THE EFFICACY OF THE TWELVE STEPS IN RECOVERY PSYCHOTHERAPY
For the past 25,000 or so years of human history, people have been finding ways to get intoxicated, and for nearly as long, they have been trying to stop. Many methods have been tried and failed or met with limited success. In May of 1935, Alcoholics Anonymous was born when a stockbroker and reformed drunk from New York named Bill Wilson met Dr. Bob Smith (another drunk) in Akron, Ohio. They discovered that the idea of one alcoholic talking to another went a long way towards keeping them sober. It became the first structured psychosocial program to treat alcoholism, and to this day remains the most widely used methodology for recovery from chemical and behavioral addictions worldwide.
It has helped countless numbers of alcoholics and addicts get sober and on the road to recovery and, when combined with psychotherapy, exponentially increases the odds against relapse.
Let’s start with Step One, which states: “We admitted we were powerless over alcohol, that our lives had become unmanageable” (Alcoholics Anonymous, 1953 p.21) This is a two-part effort. The first is the admission of being powerless and the second is recognizing that one’s life has become unmanageable. In addition, it internalizes, then externalizes the thought process. This is an interesting continuum which is a basis for successful therapy. Many patients can and have, admitted one without the other. For example, they may confess to a definable problem but also claim their life has not been adversely affected by it, saying things like, “Well, I still have a job, a roof over my head and food on the table, so it can’t be all that bad.” This is classic denial and the patient must be helped to understand that a manageable life consists of far more than the basics needed for physical survival. For example, the ability and willingness to express oneself honestly to oneself and others can arguably be included in the definition of a manageable life. The idea here is that existence for existence’s sake is merely a shell and not a definition of a life and that one’s admission of personal powerlessness is “firm bedrock upon which happy and purposeful lives may be built”. ( Alcoholics Anonymous, 1953 p.21)
The second part of this idea is expressed in Step Two, “Came to believe that a Power greater than ourselves could restore us to sanity.” Once more, the process is externalized and is a very difficult dilemma for a lot of patients to consider. Many construe this as being reduced to a state of helplessness and complete reliance upon something or someone about which they have no proof or knowledge. ( Alcoholics Anonymous, 1953 p.25) The argument here is that it appears they had no knowledge of that which had a grip on their soul or psyche, for if they had they could have stopped it (or not, depending upon the nature of their disorder). Therefore, why not stop fighting the idea of it and give it a try? After all, it is completely up to the patient to interpret what that Power is. The point, once again, is to stop fighting and start feeling. “The minute I stopped arguing, I could begin to see and feel. Belief means reliance, not defiance.” ( Alcoholics Anonymous, 1953 p.27)
This is also where the idea of humility is first introduced. To be able to accept the suggestion that one needs help and is not in a position to help oneself is humbling. Intellectually, many patients see it is a sign of weakness and disgrace, but they must be helped to understand that it is not. There is a huge difference between humility and humiliation. AA holds that humility and intellect are compatible, provided humility is placed first. ( Alcoholics Anonymous, 1953 p.30)
Step Three is one of the toughest of all of them to incorporate into a workable therapeutic frame, “Made a decision to turn our will and our lives over to the care of God as we understood Him” Back to internalization. Even for those patients with an abiding faith in a Higher Power, this concept can be difficult to accept. The reason is that most people, while believing in God, have rarely considered completely turning their will over to Him or Her or It. The popular notion that everyone has been endowed at birth with a free will is essentially correct. In the context of those suffering from alcoholism and substance abuse, however, it is that very same (flawed) free will that led them into the predicament they’re in. The idea in this respect is that those people have pretty much abused their free will to the extent that it has been “broken” into so many pieces it has become all but irretrievable. Therefore, the choice is obvious; turn over what’s left of it to a power greater than oneself that is better able to make the right choices. This is essentially a life and death decision. In cases where it has not come to that, the idea of turning one’s life and will over to anything is much more difficult to accept and will take much longer. That is why some in Alcoholics Anonymous express the idea that “the lower the bottom the greater the gratitude and, thereby, the better the chances at redemption.”
