Psychotherapy and Alcoholics Anonymous - An Integrated Approach

Psychotherapy and Alcoholics Anonymous:An Integrated Approach

William A. KnackState University of New York, College at Old Westbury

This article provides a rationale for, and a method of, combining a nonpro-fessional self-help addiction recovery program, Alcoholics Anonymous(AA), and a professional treatment approach, psychotherapy. The twoapproaches share a common goal, target similar issues, and work towardsimilar outcomes. A psychotherapy approach that integrates the two ap-proaches can be quite powerful. Treating a patient in psychotherapy who isalso working in the AA program without a good understanding of AA canresult in the two approaches working at cross-purposes, diminishing theeffectiveness of both interventions. After a brief discussion of psychotherapyintegration, the AA program is examined in detail, focusing on the philos-ophy and change strategies that are compatible with psychodynamic andcognitive–behavioral models of psychotherapy. A method for integratingthese techniques into a psychotherapy directed at treating addiction is pre-sented. Guidelines are provided to manage the implementation of this inte-grated approach throughout the process of recovery.

Keywords: Alcoholics Anonymous, psychotherapy, alcoholism, 12-step programs, psy-chotherapy integration

The rationale for integrating the Alcoholics Anonymous (AA) 12-stepapproach and psychotherapy is based upon the prevalence of alcoholproblems and alcoholism and the utilization and effectiveness of the AAprogram. More than 30% of Americans have met the criteria for analcohol-use disorder at some time in their lives (Hasin, Stinson, Ogburn, &Grant, 2007). AA is an international program with 97,000 AA groups (AAWorld Services, 1999). A total of 1.7 million members attend yearly (AAWorld Services, 1990). Morgenstern, Bux, Labouvie, Blanchard, and

I recognize the contributions of Jack Craig, and of Lori Bohm and Catherine Stuart fortheir counsel, encouragement, and support.

Correspondence concerning this article should be addressed to William A. Knack,Department of Psychology, State University of New York, College at Old Westbury, P. O.Box 210, Old Westbury, NY 11568-0210. E-mail: [email protected]

Journal of Psychotherapy Integration © 2009 American Psychological Association2009, Vol. 19, No. 1, 86–109 1053-0479/09/$12.00 DOI: 10.1037/a0015447

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Morgan (2002) stated the following: “Studies have generally found that12-step approaches yield equivalent outcomes to such science based treat-ments as cognitive–behavioral treatment (CBT). In some cases, 12-steptreatment yielded superior results . . . [in the treatment of alcohol andcocaine dependence].” Humphreys and Moos (2007) conducted a studycomparing cognitive–behavior therapy (CBT) with AA participation andfound that the AA group achieved higher abstinence rates and used lessclinical services than the CBT group. Forty-seven percent of active AAmembers have been sober between 1 and 5 years. Another 26% have beensober between 1 and 5 years. Forty percent of newcomers who stay activefor 1 year stay sober for a second year (AA World Services, 1990).

Numerous studies indicate that AA members who work the programhave a greater likelihood of staying sober (Emrick, Tonigan, Montgomery,& Little, 1993). At the same time, 60% drop out in the first year. Thissuggests that maintaining AA involvement is predictive of sobriety. Con-sequently, an important goal of psychotherapy should be to encourage andmaintain AA involvement. This approach has been called 12-step facilita-tion (Nowinski, 1996). However, simply supporting a psychotherapy pa-tient’s participation in AA fails to result in a unified treatment approach ifthe two models of change are not working together in a coordinatedmanner. Failing to fully understand the message and methods of the AAprogram can result in the perception of incompatibility and/or result in thetwo approaches working at cross-purposes. To achieve this level of consis-tency in the treatment approach, the two models must be integrated.Additionally, participation in the AA program and integrating AA withpsychotherapy can be reciprocally beneficial, enhancing the effectivenessof both the psychotherapy and the AA experience.

PSYCHOTHERAPY AND PSYCHOTHERAPY INTEGRATION

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

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both the problem and of the cure is achieved, (e) The patient is remoral-ized, and (f) There is an expectation of improvement and consequently theexperience of hope. The identification of common factors among seeminglydisparate models of treatment, related to successful outcomes along withthe development of professional organizations and journals, has facilitatedthe integration of different treatment approaches (Gold, 1996; Norcross &Goldfried, 1992; Stricker & Gold, 1993). Early attempts at integratingpsychotherapeutic approaches include an integration of psychoanalysis andbehavior therapy (Wachtel, 1977) and a multimodal approach advocatedby Lazarus (1989, 1992).

Gold (1996) summarized three approaches to psychotherapy inte-gration. These are (a) technical eclecticism, in which two or moretechniques from different systems are applied systematically and se-quentially; (b) the common-factors approach, in which common factorsin all psychotherapies are emphasized and relied upon; and (c) theoret-ical integration, in which seemingly incompatible philosophical differ-ences are united, and behavior is explained in terms of interactions. TheAA program and psychotherapy can be integrated using each of thesethree approaches. To understand this, it is first necessary to identify thekey points of the AA program.

THE PROGRAM OF AA

AA was founded in 1935 by William Wilson, a stockbroker, andRobert Smith, a surgeon. According to the originators, the program wasestablished because medicine and psychotherapy had little to offer theaddict in the way of treatment. AA was formed when two alcoholicsstruggling to get sober and stay sober themselves found that they couldachieve and maintain sobriety by helping others to do so. Thus, while themotivation for helping others is self-centered, the result is altruistic in thatothers receive help. AA grew to the scale of a social movement. It has beenan international organization since 1940. Although the goal of successfulparticipation in the AA program is abstinence, abstinence without a cor-responding change in character or personality is viewed as unstable. Alco-holism is conceptualized as a problem that is “90% thinking and 10%drinking.” The idea that one will not remain sober “without undergoing aprofound personality change” (AA World Services, 1967, p. 1) is certainlyconsistent with psychodynamic approaches to the psychotherapy of alco-holism, which is discussed in detail later.

