ACCSA Lecture Notes Flashcards

ACCSA & M13 Twelve Step Treatment

• Compiled from NIAAA (National Institute on Alcohol Abuse and Alcoholism).
• The program is consistent with active involvement in Alcoholics Anonymous or other 12 Step Meetings.
• Assumes alcoholism is a progressive illness affecting body, mind, and spirit.
• The only effective remedy is abstinence.
• Adheres to the concepts in the "Twelve Steps and Twelve Traditions" of AA.
• Overall goal: facilitate patients’ active participation in 12 Step Fellowships.
• Regards active involvement as the primary factor for sustained sobriety (“recovery”).
• AA viewpoint: Alcoholism is a chronic progressive illness that may lead to insanity or death if not arrested.
• Characterized by loss of ability to control alcohol use.
• Alcoholism has specific and predictable effects (symptoms) on the individual.
• Affects victims on psychological, social, and spiritual levels.
• Characterized by “denial,” or resistance to accepting loss of control.
• AA makes no commitment to a particular causal model, but focuses on loss of control and denial.
• Emphasizes:
  • Spirituality: Belief in a “Higher Power,” defined individually, representing faith and hope.
  • Pragmatism: Doing “whatever works” to avoid the first drink.

Recovery

• Recovery: Process by which alcoholics become abstinent and undergo self-help/mutual aid to heal the self, relations, higher power, and world.
• Includes:
  • Belief system and program of action.
  • Groups and meetings.
  • The Twelve Steps.
  • Helping others within a network of recovering peers.
• Personalized and self-paced journey undertaken interdependently with alcoholic peers.
• Recovery as self-help: individual decides on meeting attendance, how/when to do the steps, sponsor relationship, spirituality, service to others, etc.
• Recovery as mutual aid: journey is not done alone but with peers and a higher power who reciprocally assist.
• Actual recovery: choices are shaped by practices of groups, sponsor, and friends.

Basic Beliefs About Alcoholism

• AA’s definition of alcoholism: "an illness, a progressive illness, which can never be cured but which, like some other diseases, can be arrested."
• View in AA: alcoholics are sick people who can recover if they follow a simple program.
• Once a person is alcoholic, “free will is not involved, because the sufferer has lost the power of choice over alcohol…"
• Importance is to face the facts of the illness and use offered help.
• Alcoholism is a spiritual, mental, and physical illness, requiring healing of all aspects.
• Abstinence alone is insufficient; alcoholism is a “symptom” of underlying character defects.

Becoming Abstinent

• Recovery in AA: viewed in terms of phases/stages (beginning, middle recovery, oldtimer).
• Professionals (e.g., Brown) formalized a developmental model of four phases: drinking, transition, early recovery, ongoing recovery.
• DiClemente’s transtheoretical approach: five stages.
• Transition (beginning phase): stopping drinking and giving up the illusion of control.
• “Hitting bottom”—surrendering or admitting defeat.
• Giving up “denial.”
• Newcomers receive extra attention: stopping drinking and accepting loss of self-control is difficult.
• Radical change of thinking is necessary.

Practical Advice for Newcomers

• Go to meetings, don’t drink, stay away from “slippery” places, say your prayers (ask for help from a higher power).
• Newcomers cautioned to wait to make drastic changes to job/family until more stable.
• Complex suggestions about working steps or major life changes are for members through transition into early recovery.
• AA confronts denial about drinking selectively: challenges loss of control and the need to stop drinking, but retains denial/rationalization positively.
• Practices are complementary to professional therapy.
• AA’s twelve steps can lead to restructured thoughts.
• “AA meetings…provide an atmosphere in which cognitive restructuring can take place.”

Identity Changes

• Drinking newcomer faces a difficult belief system: Abstinence is necessary, surrender control, admit powerlessness, and develop belief in a higher power.
• Acceptance of loss of control and assuming the identity as an alcoholic form the core of recovery.
• Alcoholic is not simply someone who drinks too much but a person whose human frailties are extreme.
• AA process involves two identity changes:
  • From drinking non-alcoholic to alcoholic.
  • The recovering alcoholic.
• AA literature talks about a conversion process of surrendering control to a higher power as a spiritual awakening and an identity change.
• Newcomers often misunderstand self-labeling “alcoholic” negatively.
• Within the fellowship, the alcoholic identity is positive: represents shift from trying to control drinking to hope for a constructive life.
• Self-diagnosis is an important part of developing an alcoholic identity.

