Twelve-Step Programs as an Adjunct to Psychotherapy and Psychopharmacology

Abstract

With increasing constraints on time for traditional psychotherapy and patient counseling, it behooves us to find other methods of giving the patient tools to cope with his or her illness. In addition to psychotropic medications that have never before been available (selective serotonin reuptake inhibitors and related compounds) and crisis intervention, we have a plethora of 12-step programs that can give the individual ongoing support. Our goal is to restore the patient to full psychosocial function, avoiding self-medication, drug and alcohol abuse, and the cycle of hopelessness, despair, death, and suicide. We are concerned with the patient's lifelong maintenance and state of balance, finding a spiritual center from which to grow as an individual, and ultimately, to help others with similar problems. Twelve-step programs serve as a viable means of achieving these goals. Along with medication, support, encouragement, and therapy when available, patients can be guided to achieve new levels of meaning and fulfillment in their lives.

For the past 20 years, I have visited and studied various support groups, and alcohol and drug rehabilitation resources (including 12-step programs). At first, these visits were at the invitation of patients. I then made a concerted effort to visit various programs to inform my practice of medicine. Because I am not personally affected by alcohol or substance abuse, some meetings were not open to me. However, over the years, I was able to sit in on many meetings and appreciate the variety and quality of programs available in a metropolitan area.

One of the programs I found personally helpful is devoted to wisdom in handling money, planning for the future, keeping track of saving and spending patterns, and eliminating compulsive use of credit cards. This experience eventually led to my conducting weekend seminars for health care professionals who were discouraged, depressed, or burned out and looking for a way out of a profession to which they had devoted the major portion of their lives. Much of this discouragement grows from the depersonalization of health care.

In managed behavioral health care, time and resources for psychotherapy are significantly reduced. Many psychiatrists in the greater Los Angeles area spend only 15 minutes evaluating a patient—even less on follow-up visits (personal observations). These encounters are referred to euphemistically as “medchecks.” Primary care physicians must find more resources within their communities so that patients do not have to depend on brief, superficial encounters with psychopharmacologists and are not left alone to unravel the difficulties and complexities of their lives. When psychotherapy is provided through insurance plans, it may be limited to 20 or fewer sessions per year. In my experience, the quality of psychotherapy varies widely. If patients are fortunate, they will be assigned to a therapist with training, insight, and ability. Our goal must now be, within the context of managed care and an increasingly complex, stressful society, to empower patients with the information to find other resources outside the traditional therapist-patient relationship. Experience and published research suggest that traditional 12-step programs, based on the Alcoholics Anonymous model, can provide solutions over a long period of time.

In a recent review, Chappel and DuPont state:

The preponderance of the research data now available indicates that the 12-step programs … are most helpful … as they seek to achieve secure, long-term abstinence. A growing number of clinicians are recommending that physicians become more knowledgeable and skilled in referring and supporting patients in working 12-step programs of recovery.¹

Adjustment through various 12-step programs is as sociated with longer lives, better mental health and marriages, and responsible and successful parenting and employment.¹

COMMUNITY PSYCHOTHERAPY AND PSYCHOPHARMACOLOGY

One of several practitioners in a suburb of Los Angeles, I combine family practice with psychiatry and psychopharmacology. Patients are referred by local therapists for evaluation or self-refer with anxiety, panic attacks, depression, or marital discord, in addition to general medical problems.

I set aside a special room in my office for the purpose of addressing problems of mental distress or illness. This room is relatively soundproof, away from the phones and front desk and simply furnished with a table and 2 chairs. In this quiet setting, we can explore the problem, typically spending about 30 minutes in the initial interview. Regardless of the presenting symptoms, I try to achieve certain goals at this initial assessment—not identical with each patient. My goals include identification of the presenting symptom(s), an empathetic beginning to the therapeutic alliance, an understanding of the scope and complexity of the problem, agreement on short-term goals, a prescription for appropriate medication or review of current medications, and strategies for coping with similar problems in the future.

Certain predictable patterns became apparent using this approach—a cluster of common traits, in men and women, regardless of the presenting problem. Many had an abusive childhood, one or two alcoholic parents, chronic feelings of worthlessness of early onset, low self-esteem, problems relating to and sharing feelings with others, a sense of loneliness and isolation, and addictions.

When the patient is referred by a non-MD therapist, prescriptions are usually the stated reason for referral. My job is to assess the severity, acuteness, or chronicity of the problem and initiate medication. But this is only one step in unlocking the door to wellness. To realize a patient's full potential and pave the way for future growth, I encourage a balance between the psychotherapy, medication, a regular exercise program (which many have given up in their current state), and a 12-step program. A patient is usually ready for referral to a 12-step program when he/she has hit “bottom”—behavior or situations that have resulted in the loss of some or all of the vital connections supporting his or her ego structure (home, spouse, children, job, and self-esteem). I see my task as pointing the patient in the right direction.