A good description of the application of the AA program can be foundin a section of Alcoholics Anonymous (AA World Services, 1939) titled

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“How It Works.” This section and other portions of the text are para-phrased and summarized here:

The AA program consists of people in recovery helping themselves byhelping one another. It is described as a program for people who want it,not for all who need it. It is stated that, “If you want what we have, do whatwe do,” and “it works if you work it.” The only requirement for member-ship is a desire to stop drinking. Honesty, openness, and willingness tofollow the program are necessary for success. There is recognition thatthere are those who will not be successful. Typically, it is those individualswho are not willing or capable of following the program. As people recoverin AA, they work toward progress, not perfection. Three pertinent ideasare emphasized: (a) They were alcoholic and could not manage their lives(this is to say that there is recognition and acceptance that they cannotdrink in a controlled and safe manner, and there have been significantnegative consequences of their drinking); (b) They could not stop drinkingon their own; and (c) The way to gain control is to surrender to a “higherpower.” This is one of the great paradoxes: By admitting and accepting alack of control or powerlessness, one gains control. To surrender is toaccept that one cannot manage his drinking on his own. One then “turns itover” or looks to someone or something else for guidance, direction, andsupport. This someone or something else is referred to as a higher power.For some, the higher power is a sponsor who has been successful inrecovery. For many, the higher power is the group. For others, the higherpower is a deity.

These three ideas have been summarized in the following way: “I cannotdo this alone. Something or someone else can. I will ask for help and followdirection.” Following directions requires following the program, which meanstaking certain steps. Following the steps results in a realization of “ThePromises,” which are the positive changes achieved by the individuals whofollow the steps. It is asserted that only Step 1 (accepting that one cannotdrink) must be done perfectly. The remaining 11 steps are works in progressover the course of one’s life. The 12 steps and promises are presented inAppendix 1.

COMMON FACTORS: AA AND PSYCHOTHERAPY

A review of how AA operates and of common curative factors inpsychotherapy suggests a number of similarities. It can be argued thatthe AA group as a whole and the AA sponsor in particular constitute “atrained socially sanctioned healer.” The social sanction is implicit in thesocial recognition and utilization of the AA program. The AA program


is most frequently a major component of inpatient and outpatient treatmentprograms. Judges frequently mandate defendants with alcohol and drug prob-lems to attend AA. Physicians, psychologists, and other mental health profes-sionals routinely refer patients to AA. The government has supported theincorporation of AA groups in prison treatment programs. This suggests thatthe AA approach has both social recognition and social sanction.

Psychotherapists, patients, AA sponsors, and “sponsees” are alltrained in their respective models of treatment. Psychotherapists attendformal professional training programs in schools that are freestanding oruniversity based. Many therapists have learned much about the practice ofpsychotherapy as a function of having been patients themselves. As prac-ticing therapists, we certainly learn from our patients. Psychotherapy pa-tients are “schooled” in different ways. Sometimes this schooling occurs asa function of the experiential process. They learn the model as theyprogress through the treatment process. In some approaches, there arereading and homework assignments. In other approaches, the therapistmay be more directly instructional. The training in AA that the healers(both sponsors and the AA group as a whole) receive occurs in the processof joining AA and being “schooled in the model” in a manner similar to theschooling that psychotherapy patients receive.

There are formal “training” experiences in AA. There are AA meet-ings specifically devoted to schooling in the model. There are “Big BookMeetings,” in which the handbook of AA is read and discussed. There arealso “Step Meetings,” in which each of the 12 Steps is read and discussed.AA groups offer a regular succession of these meetings. A sponsor issomeone who has sufficiently learned the steps and their application so thathe or she can guide a more junior member through them. The role is verymuch a teacher/therapist role in which the student is taught, in part, bymodeling. Sponsor/sponsee interactions can also be rather Socratic innature. Sponsors often direct sponsees to read specific literature to informa discussion to follow. As one works through the 12 Steps, the literature isregularly used to direct, guide, reinforce, or challenge behavior. AA groupshave requirements for being a sponsor, such as having completed at least1 year of sobriety and having worked through all 12 steps. Thus, the group“socially sanctions” the sponsor.

The change process in AA is quite formal. Members begin as new-comers. From the beginning, it is communicated that they need to learnhow to get sober and remain so. The message is sent: “If you want whatwe’ve got, do what we do.” Newcomers are encouraged to attend meetings,pick a home group, get involved and give service, get a sponsor, and beginworking the steps. Each day in early sobriety is recognized. Recognition isthen provided for 90 days and then yearly intervals. As newcomers work

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through each step with their sponsors, they are also encouraged to sharetheir experiences related to each step in the larger group setting. Theyreceive feedback from the group as to how well they are doing. Thesponsor determines when a step has been successfully completed and thenplaces the sponsee on the next step. There are certain meetings thatmembers are not allowed to lead unless they have completed all 12 steps.

As a function of the process described here, an understanding of boththe problem and the cure is achieved. Members attempt to achieveprogress, not perfection. They see around them others who have beensuccessful, as well as those who have relapsed and come back and areenjoying a new success. Members experience an increase in self-esteem,agency, and personal value. They are “remoralized.” There is an expecta-tion of continued improvement and, consequently, the experience of hope.This change process parallels the change process in psychotherapy de-scribed by Frank (1961).

The psychotherapeutic process, or “talking cure,” is a verbal treatmentthat promotes behavior change by facilitating the development of introspec-tion and insight, motivating effort and persistence and often providing acorrective emotional experience and/or teaching skills depending upon thespecific model of psychotherapy. The AA program and psychotherapy sharethese common processes, target similar issues, and pursue similar resolutions.

THEORETICAL INTEGRATION

Bandura (1978) presented and discussed a causal model of humanbehavior termed reciprocal determinism. This model is best summarized bythe formula B f (P 43 E): Behavior is a function of an interactionbetween the person and the environment. The person consists of bothbiological and psychological components. Psychological processes includeperception and the analysis and organization of information from theenvironment. The environment can be categorized as familial, social andcultural, recent and remote. Opazo (1997) formulated a supraparadigmaticintegrative model that is based upon six parameters of the psychologicalsystem. The parameters of biological, environmental, behavioral, cognitive,affective, unconscious, and systemic are organized around the self. The selfsystem integrates influences from these parameters by translating theexperience of the parameter giving it meaning. These parameters interactin a reciprocal or circular fashion so that cause and effect can be difficult todetermine. Guajardo, Bagladi, and Kushner (2004, p. 41) stated that thismodel provides “a complete source of potential etiologies” (of addiction)and their interaction.


