Monthly Archives: May, 2015

In Defense of the 12 Steps: A Psychologist’s Perspective

A controversial article by Gabriel Glasner came out last month in the Atlantic titled “The Irrationality of Alcoholics Anonymous” [1] As a Psychologist who has witnessed the power of 12-step Programs transform lives, I wanted to share my perspective.

AA is not evidence-based treatment. It is a peer-led support system.

In her article, Glasner states, “Nowhere in the field of medicine is treatment less grounded in modern science.”

12 step meetings are a community-based support group. AA is not a treatment program, nor is it evidenced-Support_Groupbased research. AA or any other 12-step program is not therapy or medicine. It is a group of people assisting each other to stay sober or free from other addictive behaviors and learn new tools to manage their emotions. There is no double blind research going on during meetings. There are no medical professionals such as Psychiatrists, Social workers, or Medical Doctors facilitating the meetings and collaborating on the care of patients attending meetings. AA is a peer-led support group. As one member of AA said to me ironically “it’s not named “Well-Persons’ Anonymous.” By its very definition, AA is made up of sick people becoming well helping other sick people become well. The Preamble to AA and Tradition 3 of the twelve steps and twelve traditions both state:

“The only requirement for A.A. membership is a desire to stop drinking… A.A. is really saying to every serious drinker, ‘you are an A.A. member if you say so. You can declare yourself in; nobody can keep you out.’” [2]

The history of AA is a fascinating story of two alcoholics, Bill and Bob, discovering experientially that the only thing effective in keeping them sober was supporting and being of service to another alcoholic struggling to be and stay sober.

AA and other 12-step programs complement treatment

This peer support can lend itself to complementing treatment such as individual cognitive behavioral therapy, family systems therapy, psycho-education, and/or medication. Many addictions/addictive behaviors (including but not limited to alcohol use, disordered eating, compulsive spending, sexual addiction) are medicating underlying mood disorders such as anxiety or depression. In terms of evidence-based treatment, cognitive behavioral therapy (CBT) has been found to be the most effective treatment for recovering from mood disorders such as anxiety or depression. CBT in combination with pharmacotherapy is often found to be the best treatment. [3]

Common to addictive behaviors, as well as the underlying anxiety and depression, are “cognitive distortions” and “automatic negative thoughts.” Cognitive behavioral therapy uses a collaborative approach to challenging these thoughts by asking the client to look for evidence in their life to see if they actually true. Some cognitive distortion categories and examples are:

Overgeneralization:

“It’s really bad right now and so it always has been bad and will always be bad”cog distort

Personalizing:

“If there’s something wrong here, it must be my fault”

Jumping to conclusions and Mind Reading:

“I know she hates me because she just frowned. She is thinking I’m a bad Mom,”

Shoulds:

“I really shouldn’t be feeling this way. I should pull myself up by my bootstraps and be happy already”

Emotional Reasoning.                                                                                                  

“I feel stupid, boring, and ugly, therefore it must be true.” [4]

   Cognitive distortions are not limited to those suffering with addictive behavior or drinking problems. We all have cognitive distortions. However, these distortions become magnified and appear to be the truth in the mind of someone suffering with anxiety or depression, often triggering them to drink. Alcohol, however, is a depressant, and therefore often leads them further into the very cognitive distortions from which they are trying to escape. In AA, group members will often state things like “My best thinking got me here,” or “I am working on my stinkin thinkin.” In therapy, an environment of collaborative empiricism (“Is it really true that she is thinking you’re a bad mom? Is there any evidence to support that thought?”) can help decrease the negative power that cognitive distortions hold over someone. Often these cognitive distortions grow and get reinforced from family systems with parents with alcoholism or mood disorders. (Children don’t have the executive functioning developed yet to reason things out without personalizing and so “it must be my fault” as a child’s interpretation grows into an adult thinking “it must be my fault” when someone else gets angry or depressed or their boss blames them for doing an imperfect job.)

