack postulate that "the idea of God, or a power greater than oneself, may be a step in the direction of taming and transforming infantile omnipotence and serving in early childhood to establish a capacity for object love."8 Very little research has been done in this area. However, so many people in stable, healthy sobriety attribute their recovery to spiritual activity and experience that we must consider the possibility that spiritual factors can play a role in healing and find ways to research that relationship.
The common misunderstanding involving step 1 ? is to confuse spiritual with religion. This confusion is typified by the depressed alcoholic nurse who angrily accused me of stuffing religion down her throat when I insisted that she give AA a fair trial. With education, she accepted the need to participate. Psychotherapy continued for one year following inpatient treatment. She has nowr completed five years of stable sobriety, works an active AA program, and states that she is functioning better than at any time in her life.
The education we psychiatrists can provide our patients and other physicians is that, although AA is a spiritual program, it is not in any way a religion. There is no membership requirement other than a desire to stop drinking. Anyone, including the atheist, is welcome. There is no creed, dogma, or theology to be learned or accepted. AA is compatible with every known religion or with no religion at all.
Many recovering alcoholics and addicts believe that they would not be alive today if AA were a religious program. The genius of the 12-stcp programs is that the recovering person's experience with an internal healing process is left entirely up to him or her. No other person, group, or authority attempts to define or describe what that experience will be. Atheist or agnostic psychiatrists can help their recovering patients by supporting the acknowledgment of something inaccessible to our five senses and different from the person, which may help the healing process. At the least, we should be comfortable with the fact that there is still much about life and the universe that is a mystery.
There is no evidence that working steps three and ? is harmful. Ellis and Schoenfeld's contention that these steps create a passive dependency that weakens the person is not supported by evidence.1' Their objections appear to be based either on a primitive anthropomorphic conception of God parentally taking over people's lives, or on the known harm people have done to each other in the name of religion. In the 55-year history of AA, with millions of people, there is not one documented fight, disagreement, or rejection based on differing understanding of what is God or a Higher Power. There is almost unlimited tolerance for different beliefs and experiences, even though the individual is expected to conform to the rules of the meeting and not be disruptive.
This personal experience of tolerance, acceptance, and love has been lifesaving to many alcoholics and addicts. Far from making them passive, the recurring experience of recovering people is that their Higher Power will do nothing for them that they can do for themselves. The serenity prayer describes this experience: "Grant me the serenity to accept the tilings I cannot change; the courage to change the things 1 can; and the wisdom to know the difference." Research is needed in (his fascinating and mysterious area.
Step 12 is the service step. Working this step expresses both gratitude and need. The need reflects the discovery by Bill W that he needed to talk to another alcoholic in order to maintain his sobriety. Altruistic effort is thus linked to enlightened self-interest. The "message" of the 12th step is not a sermon. It is a personal sharing of the recovering person's experience with alcoholism, the strength they have found in working a program, and the hope that the currently suffering alcoholic can find similar healing and relief from their disease. The sharing is personal. There is no pressure in this program of attraction that is worked one day at a time. Step 12 can also be considered a maintenance step in the practicing of 12-step principles in all aspects of the recovering person's life.
Working a program of recovery in AA or other 12-step programs is usually accompanied by periods of emotional distress. Psychiatrists will get tiie best results when they look upon these symptoms from a developmental rather than from a pathological point of view. AA members view these symptoms as a motivation for change. They are likely to resent and resist efforts to medicate them. When they selfmedicated their anxiety, depression, anger, insomnia, and other symptoms with alcohol or other drugs, they got worse. Many recovering alcoholics and addicts now believe that it is vital for them to experience and work through these negative feelings in order to change for the better. It is ironic that this attitude, which is so consistent with psychotherapeute and psychoanalytic goals, should be a major source of conflict between AA members and psychiatrists. When we prescribe too quickly, especially with controlled medications, we risk losing the respect of our recovering piitients.
