Overlapping Mechanisms of Recovery between Professional Psychotherapies and Alcoholics Anonymous

Abstract

Background:

Much research over the past 25 years has focused on elucidating the mechanisms by which Alcoholics Anonymous (A.A.) affects behavioral change in its participants. In addition to research on the spiritual mechanisms for which A.A. is best known in the popular conception, research on mechanisms of recovery (MOR) has predominantly supported social, cognitive and affective mechanisms that are also present in many professional psychotherapies.

Aim:

This paper compares and contrasts the theorized MOR of A.A. with those found in several common professional psychotherapies to illustrate analogous elements. Methods: Literature review, summary and synthesis of studies examining the MOR of both A.A. and common psychotherapies including analytic/dynamic therapies, cognitive-behavioral therapies, and acceptance and mindfulness-based therapies.

Results:

There exists significant overlap in theorized MOR of A.A. and mainstream, professional psychotherapies. Mechanisms with the greatest overlap include those mobilizing stress and coping theory, behavioral choice theory, and social learning theory, while mechanisms more unique to A.A. compared to professional psychotherapies mobilize social control theory to a greater degree.

Conclusions:

In caring for patients with addiction, practicing clinicians will find it useful to be aware of overlapping analogous elements found in the A.A. program and professional psychotherapies and how they can complement one another.

Background:

Alcoholics Anonymous (A.A) and other 12-step mutual help programs are offered worldwide and are among the most widely utilized resources for helping individuals recover from substance use disorders (SUDs). Many formal professional treatments, such as 12-step facilitation, have been developed to increase engagement with free community A.A. resources and have been shown in randomized controlled trials to substantially enhance post-treatment abstinence rates (Group, 1998; Walitzer et al., 2009) as well as substantially reduce health care costs (Humphreys and Moos, 2001, 2007). Unfortunately, education on the benefits of the A.A. program and how it may be incorporated into mainstream professional psychotherapies for SUDs (e.g., cognitive-behavioral therapy) is lacking in many clinical training programs (Marcovitz et al., 2017). Many clinicians are unaware of the similarities between professional psychotherapies and A.A. and how these approaches can actually be complementary. Accordingly, this paper aims to inform clinicians about core similarities between professional psychotherapies and A.A., particularly with regard to shared mechanisms of recovery (MOR) that are targeted in both approaches. By mechanisms of recovery, we are referring to specific processes, events, or behaviors that facilitate recovery from SUDs.¹ For example, these mechanisms of recovery can include learning coping skills, improving social bonds, increasing engagement in rewarding activities not involving substances, and increasing involvement with peers who model positive behaviors.

Several previous papers have addressed the intersection of recovery mechanisms in A.A. and in clinical psychology (McCrady, 1994; Moos, 2007; Kelly et al., 2009) or in neuroscience (Galanter, 2014). These prior reviews have focused on social, cognitive and affective recovery mechanisms present in A.A. that are similar to those in psychotherapy in general. This paper, in contrast, is organized for the practicing clinician, and focuses on comparing A.A. directly to each of several specific mainstream psychotherapy approaches, including dynamic/analytic therapies, cognitive and behavioral therapies, and acceptance and mindfulness based therapies. We think this approach may allow clinicians to draw connections with their day-to-day work and better understand the complementary role of 12-Step based mutual help organizations.

In this review, we describe key psychotherapy approaches and compare and contrast recovery mechanisms between the psychotherapy modality and A.A. philosophy and practices. At the end of each section, we will summarize our findings and attempt to organize the array of possible therapeutic mechanisms through which both professional psychotherapies and A.A. may confer benefit. To guide our discussion, we use the theoretical framework described by Moos (Moos, 2007), which includes four well-established theories of mechanisms that cut across specific therapy modalities.

1. Stress and coping theory – recovery involves improvements in coping skills and self-efficacy. A patient or A.A. member experiences adaptive change by learning new skills for coping with challenging emotions and situations and therefore gains a greater sense of efficacy (that also mitigates stress).

2. Social control theory – recovery involves “strong bonds with family, friends, school, work, religion, and other aspects of traditional society that motivate individuals to engage in responsible behavior and refrain from substance use and other deviant pursuits.” A patient or member adopts the attitudes and beliefs of the community in which they are immersed, which in some cases can be protective against substance use.

3. Behavioral choice theory – recovery involves reinforcers or rewards for activities that effectively compete with substance use. A patient or A.A. member may find that various elements of the therapy or A.A. program reinforce sobriety including attention, praise, sobriety medallions/tokens, service positions (given in A.A. for periods of continuous sobriety), etc.

4. Social learning theory – recovery involves learning based on peer modeling of abstinence and other more adaptive behavioral strategies. A patient or A.A. member may learn to model the behavior of therapist or A.A. peer in adaptive ways.

