THE 12 STEP PROGRAMS

1
THE 12 STEP PROGRAMS

• What the practicing clinician should know.
• (CSAM 2002)

2
OBJECTIVES

• At the end of this session each participant will
  be able to
• 1. Describe the main reasons for referring
  patients to the 12 step programs.
• 2. Discuss what it means for a patient to work a
  12 step program of recovery, including-Going to
  meetings
  -Finding a sponsor and a home
  group -Working the steps

3
OBJECTIVES

• 3. Describe the most effective way to refer
  patients to 12 step programs, including
  requesting 12 step calls in hospital.
• 4. Discuss the principles involved in the 12
  steps, including the difference between a
  spiritual and a religious program.

4
Why the 12 Step Programs?

• AA and NA have helped millions of alcoholics and
  other drug addicts
• Most effective way of staying sober
• Know how to refer and support
• 12 steps adapted to deal with over 200 human
  problems

5
12 STEP PROGRAMS

• Best Known
• Alcoholics Anonymous (AA)
• Alanon
• Narcotics Anonymous (NA)
• Cocaine Anonymous (CA)
• Gamblers Anonymous (GA)
• Overeaters Anonymous (OA)
• Debtors Anonymous (DA)
• Sex and Love Addicts Anonymous (SLAA)

6
History of AA

• 1935 two hopeless drunks, Bill W. and Dr. Bob S.,
  managed to stay sober by talking to each other
• They worked with other alcoholics
• Three year period empirical field research
• approximately 100 were staying sober
• Method of maintaining sobriety
• chapter 5 and 6 of Alcoholics Anonymous, (2001)

7
History of AA

• Bill W and Dr Bob decided they needed to talk to
  other alcoholics 6/35
• 6/36 5 recovered
• 6/37 15 recovered
• 6/38 40 recovered
• 6/39 100 recovered
• Big Book written with help of 3 groups, separated
  from Oxford group (Tiebout, 1944)

8
History of AA

• Non-alcoholics involved from the beginning
• Cooperation with professionals
• AA wants to be friends with its friends.
• Cooperation with the Professional Community (CPC)
  committee grew out of desire to help suffering
  alcoholics

9
History of AA (cont.)

• Research in 1980s and 1990s
• AA most effective way for alcoholics to maintain
  long term sobriety
• (Vaillant,19831995)
• AA/NA compatible with treatment of all medical
  and mental disorders
• Should be considered essential in treatment of
  addictive disorders

10
How Does A 12 Step Program of Recovery Work?
11
Going To Meetings

• Acceptance of newcomers is warm and genuine
• Core is sharing of experience honesty,
  openness, and a willingness to change
• Many meetings to choose from
• Open, Closed, Beginners, Step Study, Big Book
  Study, Speaker, Discussion

12
Choosing A Home Group

• Can serve as both an extended family and a
  recovery support system
• A phone list is of great benefit
• shown significantly to reduce the risk of relapse
• Introduces service and responsibility

13
Use a Phone List

• People who are willing to have you call
• Home group members usually good choices
• Call within a week and ask questions about AA -
  breaks the ice
• Men most reluctant to call
• Help sobriety of the person called
• Reduces relapse
• (Sheeren J Stud Alcoh, 49104, 1988)

14
Choosing A Sponsor

• Until a sponsor is acquired ask for temporary
  contact who will introduce patient to the
  fellowship and take them to meetings.
• Main task of sponsor is to help work the steps
  and develop a personal program of recovery.
• Having a sponsor significantly reduces the risk
  of relapse (Sheeren, 1988)
• A sponsor will help work on being Honest, Open,
  and Willing (H.O.W.)

15
Working the Steps

• Originally discovered through empirical research
  to help hopeless, chronic alcoholics maintain
  sobriety
• Useful to problems other than alcohol or drug
  addiction

16
Step One We admitted we were powerless over
alcohol - that our lives had become unmanageable.

• Addresses denial
• Promotes honesty and self examination, resistance
  can be great
• Accepts identity as an alcoholic or addict
• Principle Honesty

17
Step TwoCame to believe that a power greater
than ourselves to restore us to sanity.

• The person recognizes that they need help. I
  alone can do it, but I cant do it alone.
• Sanity is recognition that continued use of
  alcohol or other drugs will have continued
  negative effects
• Helps open the person to new internal experience
• Principle Hope

18
Step ThreeMade a decision to turn our will and
our lives over to the care of God as we
understood Him.

• Difficult for atheist, helped by thinking of an
  accepting and loving life force within
• Practicing letting go weakens the grip of
  obsessions, craving, worries, resentments
• Principle Faith

