The influence of the Twelve Steps recovery program of Alcoholics Anonymous (AA) is pervasive, but many psychiatrists treating patients with alcohol use—or other substance use—disorders may be unaware of exactly how it can help them in their work.
There are more than 50,000 AA meetings a week nationwide. Meetings are free, easily accessible, and unintimidating (speaking is not required, although eventually it is what works). However, the Twelve Steps have been controversial recently, with books and articles declaring that they do not represent “evidence-based” treatment. While one can argue that AA is not really treatment per se, there is in fact a body of empirical research demonstrating its clinical utility. The largest trial was Project MATCH, which was a randomized controlled trial funded by the National Institutes of Health. The trial found that 12-step facilitation (TSF) therapy was as effective as cognitive behavioral therapy (CBT) or motivational enhancement therapy for reducing frequency and intensity of drinking. In TSF, a therapist uses a number of strategies to encourage optimal participation in 12-step meetings. (For more on the evidence for AA, see TCPR, June 2014).
The Twelve Steps of AA also apply to Narcotics Anonymous (NA), Cocaine Anonymous (CA), and other substance-specific groups; however, AA is the most common of these.
The steps are both actual tasks and a sequence of psychological processes. In AA’s terms, this sequence leads to a “spiritual awakening,” but one can equally view it as progress in recovery from substances, as well as progress in learning how to live a more satisfying life.
First ‘steps’ “Give it a try,” is what psychiatrists might tell their new patients about AA, said John F. Kelly, PhD, Elizabeth R. Spallin Associate Professor of Psychiatry at Harvard Medical School and director of the MGH Recovery Research Institute. “And say, ‘Let’s talk about it next time.’” Patients should go to 3 meetings a week, at first, said Kelly. Research has shown that this is the minimum number of meetings associated with abstinence. While the core literature of AA recommends 90 meetings in 90 days, for new members, researchers have found that there are no increases in engagement after 60 meetings—that the benefit plateaus at this point. Empirically, Kelly says, there is not enough evidence to show that 90 meetings in 90 days is beneficial.
The ideal way to introduce a patient to AA, said Kelly, is for the psychiatrist to know someone who is a member, and can take the patient to a meeting. And if the psychiatrist has other patients who are in recovery and going to meetings, those patients would be the best people to do this, he added. “The most sure-footed way to get a patient to a meeting is to have them taken there by a peer who is in recovery.” Psychiatrists can accomplish this kind of introduction by asking for an experienced patient’s consent to be contacted by patients who are new to AA. The next best method is to get a list of local meetings and identify with the patient which ones would be most convenient, said Kelly. (To find meetings, go to this page and click on your location.)
TSF therapy Over the past 25 years, researchers have consistently found that TSF is effective, said Kelly, who points out that its effects have been shown to be equivalent to CBT, and other modalities. Since the aim of TSF is to encourage regular AA attendance, its benefits may be identical to the benefits of AA, although it is also possible that TSF helps via non-specific aspects of any psychotherapy.
Actually working on the steps will be too complicated for brief psychiatric visits, said Kelly. “It’s more important to just prescribe some attendance at AA, and to have the patient come back and discuss their experience,” Kelly said. Encourage patients to say something at their AA meeting, if only to say their name and why they’re there. “Just talking at a meeting has been shown to increase rates of engagement and better outcomes,” he said. It might be something as simple as, “I’m checking it out, not sure if I’m an alcoholic, but I’ve had a problem and I’m finally doing something about it.’”
Medications Psychiatrists need to warn their patients about not disclosing their medication status in AA, said J. Scott Tonigan, PhD, research professor in the Department of Psychology at the University of New Mexico. His advice is: don’t tell people, it has nothing to do with AA.
Along with Kelly, Tonigan 10 years ago surveyed AA members’ attitudes toward medications, and they found a “mixed bag” of responses (Tonigan JS and Kelly JF, Alcohol Treat Q 2004;22:67–78). “While the core AA literature is nonjudgmental, our paper showed that there is a segment of AA members who are hostile to medications, who will say, “You’re not sober if you’re taking methadone, lithium, Prozac, and other psychotropic medications,” said Tonigan. Kelly and Tonigan have sat in on many open meetings, and they see no benefit to disclosing medication use. “The psychiatrist needs to tell the patient, ‘Your use of this medication is irrelevant to the Twelve Steps,’” said Tonigan.
When getting to Steps 4 and 5, in talking to the sponsor, the patient will have to disclose medications, noted Tonigan. The psychiatrist who is sensitive to Twelve Steps philosophy should prepare the patient for judgmental statements and suggest another sponsor if the patient gets the message that the medications are bad.
AA for severe alcoholism Joseph Nowinski, PhD, author of the Twelve Step Facilitation Therapy Manual for the National Institute on Alcohol Abuse and Alcoholism (NIAAA), which was used in Project MATCH, said that it’s important for psychiatrists to tell patients to just go to some open meetings at first. The psychiatrist will be addressing Step 1 automatically in the assessment, using DSM-5, which separates alcohol use disorders into mild, moderate, and severe. If the patient has mild or moderate addiction, AA might not be appropriate, said Nowinski.