Given all of the above, it is worth noting, however, that this level of willingness can be life-changing, in that it leads the patient into action and it is only by action that one can begin to cut away the self-will that has gotten them into trouble in the first place. ( Alcoholics Anonymous, 1953 p.34) Therefore, it is a matter of fact that unless the patient is aided in some way to develop this quality of willingness, he will be unable to make the decision to exert himself. This in itself is an act of one’s own will and all the Steps from this point on depend upon a sustained and personal effort pertaining to this principle. ( Alcoholics Anonymous, 1953 p.40)
Step Four, “Made a searching and fearless moral inventory of ourselves.”, is a key component in the arsenal of the therapist. This is an intensely personal and internalized process. “Nearly every serious emotional problem can be seen as a case of misdirected instinct. When that happens, our great natural assets, the instincts, have turned into physical and mental liabilities. Step Four is (our) vigorous and painstaking effort to discover what those liabilities in each of us have been, and are.” ( Alcoholics Anonymous, 1953 p.42)
The scientist, philosopher and religious teacher Emmet Fox once wrote, “Fear is the cause of all our problems in this world.” (The Power Of Constructive Thinking, Fox, 1928 p.9) In the words of AA, “pride, leading to self-justification, and always spurred by conscious or unconscious fears, is the basic breeder of most human difficulties, the chief block to true progress. These fears are the termites that ceaselessly devour the foundations of whatever sort of life we try to build.”
( Alcoholics Anonymous, 1953 pp.48-49)
The following is an example of written work the patient should be given in order to uncover and explore these fears and liabilities in their own life:
| I. What am I resentful about? What do I fear? What am I angry about? Who are these people and things? | II. What did this person, experience, etc. do to make me angry? | III. How did all this affect me? | IV. What was my role in making all this happen? |
| | | | |
One of the core beliefs of The Twelve Steps states that it is from their unhealthy relationships with family, friends and society in general that most of Alcoholics and addicts have suffered the most. ( Alcoholics Anonymous, 1953 p.53) This of course includes especially those incidents which occurred during their childhood as they relate to psychodynamic, attachment, object-relations theory, etc. This exercise serves to uncover the nature of those relationships in their entirety as well as gaining insight into what role the patient played (however innocently) in the pitfalls generated from them. Since the most common symptoms of emotional insecurity are worry, anger, self-pity and depression, and stem from causes which are generally within the patient as opposed to without, the patient needs to consider carefully all personal relationships which bring continuous or recurring trouble. (Alcoholics Anonymous, 1953 p.52)
This “inventory”, however painful, must be thorough. It is wise to advise the patient to write all questions and answers they may have as aids to clear thinking and honest appraisal. It is the first tangible evidence of the patient’s willingness to move forward. (Alcoholics Anonymous, 1953 p.54)
Step Five, “Admitted to God, to ourselves and to another human being the exact nature of our wrongs.” Here the process is externalized once again in an effort to deflate the ego. In the context of alcoholism and drug abuse, the patient is always very reluctant to take this step because it lays bare a tremendous amount of shame. Telling this to someone, however familiar, is extremely revealing and takes a tremendous amount of courage. So intense is the fear and reluctance to do this, that many A.A.’s try to bypass the step completely, which is extremely inadvisable. Within therapy, however, the patient is already engaged with the therapist and while courage is still required, the environment for the exchange has already been established.
“The practice of admitting one’s defects to another person is, of course, very ancient. It has been validated in every century and it characterizes the lives of all spiritually centered and truly religious people.” ( Alcoholics Anonymous, 1953 p.56) But religion is not the only venue in modern society where this practice is encouraged. Few psychiatrists or psychotherapists would disagree that there is a deep need felt by every human being for practical insight and knowledge of their own personality flaws and for a discussion of them with an understanding and knowledgeable person. ( Alcoholics Anonymous, 1953 p.56)
Holding in one’s secrets is terribly isolating. Patients who persist in keeping these to themselves are tortured by the loneliness they must endure. ( Alcoholics Anonymous, 1953 p.57) By taking this step, they are not only freed of that isolation and loneliness but can begin to have hope for the first time that they could be forgiven, no matter what they had thought or done. Moreover, they can enable themselves to forgive others, no matter how deeply wronged they feel. (Alcoholic Anonymous, 1953 p.58) Once again, humility is the watchword as execution of this step brings the patient face to face with his defects, thus setting him “on the road to straight thinking and solid honesty.” (Alcoholics Anonymous, 1953 p.59) Only by being honest with another person can the patient be truly certain he can be honest with himself.