CHOOSING A 12-STEP PROGRAM

Choosing an appropriate program can be a difficult task (as many will attest), but there is usually a way into the maze of available programs. Obviously, a patient who is drinking heavily, getting driving-under-the-influence citations (DUIs), passing out on weekends, under threat of divorce or separation, or having violent outbursts when drinking is a candidate for Alcoholics Anonymous. Likewise, matching patients who abuse food, prescription drugs, or other substances with suitable programs seems quite straightforward. However, motivating patients to go is another matter. Many do not want to share with others, choosing rather to live in isolation or denial and let out their problems by punching in walls and doors, alienating friends and family, and putting their lives in jeopardy. They feel these support groups are for losers, are “only” about drugs or drinking (or other major compulsions), lack levity, and are principally for the down-and-out. Empathy, honesty, and persistence fosters trust and confidence in the therapeutic alliance, preparing the patient for referral. Individual timetables vary, and hitting bottom several times may be necessary. Some patients will remain disinterested. Others will find alternate sources of support. In extreme cases, an intervention can be planned with the patient, family, friends, and an intervention specialist. A successful intervention leads the patient directly into a treatment facility where 12-step programs and other group methods to overcome withdrawal, hostility, and denial are utilized.

All 12-step programs (Appendix 1) are basically about achieving the utmost in human growth and potential while controlling or conquering obsessive, compulsive, acting-out behavior. So often, people try to treat the “real” problems with self-medication, drugs, alcohol, or prescription drug abuse. Such pain is often enormous, and the manipulative behavior has been a way of life for many years. As Del Toro et al. state: “Twelve-step programs, supportive medical follow-up visits and the judicious use of medications … can greatly increase the probability of success and sustain recovery for previously addicted patients.”²

OTHER BEHAVIORS AND PROGRAMS

Twelve-step programs are available to address a number of problem behaviors. Bipolar patients often go on huge spending sprees. A compulsive spender will reach maximum limits on every credit card, jeopardizing job, home, and family. Every time the feeling of “not enough” overwhelms the individual, he or she will go out and spend, often at expensive stores where the tally can run into the thousands. Within Debtors Anonymous, subgroups deal with money and relationships, goals and visions, business owner issues, and others.

The child of an abusive, alcoholic parent will often harbor feelings of worthlessness that may not surface until adulthood or until their own children reach their teens and they have to grapple with similar feelings. An organization known as Adult Children of Alcoholics deals with issues of growing up in a home with an alcoholic parent. Many in this program have had decades of experience in this area and are willing to help a newcomer deal with feelings in an atmosphere of unconditional acceptance. In these settings, no one acts as director or therapist. Everyone learns from each other, and there is a strict format. Professionals in the group remain anonymous, but are free to share their “experience, strength, and hope” with others. Only first names are used—no titles and no pulling rank. Twelve-step programs have one overriding purpose: to help the person who still suffers.

Some patients cling to hopeless, dead-end, demeaning relationships for much of their adult life, reaching their late 30s or early 40s with depression, a full-blown panic attack, and a sense of total futility. A program called Codependents Anonymous addresses this issue. Codependents feel responsible for another person's success or failure. Some may remain in an unhealthy relationship for many years because shelter, financial support, and transportation or other basic needs are provided.

In meetings, core problems are shared with others who have direct experience. When this is done in a group context, the burden is significantly reduced. The original 12-step program, Alcoholics Anonymous, was founded in 1934 by Bill Wilson and Dr. Bob. All other 12-step programs are based on this program. The core treatise is the “12 steps and 12 traditions.” These are practical and spiritual steps that are “worked,” often with a sponsor, over a period of years. In other programs, another “disease” is substituted for the word “alcoholics,” but all the basic tenets remain the same.

There is a saying in 12-step programs that “we are only as sick as our secrets.” Medication and therapy cannot fill such a void nor eliminate the sense of isolation and the feeling “I am the only one with this problem.” Twelve-step programs strive to go far beyond acutely painful problems and achieve lifelong growth and health. Consequently, this is not “band-aid” work. It takes years of regular attendance and participation. There are workshops, retreats, and regional, national, and world conferences. For a patient who has never been able to openly share with others, attending a weekend retreat or conference, speaking to a large group about their recovery and articulating and summarizing their life story in a 20- or 30-minute presentation, is quite an experience.