See Table 1: Common Recovery Mechanisms in both A.A. and mainstream psychotherapies.

Table 1 –

Common Mechanisms of Recovery in A.A. and mainstream psychotherapies:

Therapeutic Approach ➡	Mobilizers/Specific techniques or strategies used ➡	Mechanisms of Recovery theories ➡				Proximal Outcomes/Goals	Distal Outcome/ Goals
		StC	SLT	SoC	BC
A.A.	AA Sponsor/mentor Step work (12-Step written process) Meeting attendance Fellowship	x	x	x	x	Abstinence from substance(s); admission of powerlessness and acceptance of need for support from a Higher Power; Release from Character defects; Amends to significant others; Commitment to ongoing recovery actions and service	Substance use disorder remission and enhanced quality of life
Analytic / Dynamic Therapies	Therapist Exploration of past experiences and relationships Exploration of emotional avoidance	x	x			Insight into underlying drivers of use
Cognitive Behavioral Therapies	Therapist Cognitive restructuring Skill acquisition (problem-solving, interpersonal, coping etc.) Behavior modification	x	x		x	Skill acquisition (e.g., interpersonal effectiveness, adaptive coping); behavior modification; cognitive modification
Acceptance and Mindfulness Based Therapies	Therapist Mindfulness Skill acquisition (problem-solving, interpersonal, coping etc.) Value clarification and commitment to related actions (ACT)	x	x		x	Skill acquisition (e.g., interpersonal effectiveness, adaptive coping); value-based actions

^*StC=Stress and Coping Theory; SLT=Social Learning Theory; SoC=Social Control Theory; BC=Behavioral Choice Theory.

1. Analytic/dynamic therapies – Psychoanalysis, psychodynamic psychotherapy.

Definition:

In defining the key therapeutic elements of psychodynamic psychotherapy (evolving from classic Freudian psychoanalysis), Shedler describes the following core domains: 1) Focus on affect and expression of emotion, 2) Exploration of attempts to avoid distressing thoughts and feelings, 3) Exploration of recurring themes and patterns, 4) Discussion of past experiences (Developmental Model), 5) Focus on interpersonal relations, 6) Focus on the therapy relationship, and 7) Exploration of fantasy life including dreams and daydreams (Shedler, 2010). Though Shedler’s review is primarily focused on the modern manifestations of psychodynamic therapy, classic psychoanalytic theory focuses a great deal on the exploration of the patient’s unconscious. Theory posits that as the patient gains insight into unconscious forces shaping her affect, cognition and behavior, she will gain greater freedom from these forces and relief from related distress. Some of the more technical aspects of the therapist’s exploration of the unconscious include pointing out defensive maneuvers by the patient and discussing transference and countertransference reactions. The technical terms “defenses” and “transference” are largely replaced below with lay expressions like, “attempts to avoid distressing thoughts or feelings,” and “focus on the therapy relationship” for ease of understanding.

In summary, psychodynamic therapy focuses on important past experiences and relationships to help patients understand their emotional reactions and behavioral patterns (including relationship patterns) in the present. Interpretation of both the patient’s fantasy life (namely their dream content) and relationship with the therapist help provide access to these dynamic elements from the patient’s past and present. For simplicity, we group these seven elements into four general categories below.

Analytic/dynamic therapies compared with A.A.

Past experiences and relationships: recurring themes and patterns:

The acquisition of insight occurs in analytic/dynamic therapies in part through the patient’s exploration, guided by the therapist, of relationship patterns and past experiences. As previously unexamined emotions, beliefs and desires move from pre-consciousness to consciousness, the patient will sometimes arrive at his own conclusions about why he behaves a certain way, or the therapist may provide an interpretation that directly enables such insight. In the A.A. fellowship, the member may also arrive at important conclusions by simply sharing her experience, though more often she draws connections by noting similarities or differences between her own past experiences and those of her peers. For example, an A.A. member who talks in a meeting about learning to nurture her “inner child” – presumably describing learning how to address fundamental needs that may have gone unattended in childhood – may spur a fellow member to consider how his own childhood experiences prevent him from asking others for help. In both A.A. and analytic/dynamic therapies, these insights may allow the member or patient to cope better with present challenges, may reduce the shame and negative affect that drive substance use, or may increase hope and motivation.