12 Step Programs help break isolation and provide frequent and accessible support.

For someone suffering from anxiety or depression, isolation can be one of the worst triggers to worsen the symptoms. And, as many clients can attest to, the symptoms for anxiety and depression are often at the peak during hours most therapists are unavailable for support. AA and other 12 step programs are available 24/7. If you look up AA meetings in your area, you will most likely find them meeting on the hour, every hour, often more than one! I looked up AA meetings for Sunday in San Francisco: there are 71 meetings available to attend (not including the bilingual ones). Smart Recovery (which I also am in favor of as a compliment to treatment) offers 3 meetings per week in San Francisco. In 12-step fellowship, people often share their phone numbers and provide sponsorship mentoring, which is guidance from someone further along in the recovery journey. This fellowship is available during weekends, evenings and other “triggering” times during which someone struggling with the desire to drink cannot call or will not reach their therapist for support.

Brain chemistry, Neuroscience and Medication

alcohol brain     Neuroscientists and researchers are discovering more and more about how alcohol affects the brain. Functional Magnetic Resonance Imaging (fMRI) is allowing researchers to “see” blood flow to particular regions of the brain and identify which ones are active. This is allowing them to track not only how alcohol affects brain function but also how it changes as alcohol dependence develops.[5] There are many medications used to treat alcohol withdrawal, to prevent consumption, or to reduce cravings, Naltrexone being the one that Glasner focuses on in her article. There are also many medications used to treat the anxiety and/or depression that cause many people to “self-medicate” with drinking. As a Psychologist, my opinion on medications is that they are useful as a tool, just as therapy is useful as a tool; just as support groups are useful as a tool. They all help in the healing process. However, using one alone can risk being not enough and miss an important aspect of the healing process. I would never recommend to a client to take naltrexone (For the record I am a Psychologist so it is not in my scope to prescribe medication) alone for recovering from alcohol use disorder. It would be like offering a pill to my sick child and then sending them off to the playground. The pill, should it be the right kind of medication for the sickness, would certainly help, but the pill alone without the essential rest and human kindness would be missing the mark on healing an entire person. Alcoholics and addicts are particular susceptible to the cognitive distortion that “if you take a pill, you will feel emotionally better and it will all go away.” Even in the information pamphlet for naltrexone, it states:

     Naltrexone is only one component of a program of treatment for alcoholism including counseling; help with associated psychological and social problems and participation in self-help groups. In both studies where naltrexone was shown to be effective, it was combined with treatment from professional psychotherapists.

     There is no contradiction between participation in AA and taking naltrexone. Naltrexone is not addictive and does not produce any “high” or pleasant effects. It can contribute to achievement of an abstinence goal by reducing the craving or compulsion to drink, particularly during early phases of recovery. It is most likely to be effective when the patient’s goal is to stop drinking altogether. [6]

In other words, naltrexone can be helpful for treatment and is not contraindicated with peer-led support, such as AA.

What are Alcoholism, Problem Drinking, and Alcohol Use Disorder?

Glasner seems intent on distinguishing between “alcoholism” and “problem drinking” in order to determine for whom abstinence would benefit and who can realistically continue drinking in moderation. The thought being that some people (“problem drinkers” but not “alcoholics”) can learn to drink in moderation without it interfering in alcohol-cocktails--beer-martini-curacao-soda-cosmopolitan-cola-cocktail-wine--champagnetheir life (or needing to attend Alcoholics Anonymous). Alcoholism and problem drinking are layperson terms distinguishing between severities of alcohol use.

