In case of emergency, take the (12) Steps:

Mani Mehdikhani
 
This paper considers Alcoholics Anonymous and its 12 Steps approach from a psychologist’s perspective.
The terms and intervention components can be construed in language more familiar to psychologists, an overview of how the approach may help is given, followed by a consideration of overcoming some of the potential barriers to service users referring themselves to a group.

ALCOHOLICS ANONYMOUS (AA) is arguably the granddaddy of all mutual aid programmes, now thought by some to be an essential aid in the recovery journey of addicts. I will not delve here in any great detail into the origins of the 12 Steps (henceforth I will use the terms ‘12 Steps’ and ‘Alcoholics Anonymous’ and ‘AA’ interchangeably) or on the literature on the research into the effectiveness of A or on the many controversies surrounding this topic.

I must confess that I initially had strong personal reservations about AA. There was little in my religious outlook or professional background that prepared me to accept this. I had a problem with what I perceived to be the ‘religious’ aspects of this programme. I was troubled that AA appears to promote the idea that the ‘addict’ has no control over his or her substance use and that as a consequence all attempts at controlled use are futile and ultimately doomed to fail (which leaves abstinence as the only realistic goal). I disapproved of the seemingly stigmatising labels that people in 12 Steps groups attach to themselves, such as ‘alcoholic’ or ‘addict’, informed by a simplistic and distorted view of narrative therapy (cf. Diamond, 2000). I felt that such labels internalised the person’s problems with substance use, essentially turning that person into the problem. I initially had no fondness for the use of the slogans used by AA members nor for the idea that one should set aside ‘critical thought’ (‘analysis is paralysis’), given that as a (cognitive) therapist I saw a big part of my role in terms of helping clients develop insight into their behaviours. Over time I have shed many of these and other prejudices.

Gods and higher powers
Perhaps the most controversial, and at the same time most misunderstood, aspect of the 12 Steps is the focus on the concept of God, and in more recent adaptations on a ‘higher power’. In fact, AA has been critiqued on the grounds that much of its philosophical underpinning was based on the Oxford Group Movement (a 19th century Christian movement) (Bufe, 1998). However, to attack an idea based on its origins is a species of logical fallacy (the ‘genetic fallacy’, a cousin to the ad hominem attack). In reality, ideas should be evaluated on the merits of their argument and on their ability to withstand testing (Williams, 1996). Flores (2004, p.193) has noted that ‘AA invokes a spiritual or religious vocabulary in the absence of perhaps a more accurate but inaccessible philosophical-ontological terminology’. Vaillant (2005, p.434) has further suggested that the quasi-religious terms used in AA are ‘designed to affect the reptile brain [but] the rhetoric and the emotional language of the spirituality of AA leads journalists and social scientists to understandably fear that AA is a religion or cult’. The term ‘God’ in this context serves to challenge the addict’s ‘narcissistic defences’ (Flores, 2004) and lead them to the realisation that they are, in fact, ‘not God’ (Kurtz, 1979; Diamond, 2000). In this view, God is the only being that can go it alone, without help from anyone. Everyone else needs the support of others to recover. As one AA slogan points out: ‘AA can help you if you believe in God; AA can help you if you don’t believe in God; but AA can’t help you if you think you are God.’

12 Steps: Who and what are they good for?

Relapse avoidance
There is little question that the main challenge faced by those trying to give up an attachment to a substance is not so much the initial giving up of problematic use but in remaining in control or abstinent after desistance. According to Vaillant (2005), relapse avoidance requires the presence of at least two of the following four factors: external supervision, ritual dependency on a competing behaviour, new love relationships, and deepened spirituality. Although it is possible to achieve most or all of the above in other ways, AA and her sister organisations appear to allow the opportunity to access all of the above factors in one package.

Attachment
Flores (2004) has highlighted the potential benefits of the 12 Steps in the recovery of addicts who have had difficult attachment histories, arguing that for some clients the damage (disruption to the attachment system) may have been too severe or may have occurred too early (during a sensitive period) in development for individual therapy to be truly curative. This may in some respect be analogous to the ‘normalisation’ debate (Wolfensberger, 1980) in terms of striking a balance between ‘normalising the person’ versus ‘normalising their environment’. AA may therefore represent a long-term, perhaps even a lifelong, ‘holding environment’ for some clients (Flores, 2004).

Compassion and forgiveness
Shame (a self-attacking process) and guilt (driven by caring for others) can complicate the treatment of addiction and other disorders. Addicts, stigmatised by society and isolated from their loved ones, can experience tremendous feelings of shame and guilt, which may become triggers for relapse. By working through the 12 Steps (particularly Steps 4, 8 and 9; making a ‘fearless inventory’ of those they have wronged and seeking to make amends for those wrongs) addicts are offered formalised mechanisms by which they may address crippling feelings of guilt and shame (Worthington et al., 2005). Additionally, AA’s conception of God (‘as we understand him’ (or her)) bears striking similarities to the ‘prefect nurturer’ model (Lee, 2005).