19
Step FourMade a searching and fearless moral
inventory of ourselves.

• Done by many healthy individuals, fundamental
  part of psychotherapy
• Arouses guilt, shame, grief, and other powerful
  negative emotions. A sponsor is necessary in
  working this step.
• Gets prepared for honest sharing in human
  relationships
• Principle Courage

20
Step FiveAdmitted to God, to ourselves, and to
another human being the exact nature of our
wrongs.

• Arouses anxiety, reactions of anger, disgust, and
  rejection
• Usually to one's sponsor, home group member or
  clergy person
• great relief that reaction not rejecting or
  punitive
• Helps develop honesty with oneself and others
• Principle Integrity

21
Step SixWere entirely ready to have God remove
all these defects of character.

• Characterologic and personality problems continue
• Simply getting ready to have a Higher Power,
  something other than self, remove selfishness,
  dishonesty, impulsiveness, blaming, and other
  dysfunctional behaviors.
• Principle Willingness

22
Step SevenHumbly asked Him to remove our
shortcomings.

• Recognizes the fact that I am a fallible human
  being who needs help
• Antisocial, narcissistic, avoiding, and
  borderline personality disorders slowly subside
  and even disappear
• Principle Humility

23
Step Eight Made a list of all persons we had
harmed and became willing to make amends to them
all.

• Painful, but a valuable preparation for repairing
  damaged relationships.
• A sponsor is necessary in working this step.
• If you have an unresolvable resentment about
  someone, pray for the son of a bitch.
• Essential part of capacity for empathy
• Helps develop skill in maintain relationships
• Principle Brotherly/Sisterly Love

24
Step NineMade direct amends to such people
wherever possible, except when to do so would
injure them or others

• Arouses anxiety which may be extreme
• Support necessary
• Helps repair damaged relationships
• Principle Justice

25
Step Ten Continued to take personal inventory
and when we were wrong promptly admitted it.

• Self observation, associational problem solving,
  and honesty with oneself and others
• Self observation and admission of problems
• Set the stage of redeveloping both intimacy and
  generativity
• Principle Perseverance

26
Step Eleven 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.

• Emphasis is on developing the experience one is
  capable of
• Knowledge power are for taking responsibility
  for ones own life - solving ones own problems
• Developing ones own experience leads to
  tolerance for others.
• Atheists and agnostics are welcome
• Principle Spiritual Awareness

27
Step TwelveHaving had a spiritual awakening as a
result of these steps, we tried to carry this
message to alcoholics, and to practice these
principles in all our affairs.

• Refers to freedom from the bondage of
  self-centeredness.
• Spirituality is the ability to get our minds off
  ourselves.
• Action in carrying the massage. Not a sermon, or
  even good advice. It is a personal sharing of
  the recovering persons experience, strength, and
  hope
• Principle Service

28
RESPECT THE TRADITIONS

• The 12 Traditions were developed to protect the
  12 Step programs from external and internal
  influences. They deal with
• 1.Unity 7.Self
  support
• 2.Group conscience 8.Nonprofessional
• 3.Membership 9.Nonorganized
• 4.Group autonomy 10.No opinion on
• 
  outside issues
• 5.Primary purpose 11.Personal anony.
• 6.Nonaffiliation 12,Principles
• before
  personalities

29
Service Work

• Begins with meetings
• Setting up
• Making coffee
• Greeting people
• Cleaning up
• Continues with home group
• Secretary for meetings
• Chairing meetings
• 12 Step calls
• Committee work, eg.CPC, TF,CF, etc.

30
Service and Healing

• Altruistic - no expectation of recognition or
  reward
• Exposes member to criticism
• Dealing with negative emotion
• Discovers that my problems help others (sharing
  and 12th step)
• May reflect spirituality
• Develops purpose in life
• Whenever anyone anywhere reaches out I want the
  hand of AA to be there, and for that I am
  responsible.

31
Slogans

• Its the first drink that gets you drunk
• Identify, dont compare
• Take your own inventory, not others.
• Principles before personalities
• You keep it by giving it away
• The Serenity Prayer
• Active cognitive coping strategies

32
12 Step Clubs

• Owned and run by 12 step members
• Not part of AA/NA/CA
• Valuable sober environments
• Usually many meetings
• Including group business
• Provide a daytime sober environment

33
REFERRAL

• Successful referral to a 12 step program requires
  support and contact
• Systematic encouragement
• Prof called AA member
• Patient/client talked briefly
• Arranged meeting and ride
• AA called before meeting
• Result 100 attendance ( N 10)
• Standard referral 0 attendance
• (Sisson and Mallams Am J Dr Alcoh Abuse, 8371,
  1981)
• (The Doctors Voice J Abnorm Psychol, 7278,
  1967)