Dynamic/analytic therapies do not generally prescribe writing exercises to facilitate the acquisition of insight. In contrast, in A.A. Step Work, written exercises are used with a focus on important developmental patterns and relationships. In the 4^th Step, the member writes out a moral inventory of his so-called “character defects” (i.e., maladaptive personality traits/behaviors) related to his own fears, resentments and sexual conduct (Alcoholics Anonymous, 2001, pp. 64-71). These categories are deliberately focused on the member’s prior difficulties with relationships. The member then writes “turn-arounds” on these defects, envisioning how he might take greater responsibility for his part in conflicts, trust a Higher Power to help manage his fears, or align his sexual behavior more with his values. The member reviews these writings with a sponsor as part of his 5^th Step. The member then consciously seeks release from these maladaptive responses in the 6^th and 7^th Steps, first aggregating them in the 6^th Step to increase awareness, then praying and meditating on them, and finally consciously attempting to gain release from them in the 7^th Step.. These earlier steps then serve as a foundation for ongoing reflection in Step 10. See Table 2 –Analogous elements between the A.A. 12-Step program and mainstream psychotherapies.

Table 2 –

Overlapping elements between the A.A. 12-Step program and mainstream psychotherapies:

A.A. Step	Mechanisms of behavior change relevant to professional psychotherapies
1: We admitted we were powerless over alcohol—that our lives had become unmanageable.	The member must acknowledge his inability to manage completely on his own (all therapies) and is encouraged to accept areas in which she lacks control (ABMT).
2: Came to believe that a Power greater than ourselves could restore us to sanity. 3: Made a decision to turn our will and our lives over to the care of God as we understood Him.	The member must acknowledge a need for outside help and put some faith in an outside entity for guidance through challenging terrain (all therapies). More specifically, in Step 2 the member examines the role that significant figures in childhood had in shaping her view of a Higher Power and thus her interactions with the present-day world (dynamic/analytic therapies). Through this process the member also examines her old ideas for maladaptive beliefs or distortions that may perpetuate drinking, and she commits to more adaptive ways of viewing herself and her place in the universe (CBT). She also redefines her essential views about her relationship to her Higher Power (and thus her views about her purpose), akin to clarifying her values (ABMT).
4: Made a searching and fearless moral inventory of ourselves.	The member explores and examines his patterns of behavior from the past through the lens of fears, resentments and sexual conduct. His maladaptive thoughts are mined for core beliefs whose origins are characterized, and he writes “turn-arounds” on these beliefs that describe more adaptive attitudes to which he aspires (CBT). Phrased another way, the member’s perceived identity is examined and he is encouraged to detach from negative attributes of his prior self-concept (ABMT).
5: Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.	The member shares as openly as possible with another person and in the process he decreases isolation and mitigates shame (all therapies).
6: Were entirely ready to have God remove all these defects of character. 7: Humbly asked Him to remove our shortcomings.	The member uses his 4th and 5th step to identify a list of general character vulnerabilities she wishes to improve upon (e.g. selfishness, arrogance, manipulative tendencies, etc.). She becomes aware of distorted thoughts and deep-seated core beliefs that undergird character vulnerabilities (CBT). Through the process of getting “ready” to let go of these defects, she clarifies her true goals for living (ABMT).
8: Made a list of all persons we had harmed and became willing to make amends to them all. 9: Made direct amends to such people wherever possible, except when to do so would injure them or others.	The member takes ownership of past actions and character vulnerabilities and thus he decreases his externalization of problems (all therapies)
10: Continued to take a personal inventory and when we were wrong promptly admitted it.	The member makes written “inventories” or “turn-arounds” a part of his ongoing routine to balance out her tendency to regress to older, more negative thought patterns (CBT, ABMT).
11: Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.	The member practices regular prayer and meditation as a way to maintain his sense of balance and to cultivate acceptance and mindfulness skills (ABMT).
12: 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.	The member commits to ongoing actions that are aligned with her newfound values and principles (ABMT) and also commits to ongoing service toward others in the fellowship.

Focus on the therapy relationship

In analytic/dynamic therapies, patients are encouraged to explore and address maladaptive ways of relating to others or to the therapist. Transference and countertransference reactions – technical terms describing the unconscious association that a patient may make between the therapist and another important figure in his life (transference), or the reverse process for the therapist (countertransference) – are explored and are considered a vital part of classic analytic theory. These reactions remain an important part of how modern analytic/dynamic therapists gain insight into the patient’s ways of relating with others outside the therapy office. Such interpretation allows the therapist to form hypotheses about sources of social isolation or dissatisfaction. Analysis of these areas may over time improve social functioning as patient and therapist uncover them.

In the A.A. fellowship there is no direct parallel, and in fact many meetings open by noting a formal prohibition on “crosstalk” – responding directly to another member’s share, criticizing or giving advice to another member (Alcoholics Anonymous, 2006) – out of concern members may feel judged or may collectively regress (devolve into a more immature state). Of course, members form relationships within the fellowship which may become fertile ground for lay interpretation or interpretation by the sponsor. For example, it is common that a member may realize that he or she is easily annoyed with certain other members’ sharing, and a sponsor may be able to draw his or her attention to unconscious sources of the irritation (resentments, fears, jealousy, etc.), or to the fact that others are also “sick people” and should be extended tolerance (Alcoholics Anonymous, 2001). Perhaps more importantly, what the member lacks in guided exploration of outside relationships by a skilled therapist is counterbalanced by his or her direct observation of other members’ relationships in the fellowship. As these peers share about dysfunctional or improved relationships, these anecdotes serve as powerful aspirational or cautionary tales for the individual member.