The originators of the program of AA described the alcoholism thatthey were attempting to address as a mental, spiritual, and physicaldisease. These three categories are described as subsuming biological,environmental, behavioral, cognitive, affective, and family system com-ponents, as well as a spiritual component. Although the term uncon-scious is not used to communicate the same meaning as Opazo’s utilizationof the term, there is reference to goal-directed motivations, thoughts, feelings,and behaviors, the origin of which is unknown. Thus, AA philosophy isconsistent with these aspects of the supraparadigmatic model as the structuresand practices of AA address issues in the six parameters of the psychologicalsystem.

Hopson and Beaird-Spiller (1995) conducted a study to examine thepsychological needs addressed by the AA program. The program di-rectly addresses many of the psychological needs of recovering alcohol-ics and other addicts. For example, speaking about one’s experienceprovides an opportunity to use language to represent the self andexpress feelings. It can help establish and consolidate a sense of self. Asone patient stated, “When I had to tell the story of me in 30 minutes, Irealized that I felt things that I was not aware of and how the things thathave happened to me have made me who I am.” Attending meetingsregularly can restore a sense of agency, a sense that there is somethingthat one can do, as well as facilitating self-regulation and establishingregularity. Another patient stated, “This I can do. I can go to meetings.It helped them. It can help me . . . just being on a schedule makes my lifefeel so ordered and in control.” Additionally, the emphasis on fellow-ship can establish or restore a sense of relatedness to others. Thesponsor system can restore a relationship with self and others and buildself-acceptance and trust. Unconditional acceptance contributes to self-acceptance. Many patients have described their experience of the fel-lowship of AA and their relationship with their sponsor and othermembers as a reconnection with people. For others, these relationshipsmay represent their first real interpersonal connections. One patientexpressed the following, “As I came to know other people better, I cameto know myself better. While we are not all exactly the same, we aremore similar than we are different. I have a much better sense of whoI am, and I do not feel so different and alone anymore.”

Many of the sayings that are utilized in AA are verbal/cognitivedevices or tools designed to address issues central in addiction. Sayingssuch as “Keep coming back” reinforce a sense of agency (that one can dosomething to help one’s self) and reinforce a sense of connectedness toothers. Other sayings directly address some of the personality deficits oftenobserved in alcoholics and other addicts. “One day at a time,” “Don’t drinknow,” and “Wait a minute” can help restore a sense of temporality. “This

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too shall pass,” “Easy does it,” and “HALT” (hungry, angry, lonely, andtired) can help build tolerance of affect, regulate affect, and modulatefeeling states. The meaning and utilization of these verbal/cognitive toolsor devices will be discussed further later.

Hopson and Beaird-Spiller (1995) also found the first three steps tobe associated with psychological factors important in addiction. Step 1(powerlessness) was found to be associated with the acknowledgment ofa loss of agency. Step 2 (the belief that something greater than oneselfcan help) was viewed as compensating for a lack of internal structure.Step 3 (turning it over) was associated with relief from the effort ofcarrying the weight of strong feelings without assistance and the pre-sumption of agency. These first three steps have been critical for pa-tients in psychotherapy particularly, but not only, in early recovery. Therecognition of powerlessness or of the loss of agency provides a reasonto do something different in that whatever the patient has been doinghas not worked. The second step offers hope in that it is communicatedthat there is something more powerful than the self that can work. Thisis demonstrated by the presence of an organization of people who havesuccessfully achieved what the patient could not achieve relying exclu-sively on his or her own resources. In the third step, the patient “makesa decision” to rely upon others for help. Often, for the patient inpsychotherapy, there is an increased reliance on the therapeutic processand an increase in the experience of hope.

The AA program and the majority of the psychotherapeutic ap-proaches to the treatment of addiction share the common goal of absti-nence. The reality that alcoholics cannot learn to drink in a controlledmanner is well established (Wallace, 1993, 1990). They also share similartarget issues. These target issues include motivating the patient for change,facilitating the patient’s development of a sense of self, improving self-esteem and self-care, developing the ability to manage and tolerate affectand self-soothe, and building mutually satisfying relationships with others.The desired resolutions of these issues are similar in both AA and psycho-therapy. Constructing a treatment that is integrated results in addressingthese issues in at least three arenas: in psychotherapy, in AA, and in thepatient’s daily life. This integration can potentiate progress in a reciprocalmanner. A good understanding of the psychological function of AA prac-tices and precepts allows the therapist to support, use, and incorporate intothe psychotherapy those aspects of the AA program that facilitate progressand are consistent with the model of psychotherapy that is being practiced.At the same time, doing so supports and enhances the patients’ work inAA, which is clearly associated with success in recovery. Such a unifiedapproach can be very powerful.


THE PSYCHOLOGICAL FUNCTION OF AA PRACTICES ANDPRECEPTS FROM A PSYCHODYNAMIC PERSPECTIVE

From a psychodynamic perspective, addiction has been viewed asrepresenting attempts at self-care and self-soothing (Khantzian, 1980;Kohut, 1977; Krystal, 1975, 1978), affect tolerance (Krystal, 1978; Krystal &Raskin, 1970), and a way of managing affect by changing painful psychicstates, such as emptiness and deadness (McDougal, 1982, 1989). Compul-sive substance use has also been discussed as a remedy for narcissisticinjury and internal fragmentation (Kohut, 1977; Wurmser, 1974, 1984),helplessness and rage (Dodes, 2002; Wurmser, 1984), self–object differen-tiation (Krystal, 1978), and negotiating separation and connectedness(Kernberg, 1975; Krystal, 1975, 1978). Additionally, addictive behavior hasalso been described as a compromise accomplished by way of a displace-ment of action warding off other perceived dangerous behavior (Dodes,2002) and as an attempt at medicating a harsh superego (Kernberg, 1975;Wurmser, 1984). These psychodynamic factors in addiction are directlyaddressed by aspects of the structure and practice of AA beyond thosereported by Hopson and Beaird-Spiller (1995).

