McPeake, JD: Ecological Relevant Cognitive Behavior Therapy: The Slogans and Sayings of Twelve Step Programs and Their Use in Chemical Dependency Treatment. Journal of Chemical Dependency Treatment (accepted for publication Spring 2004).
Introduction
Among contemporary schools
of therapy for chemical dependence Cognitive Behavior Therapy (CBT) is one of
the most widely research and demonstrably successful (Monti, P.M., Abrams, D.B.,
Kadden, R.M.& Cooney, N.L., 1989; Project Match 1997). CBT explores and
exposes patterns of thinking and behavior that are dysfunctional, attempting
to replace both with more adaptive strategies. Twelve Step based therapies also
produce successful treatment outcomes (Project Match 1997; McCrady, 1998) and
have the advantage of dovetailing with a unique, freely available, international
network. In part, Twelve Step approaches produce their effects through an “ecological
relevant” informal CBT approach implicit in the extensive repertoire of
slogans and sayings which recovering members of Twelve Step Programs learn and
practice. These slogans and sayings also expose dysfunctional patterns of thought
and behavior and offer pragmatic, real world responses.
This paper examines the use of slogans and sayings as CBT tools to treat clients.
These slogans and sayings provide an ecologically relevant mechanism and a contextual
bridge allowing the therapist to understand and use the language the patient
experiences. The therapist may then present clinical interventions that begin
with this language and support, re-interpret and discuss the underlying cognition
and behavior. The slogans and sayings also provide the therapist with rapid
insight into the cognitive world of the recovering person. In addition, slogans
and sayings have mnemonic characteristics, which allow them to be easily retained
and also provide when divorced from their Twelve Step context pure CBT strategies,
e.g., “Think the drink (drug) through.” Slogans and sayings facilitate
an affective connection with the process of recovery. Finally, slogans and sayings
appear to have the potential to produce sudden and constructive rearrangements
of cognitive life.
After offering a clinical illustration this paper continues with a summary of
themes derived from hundreds of slogans and sayings with suggestions for their
utilization in clinical work.
Case Illustration #1
William was a 22 y.o., unmarried,
white, male, college student with a history of substance use disorder, epilepsy
and a mild stutter. William was referred to our outpatient program by a family
friend. William came from an intact, upper SES family that included a sister
several years older. William’s father, owner of a business, drank regularly
in a controlled fashion and his mother, who was the prime mover in seeking treatment
for her son drank socially. On initial evaluation William was smoking marihuana
daily, ordering anxiolytic medication via the internet and drinking regularly.
His epilepsy was not well controlled because of non-compliance with his medication
regimen and his alcohol and other drug use. As a result of his chemical dependence
he had just barely completed his junior year at college. William and his parents
agreed to a rehabilitation hospitalization and he was referred to a program
in the Southwest. During his senior year in school he saw a therapist occasionally
and attended A.A. irregularly. Prior to graduation William and two college friends
were arrested for attempting to import MDMA into the U.S. and although he graduated,
William was placed on federal probation. Subsequent to graduation William moved
to Metro Boston and sought employment. During outpatient therapy William was
compliant and polite but only moderately involved in his treatment plan.. During
a particular therapy session as the consequences of William’s alcohol
and other drug use were under review the therapist said: “William you
weren’t always in trouble when you used, but every time you were in trouble
you had been using.” The turn of phrase had a noticeable effect on William
who repeated the expression but personalized it, “I wasn’t always
in trouble when I used, but every time I was in trouble I had been using. Yeah,
That’s me.” By his own report the idea embedded in the slogan was
a new insight. During subsequent sessions this slogan became a mantra for William
and appeared to be associated with an improvement in his motivation and commitment
to recovery. As he was also attending A.A. he reported that he heard the same
expression used and illustrated on several occasions by people, speaking in
A.A., enhancing his identification with the speaker and the program. He also
reported the not uncommon scenario that the slogan often “popped into
his head” unbidden and occasioned meditation on its meaning. William had
implicitly believed that his alcohol and other drug use were not related to
the problems and difficulties in his life. Fortuitously perhaps, this slogan
reorganized William’s cognitions.