Emotional awareness and avoidance:

The psychodynamic therapist invites the patient to identify and express strong emotions. The presence and mirroring of the therapist helps the patient to tolerate such emotions and to better understand how they interact with their thoughts and behavior on a day-to-day basis. When the A.A. group process works well, members witness their peers sharing strong emotions and vulnerabilities and learn to do the same. In both dynamic/analytic therapies and in A.A., the extent to which therapist or peers are non-judgmental and affirming will influence the extent of their sharing. However, in A.A. there is the additional variable of whether other members model true emotional vulnerability – the practice of “leading with their weaknesses,” or letting their defenses down by sharing honestly where they are struggling. In practice this variability has the potential to greatly enhance or undermine the group culture. Variability aside, dynamic/analytic therapies and A.A. both encourage the experience and expression of emotion, allowing participants to improve their tolerance of these emotions and to challenge beliefs that emotions are dangerous or shameful.

Synthesis

Here we have described analytic/dynamic therapies in terms of three key domains including exploration of recurring themes and patterns, attention to the therapy relationship, and examination of emotional awareness and avoidance. Mechanistically, these domains broadly fall under the category of the stress and coping theory. In other words, each domain relates to helping patients better understand and tolerate negative affect or resist counterproductive impulses as they come to appreciate the origins of their thoughts and feelings. The transmission of these coping skills also invokes social learning theory: the patient is learning from the therapist’s interpretations and what they model (instructional social learning) whereas the A.A. member is learning primarily from peer experience and in vivo modeling.

Here we draw a distinction between the role of A.A. and analytic/dynamic therapies at different stages of recovery. The insight-oriented work of analytic/dynamic therapies is generally considered difficult for patients in the early phase of sobriety, when powerful affect and urges may overwhelm the slower and more subtle acquisition of insight (Crits-Christoph et al., 1999). In contrast, A.A. oral tradition and writings often simply redirect the new member toward behavioral strategies for managing difficult feelings (e.g. attending meetings, calling a sponsor, putting pen to paper to write out patterns of thoughts and feelings). These behavioral strategies are often more efficient than insight-oriented strategies and therefore can be critical in the early stages of recovery when risk for relapse is high. In the later stages of sobriety and recovery, patients with addiction may benefit more from insights gained in analytic/dynamic therapies, and may also experience insights or “dynamic” progress in A.A.

In addition to stage of sobriety and recovery, motivation is another key dimension. Generally, A.A. presupposes some basic motivation for sobriety, excluding coerced attendance. In contrast, analytic/dynamic therapies emphasize an empathic stance that may soften defenses to elicit the patient’s honest internal aspirations and may be useful to patients who are more ambivalent about change and want a safe place to reflect and process. Work in analytic/dynamic therapies may therefore precede readiness to participate in A.A., and A.A. members may later return to analytic/dynamic therapy for the acquisition of more subtle insights. In this way, the two modalities can greatly complement one another.

2. Cognitive and behavioral therapies (including classic behaviorism):

Definition:

We will divide CBT into cognitive and behavioral therapies for purposes of this section, while noting that in practice, CBT for relapse prevention is often delivered as a series of modules that combine both elements. We also note here for readers less familiar with professional psychotherapies that both cognitive and behavioral elements feature prominently into Acceptance and Mindfulness-Based Therapies such as dialectical behavioral therapy (DBT) that we will discuss under their own subheading below.

Cognitive therapy, originating in the work of Aaron Beck and others, assumes the patient’s motivation for specific changes to a greater extent than analytic/dynamic therapy and is focused on teaching the patient to challenge negative or maladaptive thoughts more directly. Cognitive distortions are identified, and their relationship to emotions and core beliefs about the self are explored and deliberately restructured (Hollon and Beck, 1994; Burns and Beck, 1999). CBT also emphasizes the importance of skill rehearsal outside of the treatment session and will assign “homework” in each session.

Behavioral therapy, originating in classical behaviorism and associated with psychologists like Ivan Pavlov and B.F. Skinner, revolves around the behavioral principles of classical and operant conditioning (both of which consider how human behaviors are reinforced or extinguished based on stimuli and response) and how these processes can be leveraged to modify maladaptive behaviors. These powerful theories are often applied across various therapeutic modalities, but even in their pure form also constitute a therapeutic technique. Modern behavioral therapies use a wide array of principles that are designed to modify undesired or ineffective behavior, such as skills training (e.g., drug refusal skills, coping skills), behavioral activation, and emotion exposure.