Identity Evolution

• Identity changes evolve within AA meetings members hear each others’ personal narratives.
• Personal stories follow the format: "what we used to be like [when drinking], what happened, and what we are like now."
• Drinking alcoholic self is “self-will run riot,” whereas recovering members manifest hope.
• Newcomer can assume an alcoholic identity because he/she is among peers who have done similar things and because it contains a promise of being able to live differently.

Modes of Cognitive Functioning

• Bruner contrasts logico-scientific mode of cognitive functioning with the narrative or story mode.
• Logico-scientific mode is excellent for testing hypotheses, sound empirical analysis, and developing universal statements.
• Narrative mode emphasizes gripping stories, histories, human intention, action and meaning, and identity construction.
• AA focuses on the narrative mode of communication: oral tradition, telling stories, reshaping identity, talk being from one’s own experience, and the significance of friendship.

Social Science Perspectives

• Social scientists explain identity change: doubling back on the self.
• Individual examines himself/herself and locates himself/herself within a structure of experience.
• Doubling is practiced with self-deprecating humor and laughter.
• Abstinent AA member who accepts the alcoholic identity has a second identity, the recovering alcoholic self.
• "I am an alcoholic" acknowledges uncontrolled inner force; the recovering self is aware of the alcoholic self.
• The recovering alcoholic self learns to be constructive and serve others, becoming “happy, joyous, and free.”
• Social identity theory: identity is socially bestowed, sustained, and transformed.
• People sustain and change their identity in interaction with others.

Group Therapy

• Resident showed his self-identity as an unworthy person who could not control his feelings.
• His peers countered with positive reactions.
• The resident modified his self-image.
• New interpretation validated by peers helped maintain the slightly different view of himself.
• Repeating the account and validation sustained self-image.
• The process occurred in a stable environment where residents saw the incident, felt the same way, and were there to validate him.
• Social processes are facilitated when people are familiar with each other.
• Newcomers advised to have a home group where people know them.
• Members observe others over time, confirming the effectiveness of the program.

Practicing the Program

• Becoming abstinent is necessary but insufficient to maintain sobriety.
• Sobriety is a complex process of practicing the program to quell character defects.
• Practicing the program involves going to meetings, helping other alcoholics, “working” the steps, using tools, and asking for help.
• Extensive variability in how the program is actually practiced.

Designing and Building Sobriety

• Recovery is like building a house: The house that AA helps a man build for himself is different for each occupant because each occupant is his own architect.
• The house accommodates the rebel as well as the conformist, the radical as well as the conservative, the agnostic as well as the believer.
• The house as the “design for living” is a core place, safe from the elements.
• In AA, the house is a metaphor for a new “design for living” that constitutes recovery.
• Newly abstinent alcoholic is not necessarily viewed as a competent architect but as a willful adult who will make his/her own choices unless tamed by the first three steps.

Practical Tools for Everyday Living

• Program combines total identity change with practical tools for dealing with everyday life.
• Action and practice is emphasized, not theory.
• Unity of AA is in its techniques more than theories of alcoholism or views about God.
• Practical tools include slogans or aphorisms: One day at a time; HALT; Easy does it; Utilize, don’t analyze; Progress, not perfection.
• Slogans guide everyday behavior.
• “One day at a time” motivates, equalizes newcomers with old timers, and forgives relapses.
• Focus is on self-examination combined with prohibition of criticizing others in meetings.
• AA views humans as limited and fallible who achieve wholeness through interdependence.
• Attitude of “progress not perfection” creates permissive learning environments.

Sponsorship and Guidance

• A sponsor is a seasoned member who guides a newcomer.
• Guide’s knowledge rests on experiential understanding of applying the program.
• One learns methods of work, virtues, and experiential wisdom from role models.
• Learning is based on role modelling and experience rather than didactic instruction.
• Members discuss private material with sponsors.
• There is extensive variability in the extent to which attendees have sponsors.