ESTABLISHING, CONSOLIDATING, AND MAINTAINING ASENSE OF SELF

Krystal (1978) discussed the difficulty that addicts have with regard toself-definition and self-object differentiation. Wurmser (1974, 1984) andKohut (1977) described the internal fragmentation often experienced bycompulsive drug users. Hopson and Beaird-Spiller (1995) noted that thereare aspects of the AA experience that facilitate the development of, andconsolidation of, a sense of self. Encouraging patients to “work” theaspects of the AA program that directly address these issues provides thepatient with support and facilitates the psychotherapeutic process.

At both open and closed AA meetings, members “tell their story.”This story is most often a life history organized around the development ofcompulsive alcohol use. They share their experience, strength, and hope bytelling the group “what it was like, what happened, and what it is like now.”These life stories often begin at birth and describe early childhood expe-riences in the family of origin that shaped the feelings, attitudes, and beliefsthat precipitated and maintained drinking behavior. The role that theseattitudes, beliefs, and feelings played in the development of alcoholicdrinking and behavioral problems is discussed. There is usually an empha-sis on how these attitudes, beliefs, and feelings changed as a function of

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abstinence and recovery. Members become more aware of what is uniqueabout them and what they have in common with others. Self-object differ-entiation is enhanced. Those group members who listen to the story areencouraged to “identify, don’t compare,” facilitating an interpersonal con-nection directly challenging the sense of alienation, separation, and discon-nectedness discussed by Krystal (1975, 1978) and Kernberg (1975).

Introspection and the consolidation of the self are further enhanced inthe process of completing the fourth step, which requires that a searchingand fearless moral inventory is completed. This requires self-examinationof positive and negative traits and behaviors or actions. When this step isdone honestly and thoroughly, the self view is rather complete and theself-representation is quite real. The fourth step usually results in a writtendocument which, in the fifth step, is shared with another person. Thisperson is often, but not always, the sponsor. In sharing with another person“the exact nature of our wrongs” as they exist alongside positive traits andattributes, an honest presentation of the self is offered to another humanbeing. If the person to whom the self-disclosure is made is chosen correctly,the response is not punishment or condemnation. What is communicated isunconditional acceptance and the reality that one does not have to continueon as before. Change is possible and evident in the members of AA. Theabsence of a punishing response and the message that one’s shortcomings aresimply human directly challenges the harsh superego observed in many alco-holics and other addicts (Wurmser, 1984; Kernberg, 1975). This process alsofacilitates the development of more true and intimate relationships with othersin general, further diminishing the sense of alienation and aloneness.

ESTABLISHING A SENSE OF RELATEDNESS TO OTHERS

The process described thus far results in a clearer, more complete, andstronger sense of self and self-acceptance. At the same time, a morecomplete and more accurate view of others is being established. Thisgenerates much grist for the psychotherapeutic mill. The AA emphasis onfellowship and regular meeting attendance (“keep coming back”) facili-tates the development of interpersonal relationships. The interpersonalrelationship between sponsor and sponsee, particularly after the fifth stephas been completed, can serve as a bridge to more meaningful interper-sonal relationships with others. Because AA meets as a group, over time,social anxieties often decrease. Through the process of telling one’s storyand listening to the stories of others, one becomes known to others andknows others. In this way, group members know a great deal about oneanother, even without direct individual interpersonal interactions. Eventu-


ally, interpersonal connections are established. AA members are encour-aged to call their sponsor and at least one other alcoholic daily. All groupmembers can receive calls from other alcoholics who may need help or whoare simply following the suggestion that they make the call. Over time,newcomers find that they have something to offer to more recent newcom-ers. Self-esteem and self-worth increases with the realization that one hassomething to offer that someone else wants or needs. As one patient saidin session:

At the meeting the other week, this new guy Ted came up to me. He’s been sober6 days. He asked me how long I have been sober. I was embarrassed to answerbecause I don’t have much time. But I told him that I’m sober 2 months. You knowwhat he said to me? “Two months! God, how did you do that? I don’t think I canmake it another night.” So I told him what I do and that he can do the same thing.If it worked for me, it could work for him. I felt useful. I felt great! We talk all thetime now.

SELF-CARE AND SELF-SOOTHING DEFICITS

Khantzian (1980) highlighted the self-care deficits often observed inalcoholics and other addicts. Khantzian uses the term self-care to describethe addict’s inability to recognize the signs of danger and deteriorationassociated with compulsive drug use. When these signs are not recognized,the anxiety that would normally motivate change behavior is not experi-enced, and the alcoholic does not act in the service of self-protection andself-care. In AA, this is labeled denial. It is not thought of as an ego deficitbut as a defense. Regardless of the etiology of this self-care problem, AAdirectly addresses it in a manner that can be quite effective.

In the process of telling one’s story, the progression of negativeconsequences and the unmanageability of life associated with alcoholicdrinking become inarguably clear. Working on Step 1 involves thereconstruction the sequence of events of life conflict and associatingthese events with alcohol use. The goal is to “Tie the drinking to thetrouble in your life.” Working on Step 8 involves constructing a list ofall the people that you have had a negative impact on as a direct resultof drinking and of the attitudes and beliefs that support addictivebehavior, such as entitlement. Completing such a list further clarifies therelationship between addictive behavior and conflict and pain. Theresulting increased awareness and understanding is then used to helpthe recovering AA member to “think the drink through.” When theyexperience the impulse to drink, they are encouraged to put the nega-tive consequences in front of the thoughts about drinking. This involveslooking at where drinking has led them in the past and where it will leadthem if they drink again, before they take a drink.

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Many addicts evidence what Kohut (1977, 1993) identified as deficits inthe ability to self-soothe. This ability is typically learned in interaction withparents who soothe their child by reflecting the child’s goodness and powerand by providing a sense of calm, safety, and protection. The child may feelgood enough and powerful on his own, or he may merge with the all-powerful parent to establish a sense of goodness, power, and security.Many alcoholics and other addicts never internalize this healthy grandios-ity or the capacity to self-soothe, so they look outside themselves to anego-enhancing and calming, soothing substance. Kohut (1977, 1993) main-tained that reparative experiences later in life can correct these deficits ifthe individual is involved in higher-quality interpersonal relationships withothers who possess the missing abilities. Participation in AA can be such areparative experience.