Cognitive therapies compared with A.A.

Cognitive therapies challenge maladaptive thoughts that drive substance use (Carroll et al., 1994; Marlatt and Donovan, 2005). Thoughts that drive poor emotional coping or a low perception of self-efficacy (“My boss thinks I’m worthless”) may trigger and perpetuate substance use as a means of relieving distress. Thoughts that can lead to isolation, inactivity or other risky behaviors may also indirectly drive use (“I’ll just stop by the bar to see some friends since there’s nothing to do tonight anyway”). The cognitive therapist engages Socratic questioning techniques to elicit maladaptive cognitions and trains patients to identify and ultimately modify these cognitions; the patient practices these in exercises during and outside the session. Patients learn to separate thoughts from facts (“I am having the thoughts that my boss thinks I’m worthless because she didn’t acknowledge me”) and to learn to challenge these thoughts by more objectively considering evidence for and against the thought or increasing the flexibility of these interpretations (“Evidence against the belief that my boss thinks I’m worthless includes that she complemented my write-up last week. An alternative to my belief is that she seems to be under a lot of pressure herself so might not have thought to acknowledge me”).

From the standpoint of the A.A. program, participation in written Step Work serves to help members challenge maladaptive cognitions, and this work is further potentiated by the sponsor’s direct feedback. In Step 1 the member challenges maladaptive thoughts (primarily that he can control his drinking on his own and manage his own affairs), eliciting his fledgling insight that self-management has not worked well and that he may need to rely on others. In Steps 2 and 3 he challenges maladaptive thoughts about his relation to a Higher Power (which can inform his sense of self-esteem), the universe itself, and again, the ability to manage without outside help. In Step 4 he challenges a host of maladaptive thoughts related to his potentially dysfunctional relationships through a focus on his resentments and conduct. He also challenges thoughts about his self-efficacy though a focus on describing and processing his fears. The host of maladaptive tendencies that the individual identifies via Step 4 are further aggregated and reframed into a smaller number of character defects the member wants to overcome in Steps 6 and 7. Steps 8 and 9 further challenge maladaptive thoughts related to externalization of problems / victimhood. Steps 10 and 11 proscribe an ongoing method for the individual to continue challenging maladaptive thoughts. Step 12 encourages ongoing recovery actions and service to maintain altruistic cognitions over self-focused cognitions. The A.A. literature repeatedly emphasizes the role of the member’s resentments, fears and other negative attitudes in driving his prior substance use and warns of their potential to capsize his fragile vessel early in sobriety.

From the standpoint of the A.A. fellowship, sponsors and peers also help mobilize cognitive therapeutic mechanisms. Those members with sustained sobriety (including sponsors) will model more adaptive thinking styles, again largely based on their own 12-Step experiences and informed by the core texts of the A.A. program and will challenge the newer member with feedback about his maladaptive thinking. More experienced members not only give advice but describe to newcomers how they are applying specific cognitive skills in their ongoing recovery. While we acknowledge members may deviate quite a bit from a set script, a few common A.A. slogans oft repeated in meetings may best illustrate this point. (See Table 3 – Common A.A. slogans invoking cognitive and/or behavioral mechanisms). These slogans are directly analogous to rational responses in cognitive therapies, or phrases or slogans that can be used to counter maladaptive cognitions.

Table 3 –

Common A.A. slogans invoking cognitive or behavioral mechanisms

Cognitive
Slogan	Description of Mechanism of Recovery	Theory invoked
“Stinking thinking leads to drinking”	Cautions against the risk of drinking that comes along with negative thinking	StC
“Hungry, angry, lonely, tired” (H.A.L.T.)	Heightens the member’s awareness of common precursors to increased cravings for alcohol/drugs to identify them and take assertive action to their remediation.	StC
“First things first”	Assists the member with prioritization and problem solving in early and late recovery	StC, BC
“One day at a time”	Redirects the member who is at risk of being flooded by negative thoughts and emotions, especially fear and anxiety. Also displaces temptation to drink onto the future.	StC
“Live life on life’s terms” “Let go and let God” “Live and let live”	Encourages the member to practice acceptance of situations and people in the face of potentially overwhelming circumstances.	StC
“God doesn’t make junk”
Behavioral
“Meeting makers make it” and “Just bring the body”	Prescribes meeting attendance as a prerequisite for sobriety and as an alternative to drinking	BC, SoC
“Take the action and the feeling will follow” “Fake it till you make it”	Puts member on notice that they must take action in order to feel better; they should not expect insight alone to drive change.	BC
“There’s nothing drinking won’t make worse”	Reminds the member that drinking is antithetical to his attempts to rebuild their life, underscores commitment to abstinence	BC, SoC
“The program works if you work it”	Reminds the member that work/action will precede success	BC
Cognitive and Behavioral
“Keep it simple”	Cautions the member against overthinking situations in favor of adhering to simple attitudes and behaviors described in the program literature (e.g. attending meetings, providing service, practicing acceptance)	StC, BC
“Easy does it, but do it”	Cautions the member against overly rigid or black-and-white thinking (or against letting strong emotions dictate choices), but also encourages action over complacency	StC, BC
“People, places and things”	Reminds the member that triggers will inevitably arise in her environment and therefore she must prepare and respond differently