A basic understanding of the 12 traditions can help psychiatrists cooperate with the 12-step programs for the benefit of our patients. The traditions are designed to ensure the survival of AA and the other programs. Physicians are trained to expect and accept change as research opens new doors. On initial ceni tact with AA we will have many suggestions for change and improvement in the program. We will discover that, through the traditions, AA is almost totally resistant, in a friendly way, to external suggestion or pressure. The best short summary of the traditions is found in the second paragraph of the description of AA printed in every issue of the AA Grapevine, sometimes known as the preamble:
The only requirement tor membership is a desire to stop drinking. There are no dues or fees for AA membership; we are self-supporting through our own contributions. AA is not allied with any sect, denomination, politics, organization, or institution, does not wish to engage in any controversy; neither endorses or opposes any causes. Our primary purpose is to stay sober and help other alcoholics Io achieve sobriety.
The psychiatrist who understands and respects the traditions will be much better able to provide effective, recovery-supportive treatment for alcoholic or other addicted patients. When in doubt, remember that two training analysts, after years of experience with patients in AA, concluded that AA is a sophisticated, imaginative, and effective psychosocial form of treatment.''
The 12th tradition of anonymity is considered by many AA members to be the cornerstone of recovery. However, it can be confusing to health care professionals. It is one of the reasons that the psychiatrist will encounter different people when 12-step visits or temporary contacts are requested for patients. In the basic work of carrying the message, the identity of the messenger is considered unimportant. This identity may even be dangerous to the continued sobriety of the messenger if it brings him or her special attention. For this reason, AA members making 12-step visits to patients may be reluctant to identify themselves to the psychiatrist. Anonymity is viewed as a spiritual issue in deemphasizing the identity of the recovering person and focusing on principles before personalities. We need to trust the program and accept the inevitable variations that will occur among those sent when we request help for our patients.]
THE GOAL OF RECOVERY
As illustrated by the above description, recovery troni alcoholism or other addictions involves much more than simple abstinence. Detoxification is relatively simple. The alcoholic or addicted brain is then left in an irritable state, sometimes called a "dry drunk" or "white knuckle sobriety." This condition is characteri/.ed by:
* Intermittent craving, which may be intense and accompanied by drug-seeking behavior;
* Irritability that interferes with attention, concentration, memory, and relationships;
* Defensive behavior similar to that which was present when the person was actively drinking or using;
* Multiple complaints often including insomnia, anxiety, and depression.
This condition can be understood as an irritable brain reaction to a change in the alcoholic or addictive neuroadaptation that had been established during the preceding period of use. Very little is understood about this neuroadaptation or the most effective ways to return the brain to normal functioning. Clinical experience suggests that medication, apart from detoxification, is rarely helpful in this process of normalization, unless some independent treatable psychiatric disorder is interfering with the process.
Two diiiracteristics of recovery from alcoholism and other addictions are14: (1) The ability to manage the stress of living without the support of dependence-producing drugs. This ability is unusual in a society where the use of alcohol and prescription medications for stress management is widely accepted. (2) The ability to be around dependence-producing drugs without experiencing craving or engaging in drug-seeking behavior. Alcohol is the main problem due to its ubiquity, bui prescription drugs, marijuana, and cocaine are frequently encountered. Even with inpatient treatment, followed by intensive 12-step work, these characteristics take time, often months or years, to achieve.
Another aspect of recovery appears to result from the 12-step program work described above. This is a shift from the immature ego-defense mechanisms characterizing alcoholism and addiction: denial, projection, minimizing, grandiosity, acting out. As recovery progresses there is a slow shift to the mature ego-defense mechanisms15: altruism, humor, suppression, anticipation, sublimation. To the extent to which this change in ego-defense patterns occurs, recovery can also be thought of as a normative process of growth and development.
Psychodynamic psychothera peutic goals are similar, once again illustrating the compatibility of 12stcp work with psychiatric treatment. The exception to this compatibility is the prescription of dopend en ce- producing (controlled) medication. In my experience, these medications affect the brain in ways that interfere with tile learning process required in recovery- When controlled medications, especially benzodiazepines, sedative- hypnotics, or opiates, are necessary, they should be prescribed in a recovery-supportive way13: (1) Educate the patient about the risk. (2) Intensify the patient's recovery program. The patient must inform his recovery support system or network. Allow visits from AA/NA members at anv time. Allow AA/NA meetings to be held in the patient's room. (3) Hxpect drug-seeking, craving, and manipulation for additional prescriptions. Do not express anger, disappointment, or other negative emotions at this expected addictive response. (4) Withdraw dependence-producing medication quickly, before discharge from hospital, if possible.
