Using the Wisdom of AA in the Treatment of Addicts
In 1990, in the US alone, 3.75million people reported attending Alcoholics Anonymous (AA) (Room, 1995). In the same study 22.6million said they had attended AA meetings at some point in their life. Research results suggest that involvement in AA is predictive of better recovery outcomes (Barbor & Del Boca, 2003). Clearly, something about AA is attracting large numbers of people, with many using at least some part of it as a way of achieving and maintaining recovery from addiction to alcohol. However, many books on addiction counselling still contain no reference to AA and some within the psychotherapeutic profession are openly hostile to the movement and its ideas (Denning, 2000; Peele & Bufe, 2000; Velleman, 1992). This paper explores how one-to-one psychotherapists could use the experiential learning, or wisdom, of AA as they seek to help people suffering from the ravages of their excessive appetites.
Moring (1997) outlines difficulties he experiences when working with clients with addiction problems. He describes his responses in the face of a client’s apparent desire to wreak havoc and chaos in her life. As he begins to “resonate with her uncontrollable and unmanageable parts” (ibid, p.442) he experiences anxiety and a feeling of not being in control of himself or the therapy. He responds to these internal states by giving her a number of cognitive-behavioural exercises aimed at establishing some sense of self-control within her. These have some success and then again lead to frustrating failure for the client and feelings of impotence for Moring. Eventually, in the face of the client’s continuing chaos and increasing demands, he feels relieved when she finally decides not to return. The battle for control in the face of chaos and helplessness was both the client’s dilemma and the therapist’s solution.
My experience suggests that control versus chaos and omni-potence versus impotence are the confusing and frightening dynamics surrounding an addict in extremis. It is a difficult business, as shown by many agencies’ unwillingness to offer help to addicted clients and the limited success in achieving long-term recovery when help is offered. So, how could AA contribute to a psychotherapist’s ability “… to think and act utilizing experience, understanding, common sense, and insight”(McLeod, 1985), or to act wisely, in the face of the difficulties confronted by Moring?
One key aspect of AA members’ stories is the emergence of hope out of acknowledging chaos and hopelessness (Alcoholics Anonymous, 1976). Bill Wilson, one of the founders of AA, considered the combination of hope and hopelessness as expressed by Carl Jung to a suffering alcoholic, to be a “foundation stone on which [AA] has since been built” (Alcoholics Anonymous, 1985). This echoes the idea that clients might project both unconscious hope and despair, and that it is the therapist’s role to receive and be able to contain both (Casement, 1991 p.154) In the AA situation, more long-standing members can do this for the newcomer based on their own experience. In a therapeutic situation, it is the therapist’s responsibility to find their own ways of resonating with both the hope and despair in a client’s situation, and to continue without acting out in either direction. If nothing else it is an experiential example to the client that hope and despair can be lived with simultaneously.
It is also apparent from AA stories that solutions appeared to come without an exercise of control. Moring’s desire to impart control in the face of despair does not chime with many addicts’ experiences of long-term recovery. What is AA wisdom, or the common-sense acknowledgement of reality for its members? That self-control or the control of others hasn’t worked in the past and so, in order to stop the destructive behaviour, another way has to be found (Alcoholics Anonymous, 1976). There are many potential advantages to this approach: it lines up with addicts’ experiences whilst also offering some hope; it also offers a mystery and invitation from the therapist – e.g. ‘You don’t seem to be able to stop. I am powerless to prevent you. Some people stop under these circumstances. I wonder if we can work together to find what will do it for you’; it is a practical expression of an essential limitation of both the client and the therapist, without either abdicating responsibility for engaging in purposeful effort.
However, addicts often have little concept of self-efficacy or thoughts of internal justification where their addictive behaviour is concerned. Here, whatever its absolute truth, can be seen the value of the AA concept and use of a ‘higher power’. It provides a self-defined justification for a new ability to initiate and maintain sobriety. The ‘higher power’ can at one and the same time be seen as an external, “power greater than our selves” (my italics) that mitigates the lack of self-efficacy and control, and “an unsuspected inner resource”, that allows an internal justification for change, (Alcoholics Anonymous, 1976, p.45 and p.570).
The psychological, as opposed to spiritual, explanation of the value of such a mysterious object can be seen in Winnicott’s ideas on the use of transitional objects or phenomena (1951, 1990). They are those early experiences and objects that allow a non-traumatic move from unthinking omnipotence to experiencing reality and a place in the world – they mediate disillusion. Winnicott believed they play a crucial role in the ability of human beings to be creative and develop the capacity to manage new experiences. He says of them: “…it is a matter of agreement between us that we will never ask the question ‘Did you conceive of this or was it presented to you from without?’ The important point is that no decision on this point is expected” (his italics) (1951, p.239). Maybe, the idea of ‘higher power’ as a useful ‘teddy-bear’ might help less spiritual therapists to explore its value to their clients. If God exists, I am sure he won’t object to the potentially blasphemous nature of such a suggestion, in view of its potential value to a tortured soul.