^*StC=Stress and Coping Theory; SLT=Social Learning Theory; SoC=Social Control Theory; BC=Behavioral Choice Theory.

Behavioral therapies compared to A.A.:

Behavioral therapies that leverage operant learning procedures to reinforce desired behaviors (e.g., abstinence, treatment attendance) have demonstrated some of the strongest effects in substance use disorder treatment (Carroll and Onken, 2005). Both formal and informal types of “contingency management” exist in substance use disorder treatment and constitute perhaps the purest form of behaviorism. Desired behaviors can be directly reinforced in the clinical encounter. These reinforcers can be monetary or voucher-based or could be more social (especially if family engagement is involved). Some examples include formal Contingency Management (e.g., patients who meet treatment goals receive a proportional number of raffle tickets to draw prizes), extended “take-home” doses in opioid agonist treatment, or escalation of other privileges in inpatient or residential treatment. The Community Reinforcement Approach (CRA) is a broader treatment package that utilizes such operant procedures, along with other behavioral principles, to enhance skills for maintaining abstinence and to increase the natural and material reinforcers of substance abstinence.

Behavioral therapies also focus on the improvement of skills deficits, such as problem-solving, coping, and interpersonal effectiveness (e.g., drug refusal). Such skills building entails a combination of in-session didactic and in vivo exercises (e.g., role play) and out-of-session homework assignments. Functional analysis—a process of understanding the antecedents and consequences of behaviors—is used as a fundamental skill for support behavior change through identifying the function of substance use to identify opportunities for change (Haynes and O’Brien, 1990). This involves a wide array of behavior change procedures, such as modifying the environment (i.e., avoiding or changing triggers for use), providing alternative behaviors to achieve the same function as substance use (e.g., stress management), or leveraging social supports to manage triggers and urges. Behavior change principles, such as goal-setting and self-monitoring are used to facilitate these change processes.

In A.A., newcomers are taught early on that if they “take the action, the feeling will follow,” an overt plea for behavioral activation. The A.A. Big Book’s sixth chapter “Into Action” emphasizes that insight and independent self-appraisal are insufficient without the continuous action of Step Work. Indeed, the emphasis in the A.A. literature is on Step Work as a means to personal change and spiritual awakening, rather than an immediate awakening upon arrival into the fellowship that drives change (Alcoholics Anonymous, 2001). New members are told by others in the fellowship to “just bring the body” and “keep coming back” with the understanding that attendance may not lead to change instantly but will eventually yield results (anticipating that persons with addictions may be vulnerable to seeking shortcuts and quick fixes). Finally, pro-change reinforcers are numerous in the fellowship, from non-monetary forms of contingency management (i.e. the distribution of sobriety tokens for extended periods of sobriety, or the ability to hold service/leadership positions based on a minimum length of sobriety) to the gratification of “paying forward” the recovery one attains by being able to sponsor others.

Synthesis

The CBT therapist teaches the patient a variety of coping skills, including cognitive skills to manage cravings and other negative thoughts that may lead to relapse, as well as behavioral skills for managing and/or avoiding triggers for use. These elements of CBT mobilize stress and coping theory. These modalities also engage social learning theory through interactions with the therapist, ranging from role playing exercises to modeling comfort with intense emotional experiences. A subset of CBT called the Community Reinforcement Approach (CRA) devotes attention to the issue of alternative reinforcers to substance use, while elements of formal treatment literally reinforce specific behaviors within the frame of the treatment (sometimes explicitly as in Contingency Management). By focusing on the reinforcers for sobriety versus addiction, these latter examples directly mobilize elements of behavioral choice theory.