Major Themes of Slogans and
Sayings and Their Clinical Application
An informal analysis of the author’s collection of 141 slogans and sayings
suggests (Anonymous 1983) over a dozen thematic categories. Twelve of these
categories are listed below with a representative slogan or saying and suggestions
for how it has been utilized in a therapeutic context.
1. Obsession and the First Drink or Drug
Individuals who
suffer from chemical dependence are often marked by their inability to predict
when they will over use a substance and the outcome of such over use. In consequence
the first drink or drug, which often triggers craving and compulsive use, is
immortalized in a number of slogans and sayings, i.e., “It’s the
first drink (drug) that gets you drunk.” Most recovering people are aware
that this is not literally true. They realize that first use often re-establishes
craving and usually results in a pattern of return to use with adverse consequences.
The slogan and others like it, however, suggest extraordinary vigilance to initial
use and its unpredictable consequences. This slogan leads to a discussion about
the assumption that, "I can drink or drug safely and without consequences."
One client was amazed at the notion that first use, itself triggered by cues
worth exploring, was the beginning of an obsessive compulsive chain. Until this
point in her therapy she had continued to believe that she could have a “few”
and it would be OK. She said that oddly this was both dramatized and made humorous
for her by an old man, with whom she would not ordinarily identify, who at an
A.A. meeting described his unsuccessful strategy for staying sober. She said
that he related he had heard all about the danger of the first drink and so
whenever he went into a bar he would order that first drink and set it aside
on the bar. Then he would drink the second drink, the third and so on. He said
with infectious good humor that he had proved conclusively that it wasn’t
the first drink that was the problem. She noted that listening to the humorous
and self-effacing old man was one of several early turning points in her recovery.
This vignette is illustrative of the fact that slogans and sayings are the beginning
of a dialogue that can occur within the individual, in individual counseling,
or in a group setting. The dialogue productively raises questions about the
implications of “first use” in a person suffering from chemical
dependence. The slogan or saying then may become a mnemonic device that can
store in memory all of the ideas associated with the discussion. And, as this
slogan demonstrates, the added humor associated with hearing such a wry tale
from another recovering person reduces defensiveness and accelerates identification.
2. The Specific Suggestion “Don’t
drink (Don't Use!)!”
Despite the fact that objective
observers see the painfully obvious nature of this issue, that drinking or using
other psychoactive substances is the central issue, it is remarkable how often
the discovery that this is the case is a little “sartori” for the
recovering person. In addition, it is remarkable how often recovering people
enjoin each other not to use by employing “Don’t use!” both
as a greeting, salutation and unendingly repeated piece of self-talk. While
such an injunction from a non-recovering person may be angrily rejected, with
identification with recovery and recovering people, it becomes accepted and
playful. Within recovery circles a day of not using is regarded as a “miracle”
because recovering people believe that the natural tendency of the recovering
person is to use and something quite unusual must be actively happening to interfere
with this powerfully tendency. This slogan challenges the suggestion that “use”
is not the problem and that direct suggestion not to use is somehow taboo.
The following anecdote, related by a man in early recovery, demonstrates the
change in attitude toward this injunction that is symptomatic of clinical progress.
“This will sound pretty strange from a person who believed that alcohol
and other drugs were not the problem but here’s the way it is now. When
I see people who are involved in A.A. or who are trying to stay away from alcohol
and other drugs, I usually say “Don’t drink!” in place of
“Hello” or “Goodbye.” Sometimes people are surprised
or even offended, even people who have been in recovery a long time. “What
do you mean,” they sometimes say “I’ve been sober three years.”
I say “Don’t drink!” or alternatively “Don’t use!”
for me, not for anyone else. Oh, I guess that I’ll admit when someone
else hears “Don’t drink!” it might focus his or her attention
on sobriety and not drinking or drugging. If it does that I’m glad but
basically I say it for me. I want to remind myself every chance I get of what
alcohol and other drugs did to me and what a life of sobriety in A.A. is doing
for me.”