However, I have administered the Michigan Alcohol Screening Test (MAST) to a client who scored a 3 and absolutely identifies herself as an alcoholic. The MAST is a 22 question screening tool that clinicians often use to determine the severity of someone’s drinking problem. A total score of six or more indicates “hazardous drinking” or  “alcohol dependence.” The woman who scored a 3 is a high-functioning working mom who has been sober and attended AA meetings for the past eight years (some details changed to protect confidentiality) in order to “be a better mom and stay connected in my marriage without drinking to stuff and avoid anxiety.” I have also administered this test to a client who scored a 7 and still looked me straight in the eye and stated, “I don’t have a problem with my drinking.” This was someone who had missed work weekly due to hangovers, blacked out frequently, and lost relationships due to her drinking. (She later discovered that she does in fact have a problem with alcohol and is not drinking. She does not attend AA, but attends therapy, women’s groups, and has started painting instead of drinking. Again, details changed to protect confidentiality.)

Clinically, the Diagnostic and Statistical Manuel (DSM-IV) used to distinguish between alcohol abuse and alcohol dependence, the latter being more severe. It required that a person have three symptoms during a 12-month period from a list including such criteria as:

  • Need for markedly increased amounts of alcohol to achieve intoxication or desired effect; or markedly diminished effect with continued use of the same amount of alcohol
  • The characteristic withdrawal syndrome for alcohol; or drinking (or using a closely related substance) to relieve or avoid withdrawal symptoms
  • Drinking in larger amounts or over a longer period than intended.
  • Persistent desire or one or more unsuccessful efforts to cut down or control drinking
  • Important social, occupational, or recreational activities given up or reduced because of drinking
  • A great deal of time spent in activities necessary to obtain, to use, or to recover from the effects of drinking
  • Continued drinking despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to be caused or exacerbated by drinking. [7]

In the most recent manual, DSM–V, anyone meeting any two of the 11 criteria during the same 12-month period would receive a diagnosis of Alcohol Use Disorder (AUD). The severity of an AUD—mild, moderate, or severe—is based on the number of criteria met. DSM–5 eliminates legal problems as a criterion, and adds craving as a criterion for an AUD diagnosis. [8]

Research is not what heals. Relationships heal.

When Glasner states that AA is not supported by research (the subtext implying that therefore it is therefore not effective in healing from alcohol use disorder), I’m not that impressed. Research absolutely has its place. Research is necessary. I needed to do research to earn my doctorate in psychology. Research keeps the fields of psychology and medicine growing, as well as help track what is and is not working in all kinds of treatment. Research has even discovered the following in terms of what is most helpful in the therapeutic process and healing:

  • The therapy relationship makes substantial and consistent contributions to patient success in all types of psychotherapy studied (for example, psychodynamic, humanistic, cognitive, behavioral, systemic).
  • The therapy relationship accounts for why clients improve (or fail to improve) as much as the particular treatment method.
  • Efforts to promulgate best practices or evidence-based practices (EBPs) without including the relationship are incomplete and potentially misleading. [9]

In other words, it does not matter what modality the therapist is trained in if their bedside manner is crap. In clinical practice, I have discovered my clients generally want to know three things:

1) Do I care? Do I truly care about them and their process?

2) Do I know what I am talking about when I offer feedback and suggestions?

3) As they trust me, can they learn to trust themselves in this healing process?

Never have I had a client say to me: “But what did your doctoral research findings state?”

12 Step Meetings are Low cost and therefore available to everyone, regardless of whether they have insurance or the ability to pay for treatment or therapy.

I won’t be popular stating this as a therapist, but let’s be honest: therapy is expensive. 12 step meetings are not. The preamble of any 12-step meeting includes: “There are no dues or fees for membership. We are self-supporting through our own contributions.”[10] What this looks like in practice is that if it is your first 12-step meeting, you are invited to attend for free. If you are an ongoing member, you are invited to make a small donation to cover the cost of renting the meeting room and contributing to the 12-step world service organization, which is largely run by volunteers. The current standard donation amount is about $2 per meeting. Group therapy costs in the bay area are currently $60 per group session. A 24-hour stay at a private treatment facility is $1,000- $1,500 per day.