Self-acceptance and a healthy grandiosity are supported by the correc-tive emotional experience that the AA member has with the uncondition-ally accepting sponsor and with the group, both of which mirror themember’s positive qualities and accomplishments. In working Steps 2 and3, members are encouraged to recognize that something greater thanthemselves (the higher power or the “idealized parental image”) canrestore them. Members are encouraged to turn it over to (or merge with)the all-powerful entity. In this way, the powerless become empowered, anda sense of protection and serenity is achieved.

BUILDING AFFECT TOLERANCE AND MANAGING AFFECTAND BEHAVIOR

Several researchers have recognized the difficulty that addicts have intolerating and managing emotions and behavior. Krystal and Raskin (1970;see also Krystal, 1978) discussed this difficulty with the tolerance of strongemotional experiences and the impulse to medicate them. McDougal(1982, 1989) examined the use of substances to change painful affectivestates such as emptiness and deadness. Dodes (2002) and Wurmser (1984)highlighted the compulsive drug user’s vulnerability to narcissistic injury. Alack of tolerance for the accompanying experience of anger and rage, aswell as the need to medicate it, is identified as an important precipitant ofcompulsive use. Additionally, unwanted impulses and behaviors are oftenmedicated with substances decreasing the likelihood of occurrence. Dodes(2002) described the action of addictive behavior itself as a displacement ofother perceived dangerous or otherwise unwanted behavior.

The practice in AA of putting one’s experience into words and hon-estly sharing thoughts and feelings with a sponsor and with the group


allows some discharge of affect and communicates the member’s needs andconflicts to others. The atmosphere of unconditional acceptance facilitatesthis. Psychological and emotional pain is shared. Support is offered inreturn. Acronyms such as HOPE (hold on, pain ends) and sayings such as“this too shall pass” communicate the temporality of pain and distress.Specific strategies are suggested, such as “move a muscle, change athought.” Prevention strategies are also offered, such as teaching theperson in recovery to be aware of HALT (hungry, angry, lonely, tired)states. These states are presented as setting the recovering addict up forrelapse or any other undesired behavior. AA members who are strugglingwith anger, resentment, and depression are often encouraged to “make agratitude list.” This strategy is similar to, but not exactly the same as,positive reframing. Step 10 also directly addresses the experience of re-sentment and anger as these emotions frequently precipitate relapse. Themessage in Step 10 is that anger, no matter how justified it may be, canbe hurtful to the person that is experiencing it and must be managed.The message is not that anger is necessarily bad but that emotionalexperience must be balanced and unbridled anger is destructive. AAmembers are encouraged to express what they are thinking and feelingso that the thoughts and feelings are subject to the scrutiny of others.They are encouraged to look for and to examine their particular vul-nerabilities that contribute to their experience of hurt and anger. Indi-vidual motives can be checked. Support is offered. Ultimately, individ-uals are encouraged to take responsibility for what they do, regardlessof how justified the anger may be. AA strategies similar to positivereframing are suggested in these situations as well.

Narcissism plays a major role as a risk factor for substance use andas a moderator variable related to relapse. Dodes (2002) stated that alladdictions are displaced efforts to repair underlying narcissistic injuries.Addiction is often driven by the rage associated with the narcissisticinjury (Wurmser, 1974, 1984). In the service of supporting pathologicalnarcissism, substance abuse may be a defensive/compensatory strategyto maintain and enhance self-esteem and cohesion of the self (Kohut,1977, 1993). Patton, Connor, and Scott (1982) stated that by ingestingalcohol and other drugs, the narcissistically impaired person may ac-quire the confidence so painfully lacking, addressing a deficit in whatKohut called the grandiose self, or the substance may be used to calmand protect himself or herself addressing a deficit in the omnipotentidealized parental image.

Active participation in the program of AA directly addresses many ofthe issues and conflicts revolving around pathological narcissism by pro-viding a reparative experience. The communication of unconditional ac-ceptance and the expectation of, and tolerance of, normal human failings

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helps to address self-criticism and perfectionism. AA members are taughtthat they are intrinsically of value and that they do not have to be perfector “better than.” The goal is to be “right-sized.” Being right-sized meanshaving an accurate self-appraisal that is neither self-deprecating nor self-aggrandizing. Honest and accurate self-disclosure submits the self-appraisal to examination and feedback is offered. The issue of narcissisticgrandiosity and self-focus is approached with the AA program’s emphasison humility. It is explained that to be humble is “not to think less ofyourself, but to think of yourself less.”

Opportunities for positive mirroring exist at the initial contact withAA, and the “goodness” of the individual is reinforced throughout. Asense of agency and power is instilled. The message is sent: “It works if youwork it, so work it you’re worth it.” An omnipotent idealized object isoffered for merger as the higher power: the group and sponsor. With aninternalized sense of goodness and power and in response to normalhuman failures of largely competent and dependable group members, therecovering AA member develops additional competencies. Self-esteem issupported by real-world accomplishments. Members can now see them-selves as of value to others as well. Narcissistic supplies are accrued, andself-esteem and independence are increased.

AA AND CBT

The AA program is essentially a cognitive– behavioral program. Itfacilitates changing one’s perception or understanding, resulting inchange in emotional experience and behavior. Morgenstern et al. (2002,p. 665) reported findings that “overall, supported the role of 12-stepcognitions in mediating outcomes in 12-step treatment.” The AA pro-gram maintains that alcoholism is 10% drinking and 90% thinking. Toget sober and stay sober, one must change one’s “stinking thinking.”The cognitive changes that are sought are all along the lines discussedearlier in detail. The cognitive psychotherapist can utilize or reinforceselect components of the AA approach that are consistent with anyparticular treatment goal. For example, if the patient’s unrealistic beliefthat she cannot live without drinking is the focus of treatment, helpingher to see that others who have felt as she does are now living happilyin sobriety can be enormously helpful. Encouraging them to attend AASpeaker’s Meetings allows them to hear the stories of people who felt asthey do who have learned to live a sober life. Utilizing the saying “If youwant what we have, do what we do” not only communicates that a lifewithout alcohol is possible but also suggests a strategy for change.