Another difficulty faced with many addicts is their breathtaking ability to ignore or make light of extreme problems in their lives. AA stories refer to an inability and unwillingness to see problems caused by addictive behaviour (Alcoholics Anonymous, 1976). Heatherton and Baumeister (1991) suggest that addiction is both a motivated attempt at withdrawal from aversive self-awareness (unwillingness) and the cause of irrational beliefs and reduced engagement with reality (progressive inability). They also suggest that the very act of being confronted with self-knowledge that damages self-esteem leads to addictive behaviour. So, where does this leave the therapist? Exploring someone’s damaging addictive behaviour and convincing them they have a problem may present them with “…the same motivations and aversive self-awareness, which could cause [them] to turn to … forms of escape” (ibid:102).
A number of writers have noted evidence of pre-conditions linked with engaging in a goal of sobriety and the attendant increase in self-awareness; these include sensed attainability (Carver and Scheier, 1998), enhanced self-esteem and/or reductions in threats to self-esteem (Heatherton and Baumeister, 1991), and interdependent relationships involving both governing systems outside the self and the idea of value to others (Khantzian and Mack, 1994; Williams, 2002). AA has been an embodiment of these ideas in many people’s accounts of their recovery over the last six decades (Alcoholics Anonymous, 1976; Knapp, 1996).
The idea of sensed attainability, or hope, was dealt with in the earlier part of this paper. Self-esteem enhancement and threats to self-perception are addressed in at least two ways within AA. Firstly, addiction is not seen as a moral issue and so an acknowledgement of a problem is not an acknowledgement of a moral failure. AA colloquially uses the idea of a ‘sick person trying to get well rather than a bad person trying to get good’. Within a therapeutic setting the addiction can be seen as a genuine, although ill-fated, attempt to compensate for deficits in the addict’s developmental environment.
Secondly, AA is essentially a meeting of equals, people coming together with common issues and a common humanity. AA members involved in talking to newcomers are advised to describe their “drinking habits, symptoms and experiences” and to “let him match your mental inconsistencies with his own”. Partly, this approach is intended to demonstrate esteem for the other by allowing a self-diagnosis. In Miller’s words it promotes confrontation with reality as a “goal, not a style” (1991:13). It allows self-realisations to be encountered at the same time as being bolstered by the knowledge that these self-failings have been experienced by others, who don’t seem to be ‘failures’.
So, how can a therapist make use of these ideas? For a therapist to adopt fully the AA practice of help by self-disclosure is seen as a problematic area by many schools of psychotherapy. However, experienced therapists have written about the value of self-disclosure under circumstances where: clients have difficulty in grasping and articulating their experience, the therapist uses it selectively, and the client can make use of it (Bollas, 1987; Fransella and Dalton,1996; Parlett and Hemming,1996).
Clearly, many addicts can’t fully understand or articulate their experience, hence their need for tortuous rationalisation or escape. Secondly, AA wisdom is that self-disclosure is best used selectively with newcomers in moments of regret, confusion or despair. Finally, the AA experience suggests that, given the right type of self-disclosure, addicts can make use of it both to recognise their own patterns and to mitigate their own isolated shame. AA suggests that only another addict can offer this kind of help. However, the work of Christopher Bollas suggests another way forward.
Bollas is clearly not psychotic but, in his work with severely disturbed patients, he recognises that he is “receptive to varying degrees of [the client’s] madness within [himself]”, whilst also retaining some ability to think in ways not possessed by the client (1987:204). He suggests it is possible for the client to induce “madness” within the therapist. He cites a number of clinical cases where he has worked internally to “treat his own situational illness first”, (ibid:204). Bollas records how he has used his tentative disclosure of both the direct experience, and resultant associations to parts of his own life, to help these clients achieve new elements of self-realisation. Interestingly, he describes how he talks to clients about these ideas in similar ways to those expressed in AA literature and meetings – not as an interpretation of another’s condition, but rather ‘This is my direct experience. Use it if it makes sense for you’. Bollas’s work wasn’t with addicts and more research would be required to establish its efficacy in this field. However, both AA and psychotherapeutic experience suggest it is a rewarding avenue of investigation for therapists prepared to open themselves to such an experience.