The A.A. program also provides each member with a variety of cognitive and behavioral tools, some through Step Work (especially Steps 4-7) and others through immersion in the fellowship itself. As members try out new behaviors (making phone calls, writing out Step Work), various theories of change begin to reinforce one another. A member who is told to call her sponsor when she wants to drink (social learning theory) may find this helps her cope with difficult situations (stress and coping theory). To this point we might expect a similar cascading effect in CBT, yet because of the A.A. fellowship, the cascade extends somewhat further. In this example, the member’s improved coping increases her trust in the group ethos of abstinence and service (social control theory) and provides a reward (i.e. connection with a mentor or friend) that she previously sought in alcohol (behavioral choice theory). As that member advances in sobriety, she is encouraged to take value-based actions (akin to what we discuss below in Acceptance and Commitment Therapy) that further reward her interest in service and sobriety. We observe here that many reinforcers for sobriety are self-perpetuating within the fellowship. In this way, behavioral activation may drive lasting change in A.A.

3. Acceptance and mindfulness based therapies (AMBT)

Definition:

Acceptance and mindfulness based therapies (AMBT) include dialectical behavioral therapy (DBT) (Linehan, 2018) acceptance and commitment therapy (ACT) (Hayes et al., 2011a), and mindfulness-based relapse prevention (Bowen et al., 2011). They are sometimes called “third wave” behavior therapies, build upon and share similarities with psychodynamic, cognitive, and behavioral therapies. Nevertheless, AMBTs are considered unique because they have a strong focus on three particular processes: 1) experiential acceptance – the ability to experience distressing thoughts and feelings in an open and accepting way (often simply called distress tolerance), 2) mindful awareness – the ability to be more fully aware of ongoing internal experiences, external experiences, and one’s actions in the present moment, and 3) values-based action – the process of actively making choices and acting in a manner that is in line with personally-chosen principles of living. These three core processes can be remembered with the phrase: “open, aware, and active” (Hayes et al., 2011b).

Acceptance and mindfulness-based therapies compared with A.A.

Mindfulness-based relapse prevention (MBRP) is a group-delivered aftercare treatment for SUDs designed to reduce the risk and severity of relapse through formal training in guided mindfulness meditation exercises. During sessions, the therapist’s role is to guide participants through various meditation exercises (5 to 20 minutes), facilitate active post-practice processing of the exercise, and connect client comments to core themes about acceptance, mindfulness awareness, and valued choices during the recovery process. The therapist also encourages clients to develop a daily mindfulness practice routine. One core meditation exercise is the body scan meditation, which helps clients learn and practice a variety of skills related to mindful awareness (directing awareness to body sensations, differentiating body sensations from emotional experiences) and acceptance (bringing an open and curious awareness to uncomfortable physical sensations). Another core meditation exercise is called “urge surfing.” This exercise involves brief imaginal exposure instructions to elicit an urge (imagining encountering a trigger) or general distress (imagining an argument with a friend), followed by guided instruction in mindfully observing the actual momentary experience of having an urge or being distressed, using one’s breathing to “ride out” or “surf” the wave of discomfort, and deliberately noticing the opportunity to “make choices” in the presence of distress.

Other AMBTs, such as DBT and ACT, involve less formal meditation training, and instead focus on briefer guided experiential exercises, metaphors, role-plays, worksheets, and didactic instruction. DBT, which involves the combination of individual therapy and group-delivered skills training, was originally developed for borderline personality disorder (BPD). DBT also has empirical support for individuals with co-occurring BPD and SUD (Maffei et al., 2018). DBT focuses on four core skill domains: mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation. In DBT, mindfulness skills are considered the foundation of all other skill domains. Therefore, DBT involves frequent practice of brief, guided mindfulness exercises to facilitate mindful awareness. Similar to DBT, ACT also involves a wide variety of brief guided experiential exercises to foster mindful awareness and acceptance. ACT also is unique from MBRP and DBT in its particularly strong focus on values-based action, through active discussion, worksheets, and application to daily life. There is preliminary empirical evidence supporting ACT as a treatment for illicit drug use disorders (Lee et al., 2015).

Through its rich oral tradition of slogans (see Table 3), literature, Step-Work and personal narratives, A.A. also offers a variety of tools for bolstering mindful awareness, acceptance, and values-based action. The serenity prayer (“God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference. Thy will, not mine, be done.”) (Steps, 1981) is a clear example of an A.A. component focused on the importance of acceptance during the change process. The HALT acronym (Hungry, Angry, Lonely, Tired) is a key example of a A.A. tool aimed to facilitate mindful recognition of different types of distressing subjective experiences (See Table 3). Finally, the 12-Step process of A.A. is in large part aimed at helping the member clarify her values, and the A.A. literature urges the member again and again to commit to making valued choices on a daily basis during the journey of recovery.