As I have observed individuals who continue to work a program of recovery in Alcoholics Anonymous over long periods of time, I have been impressed by the following characteristics:
* An honest openness and willingness to learn.
* Personal humility with a tolerant acceptance of others who are struggling with alcoholism or other problems of living.
* Compassionate, altruistic caring. They are willing to help others with no compensation.
* Gratitude for the experiences they have had, for their relationships, and for their program. From an Ericksonian developmental point of view, these recovering individuals demonstrate generativity and wisdom. They are the kind of people most of us would like to be.
While the characteristics of this final stage of recovery, sometimes called serene sobriety, are not achieved by treatment and do not appear as outcome criteria in follow-up studies, they provide an incentive for encouraging our patients to continue working their 12-step programs, even when psychotherapy and other psychiatric treatment is finished.
Reading an article such as this or even the Big Book of Alcoholics Anonymous is not enough to develop the skills necessary to support recovering patients who are in psychiatric treatment. Some direct experience is necessary. This can be thought of as a mini -residency in AA or 12-step recovery.14
* Call the local AA number and ask to speak to the chair of the Cooperation with the Professional Community (CPC) committee. The CPC committee is charged with the task of working with professionals and helping them become more knowledgeable about AA.
* When you speak to someone on the CPC committee, identify yourself as a psychiatrist who is interested in learning about AA. Ask tor a recovery guide or temporary contact who will help you learn about the program. Request someone who has completed the 12 steps, is sponsoring other AA members, and is working an active program of recovery.
* Meet regularly with your recovery guide. The first two meetings should include an AA meeting recommended by your recovery guide and hearing his or her story.
* Go over the schedule of local meetings with your recovery guide. Pick those that meet your interests or needs. These may include Al-Anon and Alateen.
* Plan to attend one meeting a week ior three months/ or one meeting a month for a year. Meet regularly with your recovery guide to discuss your experiences at meetings. Your recovery guide can also help you meet recovering people with experience in areas of interest to you, e.g., dual diagnosis, prison, cocaine or heroin addiction, etc.
* If you encounter limitations in your relationship with your recovery guide, do not hesitate to seek out another one.
A secondary gain to this learning experience is the possibility of personal benefit. Since 1975 I have been working with CPC committees to educate medical students and residents. While this was a positive experience, it paled in comparison with being elected as a nonalcoholic trustee to the General Service Board of AA in 1989. Much of this article has been made possible by that ongoing experience. I have learned much more about the power of sharing personal thoughts, feelings, and experience. This has been of particular value in relating to my family and friends. While the experience has not been as intensely valuable as my personal analysis, it has added greatly to my skill in providing psychiatric treatment for people in recovery.
RECOVERY STATUS EXAMINATION
When working with alcoholic or addicted patients, it is useful to assess the level or status of their recovery, in much the same way that we do a mental status exam. The following areas should be covered.
Status of sobriety. What is current usage of intoxicants? This includes alcohol, controlled medications, marijuana, stimulants, opiates, and other recreational drugs. Any current usage requires an educational response about addiction and the interference of these drugs with psychiatric or other medical treatment. The immediate focus should be on attaining abstinence for the purpose of maximal benefit from psychiatric treatment.
Nothing in my medical education, psychiatric training, and personal psychoanalysis prepared me for an understanding of the importance of abstinence in recovering alcoholics and addicts. The effects of addicting drugs on the recovering brain are illustrated by the experience of a recovering anesthesiologist, working in the field of addiction medicine, who had major surgery- hi the immediate postoperative period, he found himself wondering how to get additional prescriptions from his surgeon and how to conceal the medications from his wife and home group. The Big Book of Alcoholics Anonymous describes addiction accurately as "cunning, baffling, and powerful." The benefit of abstinence to psychiatric treatment is an increased ability to learn, grow, and develop in response to discomfort and the stimulus of psychotherapy. The stimulus and support provided by an active 12-step program of recovery complements our treatment.
Once abstinence is obtained, the following questions will both assess the level of recovery and educate the patient about the kind of work needed.
What is your program of recovery? This general question can elicit a wide range of responses. Two areas of concern are the absence of step work and/or a recovery support system. If the latter is not clear, it may help to ask, "Who else knows about and supports your sobriety?"
What meetings do you go to each week? This provides both a quantitative and qualitative indication of the degree of involvement with the recovering fellowship. Absent or limited involvement raises concern about continued sobriety and growth.