One particular area of concern in the treatment of addiction is generatingand maintaining motivation. As Nowinski (1996) highlighted, motivation sus-taining active effort in recovery is often a problem for patientsin psychotherapy, as well as for those utilizing AA. Prochaska andDiClemente (1982) addressed the issue of motivation for change. They presentchange as occurring through a process of stages. Stage 1 is referred to asprecontemplation. During this stage, the patient does not believe a problemexists. In Stage 2 (contemplation), the patient considers the existence of aproblem but remains ambivalent. In Stage 3 (preparation), the patient pre-pares to change but still retains some ambivalence. In Stage 4, the patient takesaction. He or she begins to change, but ambivalence can still be a problem.Stage 5 is described as maintenance, and the goal is to maintain change andprevent relapse. Stage 6 is defined by relapse or completion/termination.

Expanding upon this change model, Bishop (2001) delineated threetypes of patients from a clinical perspective. Type I patients are Stage 1patients. They are not volitional. They were probably sent to therapy anddo not think they have a problem. The task here is combating denial. TypeII patients are Stage 2 and 3 patients. They think they may have a problem,but they are not sure if they want to do anything about it. They need toexamine the consequences of their drinking and explore options. Type IIIpatients are Stage 4 and 5 patients. They want help and want to change.The task is to maintain progress or start again. From a cognitive–behavioral perspective, Bishop recommended applying the ABCs (activat-ing event, beliefs, consequences) and pursued hidden irrational beliefs tohelp patients manage their behavior by understanding the chain of eventsand altering their perceptions. The program of AA has much to offer allthree types of patients identified by Bishop (see Table 1).

A review of the function of the 12 steps specifically with regard tomotivation for change suggests the following: Type I patient issues areaddressed by the first step. In Step 1, acceptance of the need for change andthe need for the maintenance of change is recognized and promoted. Step1 is worked throughout the entire span of recovery.

The issues that characterize Type II patients are addressed by Steps 1,2, and 3. In Step 2, there is the recognition that help is available and changeis possible. In Step 3, a willingness to change is reflected in deciding to relyupon and follow the program. Type III patient issues are addressed bySteps 4 through 12. In Step 4, one identifies one’s own role in having madenegative choices and dysfunctional behaviors. This helps identify behaviorsin need of change. As these behaviors are shared with another person inStep 5, they are recorded, so to speak and open to scrutiny, and changestrategies are further developed.

In Steps 6 and 7, a conscious commitment to change is made. In mypsychotherapeutic work with people in recovery who are also in AA, I have

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found that the working though of Steps 6 and 7 can result in a renewedcommitment to change and significantly accelerates the psychotherapy.When a psychotherapy has stalled, I have at times recommended that thepatient revisit Steps 6 and 7 with his or her sponsor. This usually results inthe clear identification of the resistance. One patient, a recovering alco-holic who suffered from work inhibition, correctly identified his powerfulfear of criticism and rejection as a resistance to enacting some of thechange strategies that he consciously accepted when he reworked the sixthstep. When he identified and experienced his fear, the focus of the psycho-therapy shifted and he ultimately committed to and engaged in behavioralchange.

Steps 8 and 9 involve an active demonstration of the willingness to livedifferently. In the act of recognizing that one has done some wrong and hada negative impact on others, the need for change and the desire to changeis enhanced. The act of taking responsibility for one’s past behavior andattempting to make amends is a very necessary and significant change for

Table 1. Bishop’s Patient Typology and the Corresponding Alcoholics Anonymous (AA)Practice That Can Support, Motivate, and Maintain Change

Patient typology and the necessarypsychotherapeutic intervention

AA practice that can support the necessarypsychotherapeutic intervention

Type 1: The patient is not volitional.He was probably sent to therapyand does not think he has aproblem. The task here iscombating denial. These areprecontemplation patients.

Step 1: The trouble in, and the unmanageability of,life is accepted as a direct consequence ofdrinking. This is actively reinforced in earlyrecovery. AA sayings such as, “if nothingchanges, nothing changes” addresses the issue ofneeding to do something, and “change or die”highlights the possible tragic consequences offailing to change.

Type 2: The patient thinks he mayhave a problem, but he is not sureif he wants to do anything aboutit. He needs to examine theconsequences of his drinking andexplore options. These arecontemplation and preparationpatients.

In addition to Step 1 (which is worked throughoutrecovery), Step 2 highlights that an interventioncan be effective and that there is hope if onewill follow Step 3 and accept direction andguidance. The statement “If you want what wehave, then do what we do” can provide apositive motivation.

Type 3: The patient wants help andwants to change. The task is tomaintain progress or start again.These are action and maintenancepatients.

Steps 4, 5, 8, and 9 involve “cleaning house” andstarting to “clear away the wreckage of thepast.” Beginning to feel better about oneself andrecognizing growth and change is motivational.Steps 6 and 7 involve examining one’s resistanceto change and securing a commitment to furtherchange. Step 10 is about maintaining change ona daily basis, and Step 12 focuses on “practicingthese principles in all our affairs” or ongoingmaintenance.


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

PSYCHOTHERAPY AND AA INTEGRATION BY STAGEOF RECOVERY

Brown (1995) described recovery from alcoholism as proceedingthrough several stages. These stages are labeled drinking, transition, earlyrecovery, and ongoing recovery. The patient’s treatment needs are differentduring each of these stages. Yalisove (1992) further clarified the course oftherapy, the goal of therapy, and role of the therapist during each stage.

During the drinking stage of early recovery, the patient is intoxicated,unstable, and desperate. His or her contact with the therapist or with AAmay have been coerced. Because the patient’s judgment is drug affected,the therapist must function as an auxiliary ego. The therapeutic task duringthis stage is to accomplish a level of care assessment, to manage the crisis,and to provide for the patient’s immediate safety. This crisis needs to bemanaged, and the patient may need to be referred to a higher level of care(Yalisove, 1992). During this stage, AA can be enormously helpful. AAmembers can offer 24-hr support. They will be physically present with theindividual and will watch and safeguard them. They willingly transportpeople to hospitals, detoxification units, or and rehabilitation centers. Thisearly connection with AA can be quite enduring and can result in a senseof gratitude and hope. When the therapist has a role in this early connec-tion, the “positive transference” is shared.