Kalsched (1996) explores another problematic aspect for therapists dealing with addicted clients, namely relapse and its associated fall-out. He writes about a client’s guilt around experiencing the lure of sensual pleasures and her self-disgust and shame at succumbing to them. The relapse occurs as the relationship between client and therapist is deepening and the client has expressed fears of becoming too dependent on him. Kalsched describes “feelings of great anger” and a “sense of betrayal” that the client should have so clearly given the message “screw you” and “cheated” on him. What might AA offer on how to proceed in such a situation?
Khantzian (1994) suggests that AA works well in the early stages of recovery as it avoids the emotional complications often involved in one-to-one relationships, both in therapy and the ‘real world’. Relapses are seen as a natural part of the process of addiction and recovery. They are not taken as a personal reflection on anybody who has been helping the relapsed member. The basis for a stance of not acting as if a relapse was a negative reflection on the therapist or client can be found in Bowlby’s work on attachment theory (Reading, 2002).
Kalsched’s case material described a deepening attachment by the client to the therapist. Reading suggests that while the therapist acts as a “trusted ally in the pursuit of change”, as the work progresses he also comes to represent a potential threat to the “addictional bond” (2002:27). In this sense, a therapist could, paradoxically, see a relapse as evidence that his efforts at helping induce a change in the client were having positive effects.
The other AA approach is to normalise human instincts. In a number of pieces of writing about both recovering and relapsed addicts Bill Wilson, one of the co-founders of AA, emphasises this idea. He suggests that: “without [instincts] … we wouldn’t be complete human beings” (Alcoholics Anonymous, 1952:42), “the slip could have been brought about by unreasonable feelings of guilt because of other so-called moral failures… you can be penalised only for refusing to try for higher things”, “too little self-forgiveness … adds up to slips” (Alcoholics Anonymous, 1967:68 and 99). So, AA experience suggests it may be easy for addicts to trip themselves up unnecessarily through guilt about being human.
AA suggests to members that problems come from “misdirected instincts” (Alcoholics Anonymous, 1952:42), and that the road to recovery can be sustained when the instincts are redirected in the service of an objective wider than personal fulfilment. So, it’s not ‘being human’, but what you do with that gift that promotes or reduces suffering. The value of ‘meaning beyond oneself’ has been espoused by therapists who have experienced its value in their own and their clients’ lives (Frankl, 1985; Moody, 1997). Carver and Scheier suggest that “having a clearly specified goal at the more abstract level” (1998:348) promotes flexibility and self-efficacy. They also propose that a goal requiring a striving towards, rather than achievement of, leads people to remain “busy being born”, engaged in moving along “the path of growth … the path of life” (ibid:363). AA members also talk about the importance of striving for ‘progress rather perfection’. These ideas of self-acceptance, self-transcendent goals and active engagement in ‘being’ might be usefully explored in therapy. AA experience suggests they can help addicts make use of their sometimes problematic humanity in something other than self-destructive acts.
I have attempted to set out the practical experience of alcoholics who have come to lead satisfying lives. The methods by which they achieved this were based on experiential learning rather than out of theory. The things that worked kept people sober and so were retained. Some of the factors that contributed to these alcoholics’ successes are now generally recognised to help anyone in making changes or sustaining a satisfactory life: hope, self-esteem and satisfying, affirming relationships. However, the AA approach helped bring about and sustain these things for people who believed they were lost forever. The approach taken involves a complex interconnection of ideas that are mutually supporting. These ideas are based on the recognition of a common humanity that encompasses failings and limitations, and the potential and willingness to transcend them. The various ideas and techniques making up the AA approach weren’t adopted on the basis of their absolute truth, but on what was proved to work. This paper has put forward ideas on how therapists could substantiate making use of AA concepts in their work with addicts.
In the early writings of psychotherapists not a lot of thought was devoted to addicts. In fact, some seemingly intractable problems like addiction and narcissism were excluded as conditions that could be treated through a talking therapy. The theories constructed out of these early experiences and failures of psychotherapists explained why it wouldn’t work. However, pioneers such as Kohut (1971) continued to work with narcissistic clients whose condition improved. Out of his experiences he put forward ideas that expanded the old theories and led to new ways of understanding and talking to all clients. In AA there is a body of evidence showing that addicts can change their behaviour based on their relationship with another human being and a ‘higher power’. As therapists our challenge is to make sense of that experience and use it to help our clients.
Barry Smale is a BACP accredited psychotherapist working in the Capio Nightingale psychiatric hospital and private practice. He specialises in helping people work through problems with chronic stress, difficulty in self-regulation, anxiety, addiction and trauma. Barry also teaches Chi Kung and mindfulness, and lectures on the MSc for Addiction Psychology at London Southbank University.
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