34
Research in the 1990s

• Two big multi-site studies
• Project MATCH (N 1726)
• 10 sites
• Department of Veterans Affairs (N 3018)
• 15 sites
• (Projects MATCH J Stud Alcoh, 587, 1997)
• (Ouimette, et al J Cons Clin Psych, 65230, 1997)

35
Project MATCH

• 12 week, manual guided, individually delivered
  treatments
• CBT - Cognitive Behavioral coping skills
• MET- Motivational Enhancement Therapy
• TSF- Twelve Step Facilitation
• Discriminable, high exposure
• Similar therapist skill and therapeutic alliance.
  (Carroll, et al J Cons Clin Psychol, 66290,
  1998)

36
TSF

• 1. Reading Assignments
• 2. Review journal - urges and slips
• a. Sober days
• 3. Meeting attendance and reactions
• 4. Sponsor - getting started
• 5. Telephone list and use
• 6. Step work
• (Proj MATCH Vol 1 TSF Manual, 1995)

37
VA Treatment Study

• 15 Programs from 174 orientations
• 5 Twelve step N 897
• 5 Cognitive behavioral N 1148
• 6 Eclectic N 973
• 3018 followed 1 year
• One of the largest, if not the largest,
  effectiveness studies of substance abuse
  treatment.
• (Ouimette, et al J Cons Clin Psychol, 65220,
  1997)

38
DD Research

• DVA Study, N 3018
• Psychotic N 157
• Anx/Depression N 495
• Pers Disorders N 424
• Only SUDs N 1932
• 1 year follow-up
• (Ouimette, et al Alcoh Clin Exp Res, 23552,
  1999)

39
DD Research

• Outcome
• 4 groups had comparable substance use outcomes
• DD groups had same improvement in each of 3
  treatment programs
• 12 step attendance assoc with
• less psychological distress
• fewer psychiatric sx
• These findings support the inclusion of 12 step
  participation as a component of continuing care
  for DD patients.
• (Ouimette, et al Alcoh Clin Exp Res, 23552,
  1999)

40
How AA Changes Brain Function

• Alcoholic/Addicted Behavior
• Impulsive
• Antisocial
• Immature
• Painful to self and others
• Common defense mechanisms
• Denial
• Minimization
• Projection
• Grandiosity
• Acting out

41

• Behavior in an active 12 Step program of Recovery
• Thoughtful
• Honest
• Open to learn and change - humility
• Gratitude
• Common defense mechanisms
• Altruism
• Humor
• Anticipation
• Suppression
• Sublimation

42
Research Conclusions

• Twelve Step groups are normative organizations
  that help members
• Experience, express, and manage feelings
• No negative feedback from others
• Help capacity for self-regulation
• Increase self efficacy and self care
• Improve relationship to others
• Find purpose and meaning
• Increase ability to listen to others
• (Emrick Text. Substance Abuse Treatment, p406,
  1999)

43
Objections

• Too religious
• Unscientific, Folk Medicine
• An equally unhealthy addiction
• Im not like them
• They all smoke, drink, and/or use
• Learn to deal with resistance

44
12 Step Programs in Primary Care

• 1. Meeting schedules in each room
• 2. Pamphlets and Grapevine in waiting room
• 3. Patients or staff with good sobriety to take
  newcomers to a meeting
• 4. Encourage staff to attend Alanon because
  addicted patients are difficult
• 5. Dont tolerate negative attitudes and remarks
  to addicted patients.
• (Marron Primary Care, 20107, 1993)

45
CENTRAL OFFICE OF AA

• The clinicians doorway to the 12 step programs.
  Here you will find
• INFORMATION meeting schedules, other 12 step
  meetings and contacts
• LITERATURE Most of AAs and some of the other
  12 step programs
• TEMPORARY CONTACTS for your patients

46
Clinical PracticeSpiritual Issues

• . Get comfortable with the spiritual dimensions
  of healing
• Starts with Help me (morning)
• Ends with Thank you (evening)
• For atheist the group can be their Higher Power
• The search is for healing from addiction, which
  science cannot do yet

47
Conclusion

• Working a 12 step program of recovery is not easy
  
• Requires help from others, especially a sponsor
  and a home group
• Cost of time and energy
• When we refer to a 12 step program two benefits
  can be expected
• 1. Sobriety, which sets the stage for improved
  health, relationships, finances, and learning.

48
Conclusion (cont.)

• 2. Mature Growth and Development
• Tasks of adult growth and development
• Intimacy, the ability to be genuine and open with
  others
• Generativity, the ability to pass on what one has
  learned to others
• Integrity, a sense of wholeness and acceptance of
  ones self
• Goes beyond the usual goals of medical treatment,
  but one which any physician can support.