During the transition stage, the patient’s abstinence is unstable. Inearly transition, he or she may be confused and quite labile. With episodesof abstinence and/or periods of abstinence that are longer, there may besome cognitive clearing but periods of confusion and mood labiality persist.The therapeutic task during this stage is to further assess the addiction,establish the need for abstinence, maintain a stable abstinence, and pro-mote the acceptance of addiction. The structure and rules of treatmentneed to be established. A behavioral focus during this stage is often helpful.Any steps toward progress must be reinforced, and reversals or relapsesmust have appropriate consequences. The role of the therapist continues asan auxiliary ego, a teacher, and supporter of progress. It is important to

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provide guidance and direction and to promote a positive transference(Yalisove, 1992). The patient’s participation in AA during this phase ofrecovery/treatment is extremely important.

During early transition, AA offers the patient a sponsor or a tempo-rary sponsor for ego support. AA members will pick newcomers up andtake them to meetings. Beginners’ Meetings tend to focus on the first threesteps and emphasize what one must do to remain abstinent. They offersupport and instruction and provide a sober support network. Step 1reinforces the acceptance of powerlessness and unmanageability and rein-forces the need for abstinence. Step 2 offers external support through thepower of the group. A positive message and a sense of hope are commu-nicated by sayings such as “it works if you work it.” During the later partof the transition phase, the patient who is also attending AA continues topractice Steps 1, 2, and 3 to maintain abstinence and accept direction. Indoing so, the patient receives support in learning how to manage impulsesand urges. Supportive relationships with a sponsor and group memberscontinue to develop.

According to Brown (1995), early recovery is characterized by a stableabstinence. During this phase, the patient needs to adapt to reality withoutthe use of alcohol or other drugs or acting out. It is important for thepatient, the therapist, and significant others in the patient’s life to recognizethat symptoms of postacute withdrawal syndrome can persist for anywherefrom 6 to 24 months after abstinence begins (Gorski & Miller, 1986; Kelly,1994). This syndrome is characterized by cognitive problems as evidencedby the inability to concentrate, impairment of abstract reasoning, and rigidand repetitive thinking. There are also significant memory problems, emo-tional overreactions or numbness, sleep disturbances, physical coordina-tion problems, and stress sensitivity. These symptoms usually peak duringa 3- to 6-month period after abstinence begins. Therefore, lapses in judg-ment and impulse control are episodic and constitute significant relapserisks. The therapist’s role must remain rather supportive, parental, andinstructional. The patient’s strengths and weaknesses must be continuallyassessed and monitored. In general, early recovery is not the time toaddress or uncover powerful and disturbing memories or emotions becausethe patient’s nervous system is only partially repaired and the tools formanaging such an experience are not likely to be in place.

The AA program has a great deal to offer the patient in early recovery,particularly with regard to practical coping tools and cognitive strategies.Working on Step 1 leads to accepting life on life’s terms, and Steps 2 and3 help the individual to accept support from a sober support group. Steps4 and 5 help address old behaviors and attitudes that can trigger relapse.The commitment to change is reviewed and reaffirmed in Steps 6 and 7.Steps 8 and 9 help to begin to solidify change and result in the individual’s


heightened awareness of the progress that he or she has made. All of thisfacilitates the adjustment to reality without the use of medicating sub-stances or behaviors by diminishing those factors that promote relapse andproviding tools to manage the thoughts and feelings that occasioned ad-dictive behavior in the past.

In ongoing recovery, with a stable abstinence achieved, the psycho-therapy treatment can now work on developing insight into the causes ofaddiction, psychological problems, and psychiatric and character disorders(Brown, 1995). The therapist’s role is more traditional. This type of psy-chodynamic exploration is not recommended in early recovery for thereasons stated earlier, but it is important that this work is accomplished inongoing recovery to address any residual issues that will leave the patientvulnerable to relapse. When a patient has been successful in recovery formany years and then relapses, it is most often because this level of psy-chotherapy work has not been accomplished. The goal is to achieve self-knowledge and self-awareness, resolve conflict, and alleviate symptoms.

In ongoing recovery, the patient in AA continues to work on “accep-tance of life on life’s terms.” Having worked through Steps 1 through 9, theacceptance of the need for continued sobriety should be firmly rooted. It islikely that many of The Promises or positive outcomes of sobriety havebeen realized so that there are additional positive reasons to remain sober.Many core issues have been identified that can now be further examinedwith a patient who now has the ego strength to tolerate it. The patient isfirmly connected to a sober support network and has developed manycoping strategies to manage the threats to self-esteem and powerful emo-tions that a psychodynamic psychotherapy will generate. The therapist canhave greater confidence in the patient’s ability to self-monitor and addresshis or her needs in healthy ways, including relying upon others for supportand assistance.

PSYCHOTHERAPY AND AA: A BRIEF CASESTUDY ILLUSTRATION

James was a 45-year-old, married father of one son. He sought treat-ment complaining of a persistent depression, marital problems, worka-holism, and “a drinking problem.” He was quite accomplished in his field,having earned a doctorate in law and labor relations at an Ivy Leagueuniversity. He worked at a very intense high-pressured and high-profileposition on issues that had important and serious consequences. He ap-peared visibly strained and depressed. James described a family of originthat was characterized by high expectations of achievement and low

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expressed emotion. He described his wife as rather narcissistic, self-involved, and ultimately passive. He expressed feeling as if he was “re-sponsible for everything.” James worked frenetically and overcommittedhimself. Consequently, he was always behind and “disappointing some-one.” At the end of the day, he found it impossible to relax or sleep withoutdrinking. He was a daily drinker who drank more heavily on the weekends.He clearly met the criteria for alcohol dependence.

James began psychotherapy seeking relief from stress and depression.He recognized intellectually that he was drinking more than was good forhim but did not see himself as alcoholic. He also failed to see that hisdepression and many of the conflicts at work and at home were directlyrelated to his drinking as both a cause and a consequence. He needed tohear this to motivate him to do something about it and to commit to anongoing treatment and change. However, the therapeutic alliance was new,and there was not likely to be a strong enough positive transference totolerate a strong and persistent confrontation of the denial. In an effort tosplit the transference, I advised him to attend seven AA meetings so thathe “could meet other people who also drank too much and see if hethought there were any similarities or differences and learn somethingabout how they dealt with a drinking problem.” He accepted that this couldbe helpful even if he was not alcoholic. I specifically sent him to OpenSpeaker’s Meetings so that he could just sit and listen without having tospeak himself.