12 Step Programs help teach humility and service to narcissists in ways that other treatment modalities fail 

Because AA was developed by two male alcoholics and strongly influenced by the Oxford group teachings (more on this later), there is a strong focus on ego deflation, service to others, and dependence on God (a Power Greater than ones’ self). Back in my pre-doc experience working as a substance abuse counselor, I found that one of the few psychological interventions that worked with narcissists (who are notoriously impervious to interventions reflecting on the need or desire to change themselves) was another narcissist effectively challenging them. If the “challenger” was intent on sobriety and recovery, than this would often land in an open-ness toward his peer’s desire for recovery. They could hear it from each other. They weren’t very interested in hearing it from the doctor or the facilitator, unless the doctor or facilitator “had what they wanted.” This would often need to be a strong male figure that had recovered himself and was radiating a sense of power and confidence. As a newbie woman therapist, I didn’t have much of what they wanted other than perhaps a date, with which I was a) not interested and b) had professional boundaries.

Where therapy failed with the great Dr. Carl Jung and the spirituality of the twelve steps worked

One of the first members of Alcoholics Anonymous was a gentleman named Rowland. Rowland spent a year under the care of Dr. Carl Jung due to his despair over the inability to control his drinking. After this year, thinking he had been cured, he left and promptly became intoxicated:

Sometime in 1931…a young, talented, and wealthy financial wizard, had found himself on the verge of despair over his inability to control his drinking. Having attempted virtually every other “cure,” he turned to one of the greatest medical and psychiatric talents of the time, traveling to Zurich, Switzerland, to … Dr. Carl Gustav Jung. For close to a year, Rowland H. worked with Jung, finally leaving treatment with boundless admiration for the physician and almost as much confidence in his new self.

To his consternation, Rowland soon relapsed into intoxication. Certain that Jung was his last resort, he returned to Zurich and the psychiatrist’s care. There followed, in Bill Wilson’s words written to Dr. Jung in 1961, “the conversation between you [and Rowland] that was to become the first link in the chain of events that led to the founding of Alcoholics Anonymous.” That conversation, in Wilson and Jung’s later memory, had made two points. “First of all, you frankly told him of his hopelessness, so far as any further medical or psychiatric treatment might be concerned.” Second, in response to Rowland’s frantic query whether there might be any other hope, Jung had spoken of “a spiritual or religious experience — in short, a genuine conversion.”[11]

lightofintuition, LS McCabe, All Rights ReservedJung is famously quoted as saying to Bill W:

“You see, ‘alcohol’ in Latin is ‘spiritus’ and you use the same word for the highest religious experience as well as for the most depraving poison. The helpful formula therefore is: spiritus contra spiritum.”

This metaphorical understanding of what Rowland was truly seeking in turning to alcohol deeply influenced the spiritual underpinnings of AA. He wasn’t looking for alcohol- he was looking to have a spiritual experience. In the twelve steps, there are two kinds of spiritual experiences: the “lightning bolt” kind (the Aha’s! that are inspirational, sudden, and life changing) and the “educational variety,” that develop slowly over time.[12]

I often work with clients with both of these kinds of experiences. The challenging part is often that many want the “Aha!” but not the “slow educational variety.” Let’s be honest, it is much more enticing to have a sudden experience of seeing God or of completely understanding in a flash why there is suffering in the world. It is not as pleasant to learn, slowly over time, such things as how parking meters apply to you, and needing to still wash the dishes. As the author and meditation master Jack Kornfield so aptly put it “after the ecstasy, the laundry.” [13] Healing and growth occur slowly, over time, with both sustained effort and surrender. Attending 12 step meetings regularly, doing a spiritual practice such as prayer or meditation, and having a support system of trusted peers giving you feedback on your blind spots can help create and sustain this healing and growth. As they say in 12-step “you can’t kiss your own ear.” Having people you trust, both peers and a therapist, give you feedback on where to turn toward/lean in and where to turn away/detach can be invaluable to growth.

What about women?

It is often suggested that women recovering from alcoholism attend women-only AA meetings. Sexism can still exist in ways such as having men called on to speak more frequently and “the old boys network” of calling on your friends to speak in AA meetings often keeps women feeling even more shame and silence. In addition, many women have the unwelcome experience being “hit on” for dates in a place where they are seeking emotional safety during a vulnerable time of healing.