Nowinski has worked on treatment strategies for alcohol-dependent individuals, but there are people who are “almost alcoholic” (the title of a book he co-authored) who may need to get back to less risky drinking. While TSF is for severe alcoholics, there are people who are “high-functioning alcoholics.” Imagine a woman who drinks 3 to 4 drinks a day—this is too much, and adversely affecting her health, but AA is not for her. “In that case, the psychiatrist can ask, ‘What is your daily drinking routine; how can we change that?’” It may include drink refusal skills, not going out to bars after work as much, or other approaches. “But they haven’t experienced the kind of consequence that people going to AA have,” said Nowinski. “They might feel that they don’t belong there.” On the other hand, there are people with moderate (not severe) drinking problems who go to AA because they really do want to stop, he said.
Abstinence? The message at AA meetings is going to be one of abstinence, not cutting back—even though there are clear benefits to drinking less. But for patients who are not committed to stopping altogether, they could practice what Tonigan calls “sobriety sampling,” which can help patients who don’t really want to be in treatment and don’t have an abstinence goal. “We ask them, ‘How long could you try being abstinent?’ And if they say 1 day, we say, ‘Could you try 2 or 3 days?’” Once they try 2 or 3 days, they come back and report that their lives are already getting more stable, said Tonigan. “If you tell them it has to be for the rest of their lives, that’s overwhelming.” And this is built into the AA philosophy, which has as one of its most beloved slogans, “One day at a time.”
People with addiction tend to discount future rewards, researchers have found. While people who are not alcohol dependent could say they don’t want that extra drink because they don’t want a hangover the next day, the alcoholic would be more interested in the immediate reward. And eventually, that alcoholic would simply drink the next morning as well to feel better, at this point not being able to cut back at all.
For patients who do want to continue to drink, but who want to cut back, Tonigan thinks a group like Rational Recovery, which is more tolerant of ongoing substance use, might be more appropriate.
For patients who have read magazine articles and books denigrating AA, Tonigan, who worked with motivational interviewing founder William R. Miller, PhD, said don’t argue. These patients may say, “Why should I go there? It’s a crazy society of people who pray to God.” The best response, said Tonigan, is “Yes, I understand what you’re saying, but on the other hand, some people aren’t aware that there are more than 650 empirical studies on 12-step programs, and in general we find people do much better on attending these programs.”
Which steps work? For years, Tonigan and co-researchers have been trying to find out which steps AA members have completed. They found that in essence, people were working on parts of the steps, usually without completing all of them. It turns out that the steps people have completed doesn’t predict outcome; rather, continuing to work on them on a regular basis is the key. “That’s pretty shocking, because the steps are supposed to be the active ingredient of AA,” said Tonigan. “But what we do find is that working the steps helps someone have a spiritual awakening, and that is what is mobilizing the change.”
Instead of focusing on the steps themselves, psychiatrists can just encourage people to take part in the “prescribed behaviors” of the steps, said Tonigan.
Joining the human condition David Sack, MD, is an addiction psychiatrist who has been in practice more than 30 years, and he has found that 12-step programs help patients with everything that therapy and medications don’t address. Most patients with substance use disorders have co-occurring disorders such as depression, bipolar disorder, anxiety, or schizophrenia, he says. One of the biggest problems for people in early recovery is impairments in working memory. “They lose the ability to plan, to remember what they want to do and when they want to do it,” he said. “But in the Twelve Step program, the message over and over is, ‘One day at a time, one step at a time.’” This is important to these patients because they can become overwhelmed and panic, he said. The Twelve Steps program helps patients develop a strategy around getting back to work and getting stable.
Secondly, the Twelve Steps program is very good at the issue of shame, said Sack, who is also president and CEO of Elements Behavioral Health, an addiction treatment chain. “Most people in early recovery are forced to confront all the things they did when they were using,” he said. The fourth step helps them process what they did to their loved ones or their co-workers. “They write it down and tell it to another person, and then they see that the world doesn’t end,” he said. “The fourth step has tremendous curative power.” That shame, when not released, is one reason that people relapse early on in recovery, said Sack. “They’re frightened, they don’t think they can join the human condition.”
AA meetings can be remarkably helpful in teaching patients how to imagine something good in the future, which can help forestall relapse and strengthen recovery. Sack related the story of one patient who was dutifully going to AA but didn’t feel it was helping him much—something happened at a meeting that changed everything. “He told me, ‘I’m sitting in this room, I don’t know why I’m there, and I’m listening to these stories, and one day my ears perked up. I was listening to this guy who sounded just like me—drinking, cocaine, shooting up, detox—and then at the end of his sharing, he said that then he got clean, and he has a house, a car, and his car sounded great, and he has this wife and she loves him and they have dinner together—and I wanted those things too. I didn’t really care about being sober, but when I heard that, I said that’s what I want.’”
That “sharing,” as telling your experience in AA is called, is what allows new patients to see that things can get better, which can decrease their impulsivity, said Sack. Finally, it’s important to know that nobody has to say anything at a meeting. “You watch other people say things, and they get a round of applause,” he said. “The meeting shows it’s safe to share.”
Of course, it’s also safe to share in the psychiatrist’s office. But Twelve Step 5 groups and AA members are there the rest of the time, even at 2:00 in the morning when your patient may need support. This is a free resource with some good evidence to back it up. The TSF prescription may be just what many patients need.