When and how to facilitate access to 12 Steps
There has been much recent interest in the facilitation of clients’ access to 12 Steps and other mutual aid groups, including a number of guidelines by Public Health England, NICE and others (e.g. Public Health England Publications, 2013; NICE, 2007). When considering referring clients to 12 Steps meetings it is important to familiarise oneself with the basic tenets of AA, including a range of slogans. There is considerable literature around this topic (e.g. the ‘Big Book’; Alcoholics Anonymous), but it is worthwhile attending open meetings as a visitor and making contact with AA leaders and members. It also means having an awareness of what is available in one’s locality. Although some may claim that ‘all you need to start your own AA meeting is a resentment and a coffee pot’, it is advisable to check online resources (e.g., www.alcoholics- anonymous.org.uk) to find out the location of meetings that are affiliated with the wider national and international AA organisations.  In deciding whether to refer a client to a 12 Step programme, among the first things to consider might be whether your client indeed has an addiction or is ‘merely’ abusing or excessively using alcohol or drugs (‘if your drinking is getting in the way of your work you are a heavy drinker; if your work is getting in the way of your drink then you are an alcoholic’); nonetheless as one member once informed me such meetings tend to be ‘self-cleansing’, in the sense that those who do not truly belong will eventually vote with their feet. 

Facilitating access
After deciding to refer a client to a 12 Step meeting, you are likely to face the hard part: actually convincing them to go to one. I have in the past made attending meetings a condition of the offer of therapy, particularly in the case of behavioural couples therapy, which often includes this element as part of contracting. However, clients can display a myriad of rationalisations and defences when the topic of going to meetings is raised: they may say they do not like groups (‘you don’t have to like it [going to AA], you just have to do it’); they do not think they need help from other people; they may have had aversive past experiences with the 12 Steps or have misconceptions about them (i.e. the ‘religious’ aspect, or the belief that they might be forced to tell their life story at the first meeting); they may believe that they ‘heard it all before’; and so on. The key is not to lose heart at encountering this initial resistance and to keep in mind that there is no single right way that works with everyone. I tend to employ a motivational interviewing informed approach (Miller & Rollnick, 2013), which one colleague has dubbed ‘elicit-permission- elicit’; begin by eliciting whether the client has been to such meetings in the past, what they already know about AA and what they think about going to a meeting. Then ask permission to share what you know about AA, socialising them to the model whilst addressing individual concerns. For example, if someone has had negative past experiences (and have generalised from one or a few bad experiences to all aspects of 12 Steps), find out if they felt ready for AA at that time and challenge in a non-confrontational way (as one AA member once told me: ‘If you don’t like the beer at your local pub, you don’t stop drinking beer; you find another pub’). For those who feel that they know it all and that the 12 Steps have nothing new to teach them, a useful avenue to pursue might be to find out if they would be willing to put their knowledge and experience at the service of others to help with their recovery; as Yalom (1995) has alluded, if the cutlery at your table is too long to get the food to your mouth, then use them to feed your neighbour. Where possible, gently challenge any myths and misconceptions about the 12 Steps, reflect any change talk and then elicit what they think about what they have learned from you. If after all that the client still refuses to consider going to a meeting, don’t give up. Acknowledge that they are likely not ready yet to try AA and ask permission to revisit the topic at future meetings.

Conclusions
The appeal of AA is easy to spot: it is cheap (members ‘pass the hat’ to collect donations), there is no waiting list, members can attend as often and for as long as they like, both individual and group support is available, there is little of the red tape plaguing professionals in healthcare settings, and it is run by and for addicts. Nonetheless, whilst there has been growing interest in Alcoholics Anonymous and her sister organisations, these remain both controversial and highly polarising. My own views have changed over time from deep scepticism to cautious acceptance. Do I believe that AA is a universal panacea for those struggling with addiction? Even AA members acknowledge that the 12 Steps are not for everyone. However, at present deciding who to refer to AA is as much art as science . The general rule of thumb seems to be that those struggling with shame and guilt, those suffering with personality difficulties (‘defects of character’), disrupted attachment (such that ‘normalising the person’ is a faint hope), or with affective dyscontrol may benefit from this approach. On the other hand, those for whom the above does not apply – those who are militantly secular or have controlled use as their goal; those who are heavy users but not addicted; and those for whom standard cognitive-based approaches are both suitable and possibly curative – may find a better fit in alternatives .

Mani Mehdikhani, Chartered Clinical Psychologist,
Specialist Services Network, Greater Manchester West Mental Health NHS Foundation Trust