3. Other Specific Suggestions
for Behavior Change
Twelve Step Programs are
full of additional direct suggestions that frequently include imagery and goal
directed cognitive behavioral strategies. In fact, Twelve Step Programs seem
to have an implicit or covert theory that resembles clinical hypnosis and other
forms of suggestive therapeutics. From a theoretical viewpoint: certain antecedent
conditions enable a person to enter a particular state of consciousness or awareness
that allows them to do things that they previously had difficulty doing. Members
A.A. and N.A. believe that pain, suffering and humiliation will eventually create
in the chemically dependent person a subjective state that is called "willingness
(Twelve Steps and Twelve Traditions, p.34 ff., 1981)." When this state
has been achieved the chemically dependent person will be able to follow suggestions
that they had previously been unable to follow. Often the chemically dependent
person may report that they "heard" or "understood" the
suggestion for the first time, in what appears to be a spontaneous or dramatic
insight.
Corey had grown up in a family full of chemical dependence. He was fond of saying
that alcoholism didn't run in his family, it "galloped." He had been
to many A.A. and ALANON meetings with family members. Now the court had mandated
that Corey go to A.A. for himself or go to jail, but he was having trouble with
A.A. He felt that he knew a lot about A.A. from his earlier experiences. He
could sometimes predict the questions people would ask and be ready with the
answers. He felt he knew who was sincere and who was just "using"
A.A. to get out of trouble. He knew many of the old timers in his area of the
city because he had been to so many meetings with his dad, who Corey said, "Never
really got it." At a particular meeting one of the old timers listening
to Corey's complaints about his difficulty in "getting" the program
suggested to him that he should, "Look for a way in, not a way out."
The suggestion "stuck" with Corey. He couldn't get it out of his head
nor could he find the strategy that would make the program work for him. Another
A.A. member, noting Corey's frequent comments at meetings about knowing all
about it, but still not getting it, suggested that Corey, "Take the cotton
out of his ears and stuff it in his mouth." So Corey adopted a policy of
not speaking at meetings and just listening, listening hard for the thing that
would open up the program to him as he knew it had to others. While listening
he found that many of the people whose presentation and recovery he respected
had participated in a particular, intensive, Twelve Step Study in another part
of the city. Corey enrolled in this program despite the fact that it was a 22
night commitment over 22 weeks. For Corey that intensive Step study seemed to
hold the key to a happy and productive recovery. He realized that most of the
people he had been associating with were not really advocates of the Steps but
were really "Two Steppers" people who didn't drink and went to meetings
but avoided Step work. He said he should have known all along that the Steps
were the A.A. program. It was what had been missing for Corey, he had found
a way into recovery by listening. Corey subsequently became one of those A.A.
members who didn't say much, but when he spoke people listened.
4. Blaming People, Places
and Things
One of the most common and
accepted assumptions about chemical dependence is that recovery is strongly
causally related to “circumstances” or, worse, “underlying
causes.” Chemically dependent people themselves are very good at blaming
“people, places and things” for their use. They resist the need
to first change their alcohol and other drug use behaviors, often leaving this
strategy until all else has failed. In fact, we have good evidence that dependence
is caused by use, and resulting genetically programmed changes in midbrain neourophysiological
systems, i.e., the ventral tegmental-medial forebrain-nucleus accumbens axis
(McLellan, A.T., Lewis, O’Brien and Kleber, 2000), that subsequently do
not respond well to executive cortical functions. All the insight in the world
isn’t worth much, nor is changing people, e.g. wives, friends and lovers,
places, e.g., exchanging San Francisco for Boston, or things, e.g., the new
house will solve the problem. The specific alcohol and drug use behaviors that
are part of the chemically dependent person need to be changed. Consistent group
pressure is frequently needed to accomplish this. The wisdom of Twelve Step
programs has been that if you deal with the alcohol and other drug use you can
move forward, if you don’t you can’t.
Alex had been going to A.A. for only a very short time when he heard “Wherever
you go there you are.” in reference to a geographic cure. Alex was a professional
who had “started over” several times in several cities. He felt
that the Myth of Sisyphus described his life. He’d move to a new city,
he had very transferable computer skills, and begin life again. Gradually over
several years his alcohol and other drug use would produce the same scenario
he had experienced in his old location. His life, like Sisyphus’ rock,
would role back down the hill to the very bottom and he’d begin again
rolling it uphill. He tried meditation, psychotherapy and various wellness fads.