Step Six in and of itself is purely spiritual, “Were entirely ready to have God remove all these defects of character.” This is an internal question of faith in the grace of God, and for those who have that, it has been extremely liberating. However, not all patients do, and for them it would be inadvisable to attempt to force this upon them. Nevertheless, the step does impart some very useful information.
Recognizing one’s defects is a part of the processing and exploration of self that we as therapists should encourage our patients to do. It is a “venture into open-mindedness” that enables the patient to set loftier goals in terms of how he treats himself and others and to be ready to walk in that direction. “It will seldom matter how haltingly we walk. The only question will be ‘Are we ready?’” ( Alcoholics Anonymous, 1953 p.68) Getting them ready is our job, taking the walk is theirs. At the very least, the patient is encouraged to come to grips with his worst character defects and take action towards their removal. ( Alcoholics Anonymous, 1953 p.69)
Step Seven, “Humbly asked Him to remove our shortcomings” is once more about faith in a higher power and not for everyone. But it is also about the attainment of greater humility, which bears mentioning here.
For the patient suffering from a disorder of the spirit as well as the mind, it is useful to bring into perspective that character-building and spiritual values are of great importance and that material satisfactions are not the purpose of living. ( Alcoholics Anonymous, 1953 p.71) The patient needs to see that material satisfactions are not the desirable final end and aim of life. Many more problems have arisen for individuals as the result of unreasonable demands for security, prestige, power and money than have been solved. ( Alcoholics Anonymous, 1953 p.71) Even for the patient who is unable to muster a healthy regard for humility as a desirable personal virtue, they should, if at all possible, begin to recognize it as a necessary aid to survival – and that is at least a beginning. ( Alcoholics Anonymous, 1953 p.74) Moreover, humility can be a healer of pain. As the patient begins to fear pain less, the desire for humility is bound to increase. ((Alcoholics Anonymous, 1953 p.75)
Step Eight, “Made a list of all persons we had harmed, and became willing to make amends to them all.” and Step Nine, “Made direct amends to such people wherever possible, except when to do so would injure them or others.” are crucial, but are also way down the line in regards to therapy. Much work has had to have been done for the patient to be able to deal with the realization of how much damage he has done to others and to be willing to admit it to them. The most important thing here is for the patient to start with forgiving himself. That is the beginning of the end of their isolation from others.
( Alcoholics Anonymous, 1953 p.82)
As far as others, one must be very careful not to confuse one’s own peace of mind with what is best for them. Sometimes, it is better to leave well enough alone and carry out one’s amends to a particular person by doing right by others.
Step Ten, “Continued to take personal inventory and when we were wrong promptly admitted it.” is essentially a recipe for constant self-examination. Rather than allow resentments and guilt to build up, the patient is encouraged to take a good look at oneself at the end of each day and ask if there was anything they did wrong or anyone who was given short shrift by them. If so, they are counseled to make it right at the earliest possible time, thus “keeping their side of the street clean” for the next day. (Alcoholics Anonymous, 1939, p.85) “An honest regret for harms done. A genuine gratitude for blessings received and a willingness to try for better things tomorrow will be the permanent assets we shall seek.” ((Alcoholics Anonymous, 1953 p.95)
The last two Steps deal with God and taking the message of Alcoholics Anonymous to others, and while they are not particularly applicable to therapy, the spirit, especially of Step Twelve can be. It states, “Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.”
As a result of these Steps, or put another way, by virtue of working within this particular therapeutic frame, the patient can, in many ways transform him or herself. This is because he or she has been able to “lay hold of a source of strength which, in one way or another, has been hitherto denied to them.” ((Alcoholics Anonymous, 1953 p.107) It’s as if the patient has received a gift and is obliged to pass it on. In this way, the patient is able to “experience the kind of giving that asks no rewards.” ((Alcoholics Anonymous, 1953 p.106) It’s one of the rarest of all occurrences – a win/win situation. It also needs to be practiced in a thoughtful, respectful way in that it should never be proselytized or forced on anyone. Only if someone has asked for assistance is the giving meaningful. Otherwise, it is just another instance of one’s own self-will deciding what is best for others.
The patient will always have ups and downs in his or her life and troubles are a part of that, but by continuing to practice this final “step” throughout their life, they will have the ability to “take these troubles in stride” and move through rather than up against them. (Alcoholics Anonymous, 1953 p.114)
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