Q: I recently began seeing a new patient with an acknowledged drinking problem. He's asked about going to Alcoholics Anonymous, but I'm concerned that his attendance there may distract him from his work in therapy. What should I do?
A: If you're like most mental health clinicians, you've had little training in addictions treatment and minimal exposure to Alcoholics Anonymous (AA). Much of what clinicians know about AA comes from general media sources, word of mouth, and patients. But, given how common substance abuse problems are among our clients, we all need to have an accurate working knowledge of AA and its Twelve-Step Program.
Several features of AA make it ideal as an adjunct to therapy. No therapist alone can provide the kind of group support that AA makes available 24 hours a day. The process of change that occurs in AA can open up a tremendous amount of relevant clinical material, and the clinician, when properly oriented, can help resolve roadblocks and resistance that the patient encounters in pursuit of recovery.
AA developed from a meeting in 1935 between two alcoholics, Bill Wilson and Dr. Bob Smith, who recognized that through mutual support, each one could maintain sobriety. From this meeting grew a fellowship that now has nearly two million members worldwide, who attend almost 115,000 regularly scheduled meetings a year.
At meetings, AA members share with each other their personal experiences of struggle and recovery. Meetings typically last an hour, are chaired by a member, and are entirely voluntary. The only requirement for membership is a "desire to stop drinking."
AA's famous Twelve Steps outline a program of personal development and spiritual growth that addresses the changes in attitude, lifestyle, relationships, and behavior necessary to maintain sobriety. Only the first step refers to alcohol, but all of them emphasize individual self-examination, building interpersonal connections, and service to others. Members are encouraged to "work" each of these steps in sequence, but with no particular timetable or set of expectations. Usually a sponsor or a senior member of AA guides a newcomer through his or her personal development in the fellowship.
A client who begins therapy with an untreated addiction problem may benefit from a referral to a local AA meeting after the need for medical intervention has been assessed. This referral should be, according to AA tradition, a suggestion, not a requirement. Clinicians should be aware of local meetings or have a published meeting list, which they can get at any AA meeting, by calling the local AA office listed in the phone book, or by looking online at www.aa.org.
Many clients will resist attending meetings, and clinicians may use the therapeutic relationship to defuse resistance. Typically, clients are worried about having other members of their community know they've attended a meeting, wary of the spiritual aspects of the program, and uncomfortable with the open group discussions in meetings. Everyone attending an AA meeting has privacy concerns, and though "leaks" may occur, they're highly unlikely. It's helpful to remind newcomers to the AA experience that they only need to give a first name in introducing themselves. Concerns about the spiritual aspects of the program can be defused by asking for open-mindedness and reminding clients that they can interpret this as freely as they choose. Social discomforts can be allayed by reassurance that AA members are free to "pass" their turns to speak and are encouraged only to attend and listen with a goal of "comparing" their problems with those of others.
A common misconception about AA is that by viewing the addiction as a disease, you're creating an excuse for continuing to drink. In practice, this is the opposite of what happens. By acknowledging that alcoholism is a disease, alcoholics take responsibility for their recovery. Diabetics and hypertensives face a similar dilemma: the disease isn't one that they caused, but by adhering to certain principles, they can reclaim their health, restore their ability to manage their lives, and remain fully functional. AA members don't coddle each other; taking stock of one's misdeeds, assuming full responsibility for one's own behavior, making amends, and relinquishing self-pity are integral to the program.
Once a client is attending AA meetings, clinicians may best view themselves as coaches, letting the program do the work of supporting sobriety. Clarifying misunderstandings about the program and defusing resistance to its precepts are important clinical tasks, especially in the early stages of involvement. The process may raise countertransference issues, in that therapists must surrender their pride in their roles as helpers. We're used to viewing psychotherapy as the center of the change process; in recovery from alcoholism, it's critical to see AA's program as the primary agent of change. Our role complements the work on honesty, humility, and spiritual surrender that clients experience in AA.
Many members of AA cite psychotherapy as an important complement to the work they're doing, but a therapist who doesn't fully understand the program may inadvertently sabotage its good work. I recall one well-intentioned therapist who, pursuing the reasonable agenda of helping her client feel more empowered, discouraged her from attending meetings, fearing that acknowledging powerlessness over alcoholism would undermine the larger goal. Without adequate group support for sobriety, this patient's efforts at self-empowerment were severely compromised. Alternately, some of my clients have expressed their comfort in being able to discuss dilemmas rising in the fellowship with someone who understands both the AA program and their own individual dynamics.
The best "training" in AA can be obtained by attending a few meetings; nonalcoholics may go to any meeting listed as an "open" meeting, which will admit anyone who has an interest in alcoholism. Those who do attend are often surprised by the warmth of the reception they get as they walk through the door. Clinicians, in particular, are usually impressed by the degree of honesty and self-disclosure they encounter in a meeting, and by the feeling of hope, community, and good humor they experience there.
The issues of responsibility, acceptance, and prioritization are illustrated in a clinical example. Recently, I treated an alcoholic wife and a critical but overprotective husband. To her, his overbearingness was the stressor that needed to change if she were to attain secure sobriety. He defended his behavior by pointing to her pattern of relapses. Recognizing the AA aphorism "First things first," I saw that this couple's debate missed the central issue: that she must assume responsibility for her own recovery. I refocused the discussion on her actions in support of her sobriety: had she attended any AA meetings in the last week? had she taken her Naltrexone (a medicine that often cuts cravings)? had she called her sponsor? These questions, not the marital issues, were the pressing ones. The interpersonal dynamics were quite real, but they'd come later.
I suspect it's impossible to integrate AA into our clinical practice and not see some direct impact of the program on our clinical work and personal lives. A client recovering from an opiate addiction wrote me that her sobriety felt like being kicked out of the Garden of Eden. Rather than approach her with bromides ("You'll feel better soon," "You'll enjoy your children more"), I accepted and validated her pain and loss, recognizing that learning to tolerate discomfort is a key lesson in recovery.
I've internalized many of the concepts of acceptance and tolerance that I've been encouraging in my clients. I'm better able to tolerate the discomfort of dealing with difficult clients in ambiguous situations. I'm learning to "accept life on life's terms," as the AA saying has it, and this lesson has helped me, both personally and professionally.
This blog is excerpted from "Working with Alcoholics," by Mark Schenker. The full version is available in the March/April 2009 issue, In Search of a Safety Net: Helping Our Clients and Ourselves in the New Economy.
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