When he heard this expression something clicked for him. He saw that in every
instance he had failed to significantly alter his relationship with alcohol
and other drugs. Now that he was staying put and confronting his drug dependence
something good seemed to be happening.
5. Change
The issue of change as suggested
above looms large for the alcohol and drug dependent person. There is a specific
temporal order to this change within Twelve Step oriented approaches, and it
begins with changing the alcohol and drug related behaviors. Many slogans and
sayings encapsulate this fact. These slogans challenge the assumption that if
the chemically dependent person changes the circumstances that led to becoming
drug dependent she will stop using.
George was dealing with the issues of cues and triggers and discussing the issue
in group therapy but he didn’t really accept the associated ideas as they
were being presented. He was also attending A.A. meetings. Subsequent to a particular
A.A. meeting he came to group anxious to share a new insight. He said that while
he had thought he understood the cues and triggers “thing” he had
heard two expressions at that single meeting that brought it all together for
him. One speaker had noted that getting drunk was like getting mugged, “You
can’t get mugged in a dark alley if you don’t walk in dark alleys.”
he added. The very next speaker had during his qualification noted that, “If
you keep going into the barber shop you’re going to get a haircut.”
George told the group that he’d been mugged (metaphorically) so many times
and he hadn’t seen it coming and he’d had so many bad “haircuts.”
He said that after the meeting he had had a dream in which he entered a bar
and there were signs on the wall that said, “We’re going to take
your money!” We’re going to beat up on you!” We’re going
to throw you out the door!” “We’re going to make you feel
awful!” but the final sign said “And you’ll be back for more!!”
George said he now “felt,” not just understood, what triggers and
cues meant.
6. The Issue of Illness vs
Morality
The issue of whether chemical
dependence is an illness, a social problem, or a moral problem continues unabated
despite sophisticated comparisons of drug dependence with other chronic medical
illnesses (McLellan, Lewis, O’Brien and Kleber, 2000). Nevertheless Twelve
Step approaches have long championed the view that drug dependent people are
sick and need to admit that fact. With the admission of illness and the rejection
of the underlying assumption of “badness” many of the otherwise
incomprehensible aspects of recovery make more sense and it becomes easier to
participate in treatment.
John was a college educated, articulate professional who resented people telling
him how to live. He felt he had a problem with alcohol and other drugs but had
tremendous difficulty accepting the idea that he had a chronic illness and therefore
accepting the idea that he needed regular treatment. While attending an alcohol
and drug intervention program for operating a vehicle under the influence he
was required to attend a twice-weekly group session and A.A. or N.A. At an A.A.
meeting he heard the following which he related at group. A professional man
at a meeting said something like this: “I think today of just how much
subtle, and sometimes not so subtle, damage we have done to the beautiful, complex
mechanism inside our skulls. Most of us do not have a wet brain when we arrive
for treatment but it will take many months of physical and mental health before
we can successfully think clearly and effectively. Particularly during this
early period, taking suggestions that are given to us may well be a life saving
proposition. Its not a normal state of affairs to subjugate one’s behavior
to the suggestions of others but it is important to remember that whether in
a treatment center, under the care of a physician, but always with the help
of A.A. or N.A., we are very sick people with a life threatening illness. Our
fuzzy thinking, impulsive emotions, and labile moods cannot be allowed to kill
us. Remind yourself of the fact that your alcohol use has hurt you badly. It
has injured and abused the instrument that controls you, which in many senses
is you. Get out of the driver’s seat for a while and only get back in
when others tell you they think you are ready. I try to remember, ‘I’m
here because I’m not all there.’”
John brought the expression “I’m here because I’m not all
there.” to group and wanted to discuss alcohol, drugs and brain damage.
This produced several very stimulating groups. He was particularly interested
in literature that suggested impairment of executive function and decision making
in early recovery. The existence of neuropsychological deficits made the need
for practical, down to earth treatment understandable to John and allowed him
to more readily accept help and direction from others.
7. Utilization versus Analysis
Many people find their initial
experience with Twelve Step Programs difficult because of their simplicity and
directness, prioritizing specific types of behavior above analysis of the “reasons
for” or the “meaning” or “explanation” of the
person’s chemical dependence. In this sense Twelve Step Programs are like
CBT training manuals which focus on learning and practicing specific behaviors.