In 12-step programs, recovery addresses many areas of concern including relief of the depression, anxiety, or panic attacks often by using medication; recognition of how one's behavior has contributed to the problem (cognitive therapy); a rebuilding of the patient's life via a long-term commitment to 12-step principles and extinguishing compulsive behavior. Putting one's trust in a force or power greater than one's own self-will and laying a spiritual foundation for life so that being of service, sharing with others, and reaching out a helping hand to those less fortunate take precedence over wallowing in misery, isolation, and self-pity are pivotal. Growth in this process often includes becoming a mentor or sponsor to someone else.

As with the healing professions, the ultimate goal of the 12-step program is to help others who walk the same path and suffer with the same problems. Therefore, “working the steps” ultimately brings the patient to a full circle—a complete and fulfilling life. By helping and sponsoring others, the patient rises to a new level of empathy, objectivity, understanding, and service.

THE 12 PROMISES

At the end of some meetings, the 12 promises from the Alcoholics Anonymous “Big Book”³ are read. These promises make an appropriate closing for an article on this topic, for over the years I have seen these come true for many who were in despair, had lost everything, and were close to giving up.

The “Big Book” states:

If we are painstaking about this phase of our development, we will be amazed before we are half way through. We are going to know a new freedom and a new happiness. We will not regret the past nor wish to shut the door on it. We will comprehend the word serenity and we will know peace. No matter how far down the scale we have gone, we will see how our experience can benefit others. That feeling of uselessness and self-pity will disappear. We will lose interest in selfish things and gain interest in our fellows. Self-seeking will slip away. Our whole attitude and outlook upon life will change. Fear of people and of economic insecurity will leave us. We will intuitively know how to handle situations, which used to baffle us. We will suddenly realize that God is doing for us what we could not do for ourselves.3(pp83–84)

The concept of “God” or “spirituality” turns many people off and has become a major criticism of these programs. However, what is really addressed is a “power greater than ourselves.” Twelve-step programs have stressed the importance of spiritual practices for over 4 decades.⁴ It is through the replacement of anguish, inadequacy, and addiction with a new-found spirituality that these programs have been so successful all over the world.

Appendix 1. Twelve-Step Programs, Literature, and Web Site Addresses

Various 12-Step Programs

Alcoholics Anonymous, Narcotics Anonymous, Debtors Anonymous, Gamblers Anonymous, Overeaters Anonymous (including group for bulimia and anorexia), Adult Children of Alcoholics, Al Anon, Arts Anonymous, Cocaine Anonymous, Emotions Anonymous, Codependents Anonymous, Fear of Success Anonymous

Literature of Interest

Since these are basically anonymous groups, literature is usually obtained from the specific program, local or national. Health care professionals may attend “open” meetings of any of these groups, but a “closed” group will not permit outside observers, thus protecting anonymity. The following is a list of several publications of general interest:

1. Alcoholics Anonymous. New York, NY: AA World Service; 1976

2. Pass It On, The Story of Bill Wilson and How the AA Message Reached the World. AA World Service. New York, NY: AA World Service; 1984

3. Twelve & Twelve: The Twelve Steps and Twelve Traditions. New York, NY: AA World Service; 1984

4. Twerski AJ. Seek Sobriety, Find Serenity: Thoughts for Every Day. New York, NY: Pharos Books; 1993

5. A Currency of Hope. Needham, Mass: Debtors Anonymous; 1999

6. Narcotics Anonymous. Van Nuys, Calif: NA World Service; 1988

Web Site Addresses

www.addictionresourceguide.com Addiction Resource Guide-Internet Resources

www.adultchildren.org Adult Children of Alcoholics

www.alcoholics-anonymous.org Alcoholics Anonymous

www.atforum.com Addiction Treatment Forum

www.ca.org Cocaine Anonymous

www.debtorsanonymous.org Debtors Anonymous

www.edreferral.com Eating Disorder Referral and Information Center

www.gamblersanonymous.org Gamblers Anonymous

www.intervention.com Intervention Center-Family Intervention for Addiction

www.nationalcounseling.com National Counseling Intervention Services, Inc.

www.ncadd.org National Council on Alcoholism and Drug Dependence

www.ncsac.org National Council on Sexual Addiction and Compulsivity

www.netaddiction.com Center for On-Line Addiction

www.overeatersanonymous.org Overeaters Anonymous

www.recovery.org/aa/ Online AA Recovery Resources

www.sca-recovery.org Sexual Compulsives Anonymous

www.smartrecovery.org Smart Recovery Self-Management and Recovery Training

www.wsoinc.com Narcotics Anonymous