Synthesis

Both AMBT and the A.A. Program help individuals develop greater awareness and acceptance through a variety of methods (stress and coping theory). While A.A. does not involve the same level of systematic and structured training in mindfulness and acceptance skills found in AMBTs, A.A. still provides key tools (e.g., serenity prayer and HALT) that are complementary to skill taught in AMBTs. For example, during group discussions about the theme of experiential acceptance in AMBTs, it can be useful to relate the serenity prayer to negative emotional experiences. The therapist can facilitate clients in developing an understanding of the role of both acceptance (accepting that negative emotions are a part of life and we cannot avoid or stop them) and change (recognizing we can change our responses to emotions and the way we relate to them) in the process of coping with emotions. Moreover, the HALT acronym can be useful to incorporate in AMBT discussions about the usefulness of bringing more awareness to inner experiences (i.e., “looking underneath” a craving and recognizing what we are really feeling and what we really need in any moment).

Because both AMBT and A.A. programs are offered in group format, they may both tap into some of the same self-perpetuating recovery mechanisms as the A.A. fellowship (social learning theory, social control theory). For example, both MBRP and A.A. involve a substantial level of emotional disclosure, which may facilitate peer bonding (social control theory) and peer modeling of adaptive behaviors like experiencing and expressing emotions in an open way (social learning theory).

Finally, both ACT and A.A. have a strong focus on values-based action, which can enhance positive reinforcers in daily life that don’t involve substances (behavior choice theory). Importantly, engaging in the AA program may be a way for some clients to put their values into action. Hence, participating in A.A. might be a key feature of discussions about values-based actions in ACT. For example, through A.A. a client can focus on building meaningful relationships with other AA members, engaging in positive sober activities, or practicing spirituality on a daily basis.

Limitations

This paper is intended as an overview of common recovery mechanisms found within A.A. and three types of professional psychotherapy, but it by no means covers all elements of these therapies, nor does it necessarily capture all elements of potential overlap between the therapies and A.A. We selected professional psychotherapeutic interventions that are widely taught in clinical training programs and that have shown some evidence for efficacy in the treatment of SUD; a discussion of the relative efficacy of these approaches is beyond the scope of this article.

Conclusion

We have sought here to provide a discussion of how three “types” of psychotherapy (dynamic/analytic, CBT and AMBT) compare with the A.A. program on key recovery mechanisms. All modalities described here (including the A.A. program) mobilize mechanisms in the domain of stress and coping theory, yet professional psychotherapies, especially CBT and AMBT, may offer more specific advantages to patients with more severe deficits in distress tolerance and emotion regulation who may otherwise fail to receive the targeted support they need upon entrance to A.A. We have also argued that social learning theory is mobilized across modalities but may be more instruction/symbolic in professional psychotherapy, whereas the A.A. program may further mobilize powerful in vivo social learning elements. Behavioral choice theory tends to be mobilized to a greater extent in the A.A. program – through formal Step Work and through various structural elements of the fellowship – and in more behaviorally oriented modalities within CBT and AMBT that focus on reinforcers for use and sobriety in one’s environment. Finally, the A.A. program mobilizes social control theory to a greater extent than any of the professional psychotherapies through its persistent emphasis on group unity, abstinence, and service. Nonetheless, all psychotherapies are inherently social in nature when involving a live therapist, and certainly when delivered in the group setting; thus, these approaches also engage these social processes. Because AA is free and not time-limited, it may play an integral role in maintaining mechanisms of recovery in the longer-term, including mechanisms initiated by professional therapy.

“Clinical Example”.

A 27 year old woman with an alcohol use disorder finds a private practice psychologist through her insurance to address her alcohol problem. The psychologist bills herself as eclectic and states her work is informed by elements of by dynamic therapy and CBT. The woman finds some emotional relief in talking with the therapist. By talking in depth about her thoughts and feelings preceding episodic binges, her awareness of her alcohol use as a coping mechanism deepens. She also sees how alcohol serves as a release for her lack of self-esteem around relationships. She comes to understand that pressure from her parents to date and have a large social circle has amplified her dissatisfaction. However, after 9 months of weekly sessions, she is frustrated that she continues to binge episodically (though less often), and seeks out an A.A. women’s group as the result of a recommendation from another mentor. She ends an unhealthy relationship around this time and finds the support and encouragement of her group essential for accountability and monitoring. She sees how other women in the group model different ways of coping with temptation to drink and positive lifestyle choices. She also clarifies for herself that abstinence is her goal, in line with the message of the group, and feels positively when she receives a token celebrating 1 month of sobriety. She goes on to stay sober for several years and begins to sponsor other women.

In this example, the patient’s work with a psychotherapist mobilized elements stress and coping theory and deepened the patient’s insight, but her involvement in A.A. allowed her to mobilize elements of social learning theory (observation of modeling by other sober members), social control theory (setting a goal of abstinence and benefitting from accountability to peers), and behavioral choice theory (receiving sobriety token and affirmation from group for sobriety, becoming a sponsor) in order to make significant changes in her behavior and lifestyle.