A.A. culture enjoins the newcomer do the following new behaviors: don’t
use for a day, go to meetings every day, join an A.A. group, get a sponsor,
follow the sponsor's suggestions, get a job in the group, e.g., make coffee,
set up the meeting, travel with the group to commitments, sit in the front row,
“Listen to learn, learn to listen.” etc. A.A. says to the newcomer
“Learn these new behaviors!” The slogan is “Utilize don’t
analyze.” Many people coming to Twelve Step Programs think they have to
first figure out their chemical dependency, figure out the "why."
These programs in their actual day to day enactment reject that idea and instead
provide structured behavioral training. It is worth noting that after behavior
has been stabilized there is a lot of opportunity for analysis, often called
“Step work,” but that comes at a later stage in the progression
of recovery.
Like many highly credentialed professionals Martha, a psychiatrist, was offended
by what in her view was the unbelievable and “stupid” simple mindedness
of Twelve Step Programs. This was epitomized by the blue and gold banners decorating
the room where her first N.A. meeting occurred. She was particularly offended
by the “Keep it Simple” banner because she appropriately regarded
herself as richly complex. Nevertheless she was forced to attend such meetings
by her contract with the Board of Registration in Medicine in the state where
she had been discovered self-prescribing and using opioids at work. She openly
admitted to her therapy group, another requirement of her contract, that she
never would have continued the participation at self-help meetings without the
contract. She had been in psychotherapy with another psychiatrist for many years
and felt it to be a much superior modality, although her therapeutic work had
had no impact on her opioid dependence. After another instance of opioid use
turned up on a urinalysis, her surveillance was intensified and Martha faced
permanent revocation of her medical license. Martha decided to try and do exactly
what her sponsor suggested to her. Six months later she related to the therapy
group that she had joined an N.A. group, was making coffee, which she never
drank, going on commitments, helping other addicted people, etc. She said her
life had changed, she didn’t understand it. She’d figure that out
some time later. Her strategy at that time was “Fake it, ‘till you
make it.” “I’m just doing it the way its laid out by my sponsor,”
she said “its working and I don’t care why.”
8. Time: A Daily Program,
A Present Time Orientation
Twelve Step Programs have
something in common with Zen in their orientation to time. Zen says, “When
doing the dishes do the dishes.” Twelve Step Programs say look well to
this day, “The past is history the future’s a mystery.” The
emphasis in both is on now, this moment, being fully in the present. This does
not obviate the need to plan for the future, but it does encourages awareness
of the unpredictability of the outcomes of plans and attempts to prevent unhappiness
when things don’t work out exactly as planned,i.e., “You can plan
but don’t plan the outcome.” The people who come to Twelve Step
Programs are often in a hurry, they’re looking for a quick fix for a chronic
problem. American health care is pretty good at things that can be fixed quickly.
Rehabilitation medicine is a different story, slower, less glamorous, more painstaking,
with the need for more patience. This different orientation to time can be a
stumbling block.
April was a 29 y.o., alcohol, cocaine and marijuana dependent woman, divorced,
a high school graduate, with a child in foster care, living in a women’s
recovery home. She was very anxious about the future, particularly what would
happen to her young daughter. For her the idea of living a day at a time seemed
unreasonable, and her main concern was getting out of the recovery home, getting
a job and resuming life with her child. Since this was not her first attempt
at recovery, she had been in one form or another of chemical dependency treatment
on six occasions, she was at some level also aware that she lacked recovery
and living skills. April entered into a contract with staff that first involved
relaxation training. Progressive relaxation was selected as the method of relaxation
because it gave April a significant measure of control and felt to her, “Sort
of like a work out.” She reported that progressive relaxation successfully
reduced her anxiety level. In addition to daily attendance at meetings, both
in the recovery home and in the community, April established daily written goals,
e.g., daily review of the newspaper for jobs, a certain number of calls and
interviews, completing her house responsibilities, as well as a written list
of long term goals: job, apartment, living with her daughter. The strategy offered
April was that by consistent work on her recovery and daily goals she would
maximize her ability to achieve her long-term goals. In addition, to the reduction
in anxiety, she reported that she frequently became productively immersed in
her daily routine and could reduce anxiety by thinking about releasing muscle
tension and her “strategy.” She reported that for the first time
she thought she was really living “a day at a time.”