In women-only meetings, there can be an atmosphere of camaraderie, compassion, and encouragement that can be harder to find in co-ed meetings. The language of 12 step and its “bible” (The “Big Book of Alcoholics Anonymous”) is masculine and this can be a barrier for many women, especially those who are recovering from trauma in their past, whether it be religious, sexual, physical, or emotional. Recovering a sense of internal and/or feminine (instead of external and/or masculine) can be an important piece of the recovery process for some women. Stephanie Covington’s work[14] discusses many of these issues. As shame is such a silent epidemic among women, particularly those struggling with any form of addiction or disordered eating, finding safe spaces to break the isolation of this toxicity is essential to unveil and transform it. For many women using alcohol or process addictions such as codependency or disordered eating, the “ego deflation” process developed through the early AA members is not helpful because they have a weak, underdeveloped ego. This weak sense of self needs bolstering, not deflation.

Limitations of 12 step Programs

Spirituality and Moderation:

As mentioned earlier, AA historically grew out of the Oxford group, which was a religious group focused on IMG_1002dependence on God, service to others, spiritual experience, continuous change for growth, and fellowship. These are tenets that continue to be strongly held in 12 step philosophy and practice and do not work for everyone. Not everyone wanting or needing to recover from alcohol or any other substance/process addiction wants or needs to find recovery through spirituality. And as already mentioned, for those that do, the masculine or Christian language can be a barrier, re-traumatizing shame. Spirituality is not for everyone, nor is abstinence-based recovery. For those wanting to recover without using spiritual terminology or explore how to drink in moderation while using different tools to manage life skills, there are alternatives approaches such as: Harm Reduction, Rational Recovery, LifeRing, and Secular Organizations for Sobriety.

Eating Disorders and Process Addictions

     As a Psychologist currently in private practice, I specialize in working with women recovering from disorder eating, body image distress, and perinatal mood disorders. With eating disorder recovery, there obviously can’t be an “abstinence-based” (abstinence from food) recovery. You need to eat to live. Food related 12-step programs take a variety of positions on this very issue: some have a suggested plan of eating that is considered abstinent for recovery for everyone, some suggest determining what your recovery food plan is with your sponsor and healthcare professional(s), and some

“endorse sound nutrition and discourage any form of rigidity around food. Balance not abstinence is our goal.” [15]

Philosophically, I align most with EDA, as “it is not about the food” and recovery is about learning other emotion regulation tools to cope with life. I do not often recommend clients attend Food Addicts Anonymous (FAA), as it IMG_2527can feel triggering and shaming for someone who has been alternating between dieting and bingeing for much of their life to be given yet another food plan that resembles a restrictive diet as a solution to a life problem. Some meetings actually do not allow members to speak if they have not followed this food plan for 30 days, which can feel quite shaming and re-traumatizing for someone who is already struggling with food, finding one’s authentic voice, allowing imperfection, and being less rigidly black and
white.

Other process (as opposed to substance) addictions such as gambling, spending/debting, and sex/relationship/codependent addictions also have 12-step programs for people to abstain from what they identify as their addictive behavior in order to develop other tools to cope with life, on life’s terms. Again, these are not for everyone. However, AA paved the way to make available low-cost, readily available, peer-based support for many people struggling with many kinds of issues. 

12-step Programs are certainly not for everyone. And I work with many therapy clients who attend 12-step meetings and many clients who do not. All of them are on their own healing path. However, I would ask Ms. Glasner to not throw out the baby with the bath water or simplify the recovery process by simply replacing AA with Naltrexone. Recovery is a multifaceted and individualized journey in which many people may actually benefit from both AA and Naltrexone or neither of these. And without AA, without the inspiration of two men simply trying to stay sober, 1 day at a time over 60 years ago, there would be no other 12-step programs in the world today. Twelve step programs help millions of people every day all across the world. Let’s not spend our time criticizing what works quite well for some, advocate what works for each person in their own journey of healing, and by all means invest time and money researching what can work even better in the future.