In psychotherapy, James reported that he felt that he could identifywith some of what he heard “but not all of it.” This generated a fruitfuldiscussion of his perception of similarities and differences between himselfand other people with drinking problems. At this point, he concluded thatalthough he was not an alcoholic, he liked some of these people and feltthat he could learn from them. I sent him to attend a few Beginners’Meetings at which he did not have to “admit that he was an alcoholic” butonly that he had “a desire to stop drinking.” He attended these meetings,listened, and learned. He was not ready for a sponsor or even a temporarysponsor, but he left one of these meetings with a group membership listwith 50 names and telephone numbers. As this was occurring, psychother-apy time was split between direct discussions about his drinking, whichwere often precipitated by experiences that he had at AA, and furtherassessing his depression and job and marital problems. After a month or so,he came into session and told me that he thought he was alcoholic “on topof everything else.” We agreed that he would continue in AA and get asponsor and that we would work on “everything else.” In doing so, therelationship between “everything else” and his drinking became clear.Thus, the psychotherapy supported his AA participation, and his AAparticipation enhanced the psychotherapy. His commitment to change and


his connection with me and with AA grew strong. He made a commitmentto stop drinking. When he did so, he experienced withdrawal symptoms,which confirmed the diagnosis and enhanced his commitment to change.

James’s transition to early recovery was characterized by a sense ofaccomplishment and three “slips,” or relapses. Although he heard themessage from AA that relapse was part of the illness of alcoholism and thatthis simply confirmed his lack of control over drinking, his self-esteem wastenuous at best. He also evidenced the expected postacute withdrawalsymptoms particularly with regard to exaggerated affect. AA members toldhim, “You’re right where you’re supposed to be,” helping to normalize theexperience and letting him know that it will pass. In psychotherapy, hebegan to examine his negative self-view and negative expectations. Henaturally began to review the history of these feelings, which led him todisclose several traumatic and painful childhood events. My response wasempathic, validating, and supportive. At the same time, I had a discussionwith him about putting a moratorium on this area of his experience untilsome future time when he would be better able to manage it. He agreed,and he was able to do so. The AA program helped him to keep his focuson the here and now and on the primary task of staying sober.

As James achieved a stable abstinence, his fourth-, fifth-, eighth-, andninth-step work generated much grist for the mill. This work in AAinvolves honest self-examination and enhanced his self-appraisal abilities.In psychotherapy, this fueled introspection and self-analysis. He had de-veloped insight and was continuing to do so. Just after he celebrated 2 yearsof sobriety, we revisited the childhood trauma issues that had been dis-closed earlier and “placed on hold.” James experienced the appropriaterage and sadness that he was barely able to manage. He used the tools ofthe program and expressed his feelings in meetings as well as in session.This resulted in a conflict between the message that he was receiving fromme—that it was important for him to feel, express, and tolerate theseemotions—and a message that he was getting from some in AA who weretelling him that he should not allow these feelings because they couldtrigger a relapse. AA offered him strategies to avoid the experience ofanger. I supported his utilizing these tools in his daily life while I continuedto encourage his contacting and expressing his feelings in psychotherapysessions. This integrated approach was quite helpful to him. The psycho-therapy work proceeded with all of the necessary affect, but he had thetools and the personal assistance of AA members to detach from theseemotions in his day-to-day life, function, and not drink. From this pointforward, the psychotherapy proceeded in a more traditional manner butalways with the awareness that this patient is an alcoholic in recovery andthat, consequently, relapse is always a possibility that must be considered.

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CONCLUSION

The utilization and effectiveness of AA identifies the program as avaluable asset in the treatment of addiction. Although the AA programand the professional treatment approach of psychotherapy grew out ofdifferent traditions, the two approaches share a common goal, targetsimilar issues, and work toward similar outcomes. The two approaches canbe integrated on theoretical and practical/clinical levels. A psychotherapyapproach that integrates or unifies the two approaches can be quite pow-erful. Treating a patient in psychotherapy who is also working the AAprogram without a good understanding of AA can result in the twoapproaches working at cross-purposes, diminishing the effectiveness ofboth interventions. Given that addiction is an illness with a treatmentsuccess rate of approximately 40% across studies, it is necessary to utilizeall available resources. In my clinical experience, the integrated approachdescribed earlier increases treatment success and results in a more stableand durable recovery.

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APPENDIX 1

The 12 Steps and Promises of Alcoholics AnonymousStep 1: We admitted that we were powerless over alcohol—that our lives had become

unmanageable.Promise: We are going to know a new freedom and a new happiness.

Step 2: Came to believe that a power greater than ourselves could restore us to sanity.Promise: We will not regret the past nor wish to shut the door on it.

Step 3: Made a decision to turn our will and our lives over to the care of God as weunderstood Him.

Promise: We will comprehend the word serenity and we will know peace.Step 4: Made a searching and fearless moral inventory of ourselves.

Promise: No matter how far down the scale we have gone, we will see how ourexperience can benefit others.

Step 5: Admitted to God, to ourselves, and to another human being the exact nature ofour wrongs.

Promise: That feeling of uselessness and self-pity will disappear.Step 6: Were entirely ready to have God remove all these defects of character.

Promise: We will lose interest in selfish things and gain interest in our fellows.Step 7: Humbly asked Him to remove our shortcomings.

Promise: Self-seeking will slip away.Step 8: Made a list of all persons we had harmed and became willing to make amends to

them all.Promise: Our whole attitude and outlook on life will change.

Step 9: Made direct amends to such people wherever possible, except when to do so wouldinjure them or others.

Promise: Fear of people and of economic insecurity will slip away.Step 10: Continued to take personal inventory and, when we were wrong, promptly

admitted it.Promise: We will intuitively know how to handle situations that used to baffle us.

Step 11: Sought through prayer and meditation to improve our conscious contact with Godas we understood Him, praying only for knowledge of His will for us and the powerto carry that out.

Promise: We will suddenly realize that God is doing for us what we could not do forourselves.

Step 12: Having had a spiritual awakening as a result of these steps, we tried to carry thismessage to alcoholics and to practice these principles in all our affairs.

Are these extravagant promises? We think not. They are being fulfilled amongus—sometimes quickly, sometimes slowly. They will always materialize if we work forthem.


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Psychotherapy and Alcoholics Anonymous - An Integrated Approach