9. Loss of Control
Chemically dependent people,
over the course of their illness, often experience progressively more dramatic
instances of loss of control over their use, which invariably are correlated
with more dramatic, adverse consequences. Despite this evidence they fight the
notion that they cannot control their use. Chemically dependent people, who
want to be like "normal" like other people, think they may discover
a method which will allow them to "use in safety." In the Twelve Step
Model recovery begins when the drug dependent person acknowledges the inability
to control use. Many slogans and sayings address this issue and many of them
are quite humorous.
Carlos was a Spanish speaker for whom English was a second language. His alcohol
and marijuana dependence had produced numerous negative consequences, including
a recent criminal charge of possession with intent to distribute, for which
he was on probation and mandated to outpatient treatment. He came to group one
evening perplexed by something he had heard at the A.A. meeting he had attended
that week. He said that the speaker said something like, “When I drink
I break out in spots.” and he wanted to know what that meant. Was there
some kind of skin condition associated with drinking? The group laughingly explained
to Carlos that the speaker must have meant that when he used alcohol he ended
up in blackouts travelling to places he hadn’t intended to travel to.
This was particularly meaningful for Carlos because he had ended up living in
the Northeast because his drinking and drug use had hooked him up with some
itinerant kitchen laborers who finally stopped wandering when they got jobs
in Boston. Carlos too was a victim of the unpredictability of a drinking life
style and he began to see that. The slogan “When I drink I break out in
spots.” and his misunderstanding of it became part of his story.
10. The issue of Acceptance
of Help
From a Twelve Step perspective
the chemically dependent person needs to recognize the loss of control over
alcohol and other drug use, as well as, their inability to deal with their use
disorder themselves and therefore the need for help from outside the self. All
of these issues involve the acknowledgement of loss of control and acceptance
of help. Clients need to learn that accepting help from others can be viewed
as a skill and we can evaluate the need for help based on how successful we
are at the particular activity in question. And as they make progress they can
get feedback from their own performance and from other’s evaluation of
their performance and then adjust their behavior. This involves a student teacher
relationship, a coaching relationship or a mentoring relationship.
Steve was a surgeon who had been disciplined by the state board of medicine
for incidents involving excessive use of alcohol. Steve was very self confident
and intelligent and resented anyone telling him what to do. He was also very
invested in his status as a physician and had trouble listening to people who
were not physicians or at least other highly credentialled professionals. Steve
attended A.A., it was part of his contract with the board of registration, but
felt it was a waste of his time and quite beneath him. Steve also attended a
support group for physicians, dentists and other doctoral level health care
professionals where he felt more comfortable. One evening when Steve was expressing
his discontent another physician-surgeon said, “When I was using I thought
I was the best surgeon on the planet. Sometimes you need that kind of confidence,
but I was beginning to make mistakes and I had a close call with a patient and
shortly thereafter my partners intervened on me. I went to treatment and when
I returned to the practice my partners said, ‘That was like medical school,
now we’re going to apprentice you to Eddie M. and he’s going to
teach you what it takes to stay sober and live sober. You’ll do what Eddie
says or you can find a new medical group.’ Of course I was pissed but
I felt trapped and Eddie turned out to be a genial old guy who simply said,
‘Look Doc get out of the driver’s seat for 90 days. We’ll
travel around together and I’ll show you how it works.’ I did that
I “Got out of the driver’s seat.” and despite myself I learned
from Eddie just the things I needed to know, it was like being a resident all
over again just that the hours and the coffee were better.” Steve said
that was a turning point of sorts for him, the idea that recovery was about
learning a new set of skills was what he needed to hear.