What are you doing with your home group? Responses to this question will indicate the degree of involvement in the recovery support system of the fellowship and also your patient's willingness to take on responsibilities in service to others.
How do you use your phone list? Willingness to provide and recognize the need for help is an important part of working a recovery program. It helps to educate reluctant patients about the fact that they are helping the recovering alcoholic whom they call for help with problems threatening sobriety.
Where are you in your step work? Consistent, disciplined step work is probably the key to continuing growth and development in recovery. Without it a person may stay sober, but make little progress toward the healthy, mature outcomes noted above.
What are you working on wilh your sponsor and those you sponsor? The combination of learning from a sponsor/mentor, and being a sponsor /men tor to others is another indicator of generarivity and willingness to grow and develop. Research suggests that it is also a good prognostic indicator for continuing sobriety."
Alcohol and other drug addictions pose a major problem for psychiatrists. In meeting this challenge, for which most of us have little preparation, it is insufficient to treat the symptoms and/or complications. We need to treat the primary disease and set a goal of long-term recovery, if not, we run the risk noted by Vaillant in his prospective study: "Once recovered, several of the college sample saw their psychotherapy as having retarded recognition of their alcoholism."1 In this task, AA, NA, and the other 12-step programs provide po werf LiI psychosocial therapies that can enhance psychiatric treatment.
When the psychiatrist motivates and supports a patient to actively work a 12-step program, a complementary stimulus to growth and development will be added to the psychotherapeutic effect of treatment. We can help by prescribing carefully to avoid dependenceproducing medications that may interfere with recovery. Skill in cooperating with the 12-step programs is best obtained by direct experience in open meetings and personal learning with experienced recovering people who are working an active program of recovery. As an added bonus to increased professional effectiveness, we may also experience some direct personal benefits.
1. Thompsen R. Bill W. New York, NY: Harper & Row; 1975:214.
2. Pitlman B. AA. '!'he Win/ it Beyin. Seattle, Wash: Glen Abbey Books; 1988.
3. Vaillant Gl:, '!'lie Nnturnl History of Alcohulifin. Cambridge, Mass: Harvard University Press; 1983.
4. Walsh HC, Hingson KW, Merrigan DM, et al. A randomized (rial of treatment options l'or alcohol abusing workers. N Engl Mat. IWI; 325(1 l):77S-782.
5. Bean MH. Alcoholics Anonymous; AA. Psychiatric Annals. 1475; 5:83-91.
6. William W. The society of Alcoholics Anonymous. Am J Psychiatry. 1949; 106(5):370-375.
7. Bander KW, Goldman DS, Schwartz MA, Robinowitz E, English JT. Survey of attitudes among three specialties in a teaching hospital toward alcoholics. Journal of Medical Education. [987; 62(1):17-24.
8. Brickman B. Psychoanalysis and substance abuse: toward a mori.1 effective approach. J Am Acad Psycltoanal. I988; 16(3):359-379.
9. Khantxian FJ, Mack JR. Alcoholics Anonymous and contemporary psychodynamic theory. Rtrriif Dcvelofnuctits in Alcoholism. 1989; 7:67-89.
10. Sisson RW, Mallams JU. The use of systematic encouragement and community access procedures to increase attendance at Alcoholics Anonymous and AlAnon meetings. Am J Drug Alcohol Abuse. 1981;8(3):371-376.
11. Sheeren M. The relationship between relapse and involvement in Alcoholics Anonymous. J Stud Alcohol. 1988; 49: 104106.
12. DiClemcnte CL, Prochaska JO, Fairhurst SK, et al. The process of smoking cessation: an analysis of preconlemplation, contemplation, and preparation stages on change. J Consult Ciin Psyciiol. 1991; 59(21:295-304.
13. Ellis A, Schoen f e Id H. Divine intervention and the treatment of chemical dependency. J Subst Abuse Treat 1990; 2:459468.
14. Chappel JN. The use of Alcoholics Anonymous and Narcotics Anonymous by the physician in treating drug and alcohol addiction. In: Miller N, ed. Comprehensive Handbook of Drug and Alcohol Addiction. New York, NY: Marcel Dekker Ine; 1991:1079-1088.
15. Vaillant GE. Adaptation to Life. Boston, MA: Little Brown & Co; 1977:383.