Why AA “declined to talk”

One of the traditions, tradition 11, of 12-step program is anonymity. It states that “Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, and films.”[16] And so the Glasner article leaves a big void for members of AA to challenge if they are to remain true to the very program that has helped them. As a Psychologist who has seen 12 step programs transform lives, I wanted to speak up in service of the miracles I have seen 12-step programs facilitate in the people with whom I work.

 

Dr. Linda Shanti McCabe is a Licensed Clinical Psychologist practicing in San Francisco. She has worked in residential, partial hospitalization, and outpatient treatment for alcohol and substance use as well as eating disorders. She currently specializes in assisting women recover from disordered eating, body image struggles, anxiety, and perinatal mood disorders. To read more about her work, visit www.DrLindaShanti.com or her Mommy blog at www.Recoverymama.com

 

[1] Glasner, Gabrielle, “The Irrationality of Alcoholics Anonymous” The Atlantic, April 2015

[2] Ibid

[3] “Cognitive Behavioral Therapy for Depression and Anxiety Disorders,” Systematic Review, National Registry of Evidence-based Programs and Practices, Substance Abuse and Mental health Services Administration, a branch of the US Dept. of Health and Human Services http://www.nrepp.samhsa.gov/cbt.aspx

[4] Beck, A. T. (1976). Cognitive therapies and emotional disorders. New York: New American Library.

Burns, D. D. (1980). Feeling good: The new mood therapy. New York: New American Library.

[5] Nagel, B.J., and Kroenke, C.D. “The use of magnetic resonance spectroscopy and magnetic resonance imaging in alcohol research,” Alcohol Research & Health 31(3): 243–246, 2008.

[6] Rounsaville, Bruce J., M.D., O’Malley, Stephanie, Ph.D., and O’Connor, Patrick, M.D., “Guidelines for the Use of Naltrexone in the Treatment of Alcoholism,”, The APT Foundation, 904 Howard Avenue, New Haven, CT 06519, 1995.

[7] Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC: APA, 2000.

[8] National Institute on Alcohol Abuse and Alcoholism http://www.niaaa.nih.govNIH Publication No. 13–7999 November 2013.

[9] Norcross, John C., PhD, “Evidence-Based Therapy Relationships,” APA Division of Psychotherapy and Clinical Psychology task force metaanalysis, http://www.nrepp.samhsa.gov, 2011.

[10]  As stated by Bill W at THE IMPACT OF ALCOHOLISM HEARINGS BEFORE THE SPECIAL SUBCOMMITTEE ON
ALCOHOLISM AND NARCOTICS 
OF THE COMMITTEE ON 
LABOR AND PUBLIC WELFARE, 
UNITED STATES SENATE 
NINETY-FIRST CONGRESS, FIRST SESSION
ON
EXAMINATION OF THE IMPACT OF ALCOHOLISM

JULY 23, 24, AND 25, 1969 and printed in the original “AA Grapevine” newsletter of Alcoholics Anonymous.

[11] Kurtz, Ernest, Not-God: A History of Alcoholics Anonymous, Center City: Hazelden, 1979

[12] As quoted by William James in Appendix II, “Spiritual Experience,” Alcoholics Anonymous, New York: Alcoholics Anonymous World Service, 1994.

[13] Kornfield, Jack, After the ecstasy the laundry: How the heart grows wise on the spiritual path, New York: Bantam Books, 2000.

[14] Covington, Stephanie, A Woman’s way through the 12 Steps, Center City: Hazelton, 1994.

[15] Eating Disorders Anonymous, FAQ’s

http://www.eatingdisordersanonymous.org/faqs.html

[16] Anonymous, Alcoholics, Twelve Steps and Twelve Traditions of Alcoholics Anonymous, Alcoholics Anonymous World Service Inc, Copyright 1952, 2004.

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