11. The Self and Being Alone
Twelve Step oriented therapies offer the opportunity for intense,
structured, community experience within a sub-culture. This contrasts with the
common implicit assumption “I can do it myself.” This may involve
inpatient treatment programs of varying duration from detoxification to multi-month
programs. A.A. itself, to which an individual often is referred, has a “program”
which is comprised of the Twelve Steps and the Twelve Step work which they encompass,
both on a daily and long term basis. Such programs like the Alcoholics Anonymous
Way of Life (AAWOL) programs may be quite formal and institutionalized. There
are then various types of meetings both for the general recovering community,
e.g. open meetings, discussion meetings, and meetings specialized by sub-group,
e.g., men women, gays, etc. In addition, there is the “fellowship”
of A.A., the communal structures which include numerous informal contacts, e.g.,
extensive phone networks, socializing over coffee or meals, group anniversaries
and other communal celebrations, retreats, travel to and from meetings, shared
living space, and special interest groups such as recovering Harley Davidson
riders etc. The emphasis is on community and the necessity of a community that
endorses and emphasizes abstinence and recovery. The individual may participate
in as much or as little of this sub-culture as he needs or wishes.
In early recovery A.A. suggests immersing the individual in this subculture
which “holds” the person until he has developed a stable recovery.
Tom reported in group that he heard someone say at a meeting, “When you’re
alone you’re in bad company.” He related the following reaction,
“This expression really annoyed me when I first heard it and my sponsor
repeated it to me. Today I know that even though I’m still sick, when
I heard it I was very sick and left to my own devices I would have been overcome
by my illness in a short time. Naturally I argued because I didn’t understand,
but mostly because I still wanted to drink and drug which I went ahead and did
anyway, but I could only do it by isolating myself from other A.A.s and they
persisted by calling me or actually coming by the house. I needed people around
me to keep me sober, to keep me from drinking and drugging, to teach me about
living sober until I could acquire enough skills to occasionally be by myself
in safety. Eventually, A.A. gave me the wonderful luxury of being able to be
alone with myself and enjoy my self. Today I am aware that I need other people
and should not remain isolated from people who understand me, lest the illness
rear its ugly head.” The group discussion about self and others that followed
his comments was stimulating and productive.
12. A Higher Power
Twelve Step programs are
overtly spiritual in their emphasis and frequently reference God. Nevertheless,
individuals who are agnostic or atheist can and do benefit from the great flexibility
and inclusiveness found in actual A.A. practice. Frequently, for example, the
A.A. group is offered as a power greater than the individual and therefore an
appropriate substitute for a higher power. Sometimes the sponsor, the initial
mentor in A.A. or N.A., is identified as the higher power. Or the notion of
spirituality is broadly interpreted to include any ethical or philosophical
tradition that fosters positive personal growth and development. Twelve Step
programs usually bend over backwards to make it easy for the newcomer to enter
the system. Nowhere is this flexibility clearer than in the re-framing of the
word God in the following case vignette.
Joe was quite hostile to the idea of God when he finally became willing to explore
A.A. He would not say the "Our Father", a prayer that typically closes
A.A. and N.A. meetings, nor the "Serenity Prayer." He expressed his
belief that "higher power" was simply a thinly disguised euphemism
for God. Joe was so desperate as a result of the adverse consequences of his
alcohol and other drug use that he continued to participate. He realized that
many of the people he met were similar to himself and they were able to stop
using. He needed, and to some extent wanted, to stop use too. But he struggled
with God until at one meeting a man with whom he identified was speaking about
a similar problem. He talked about how he didn't believe in God, didn't want
to hear about God nor the higher power. He said that someone said, "If
you put periods in the word G.O.D. it really can simply stand for group of drunks
or group of druggies. Let a group of drunks be your higher power. How about
that?" Joe said that was one of those eureka moments in two ways. First,
the idea worked for him. He could relate to the idea that individuals who had
learned to stay sober could help. Second, he perceived how hard people in A.A.
tried to make the program fit the needs of the individual alcoholic and he felt
very grateful for that thoughtfulness.
Conclusion
Slogans and sayings from Twelve Step programs provide an additional
tool in the clinical armamentarium. They have the advantage of emerging from
the context and experience of Twelve Step programs and offer the therapist rapid
insight into the issues Twelve Step programs have historically regarded as important
to recovery. Slogans and sayings challenge destructive cognitions and offer
behavioral strategies. Such slogans and sayings stimulate group discussion and
serve as easy to remember symbols of more complex topics. On occasion they appear
to produce rapid insight in clients about some recovery issue. In addition,
they often have a wry, good humored flavor that make sensitive topics more palatable.
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