Working the Steps

• The person you are will drink again.
• Unless less self-centered, less willful, and more concerned with others, his/her character traits will result in him/her picking up a drink.
• Practice the program, especially “work the steps.”
• Steps 1-3 involve becoming abstinent through relinquishing self-will to a self-defined higher power.
• Steps 4-9 deal with character change.
  • Steps 4-9: one’s shame and remorse for the havoc caused by drinking, the wrongs done to others, one’s awful secrets, prideful self-centered behavior.
• A contemporary psychodynamic understanding of alcoholism suggests degrees of vulnerability in self-regulation involving self-governance, feeling life (affect), and self-care that are involved in the predisposition to become and remain dependent on alcohol.

AA succeeds in reversing this dependency by effectively challenging alcoholics to see that they disguise and deny their self-regulation vulnerabilities.
Implicitly, if not explicitly, AA employs group processes to highlight and then modify the vulnerabilities that plague the lives of alcoholics. The focus of AA on the loss of control over alcohol and the insistence on maintaining identity of the suffering individual as an alcoholic (i.e., it is always that one is “recovering,” never “recovered”) is a useful if not essential treatment device. It permits alcoholics to acknowledge and transform vulnerabilities in self-regulation.

• Steps 4–9 describe a general process, spiritual in nature, that can be interpreted in various ways. Step 4 pertains to identifying one’s shortcomings that have interfered in one’s life, Step 5 admitting them to another person and one’s higher power, undergoing a process of being willing to give up the character defects (Step 6) and humbly asking one’s higher power to remove them (Step 7). Having become aware of his/her defects and taken responsibility for them, Steps 8 and 9 focus on repairing one’s relationships with others. In Step 8 one identifies the harm one’s drinking has caused other individuals and in Step 9, the individual attempts to repair the harm unless to do so would cause more harm. Stolen money is to be reimbursed. Lies are to be righted. Members often find that they first need to forgive the other for the harm done to them since in many relationships harm was mutual.

Promises & Maintenance Steps

• Promises: freedom from self-centeredness, self-pity, fear of economic insecurity, serenity, a new happiness, concern for others, no regret of the past etc…
• Steps 10–12: maintenance Steps. Step 10 is to do a daily inventory to identify and correct mistakes.
• Emphasis is on taking responsibility for one’s actions.
• Step 11: meditation and prayer to maintain contact with a higher power and a spiritual perspective.
• Step 12: spiritual experience, carrying the message to alcoholics, practicing principles in all affairs.
• Spiritual experience: abstinence and freedom from obsession.
• Helping other alcoholics is the "helper therapy” principle.
• Sponsors are more likely to maintain sobriety than non-sponsors.

• The spiritual and religious elements in AA act as an important counterforce to the egoistic aspects of chronic drinking by directly confronting the denial, rationalizations, and allusion of control that support the persistence of alcoholic behaviour. Through its appeal to a higher power, AA’s insistence on humility acts as an anodyne to the self-serving grandiosity and the wallowing self-pity of the alcoholic… Step 3 and the remaining steps in the 12-step tradition of AA help the alcoholic move from a self-centered posture to a more mature one by helping the individual give up the overly prominent, grandiose parts of the self. The self-examination involved in taking “a moral inventory” (step 4), “making amends” (step 9), and “carrying the message to others” (step 12) are steps that inspire and instil a real concern for others and an increasing capacity for mature altruism. This effect of AA is genuine and lasting (i.e., for those who embrace it) and suggests that AA may produce permanent structural change, a result that has clinical and conceptual significance for psychoanalytic theory and practice.

Long-Term Recovery

• Long-term recovery has been of little research interest.
• Longer term recovery, reduced symptoms, better work and family history, and diminished risk of relapse among those sober 5 years or more.
• Alcohol abusers in both groups were more likely to get sober in AA than in professional treatment.
• He saw extensive variety in the kinds of involvement in the larger Core city sample who became sober through AA: Some went to AA initially for a few weeks, then stopped going; others went for a few years, then stopped attending while for others AA became a part of their stable life structure.
• “securely abstinent.” – Continuous abstinence for three or more years, less likely to die and more likely to enjoy their lives in the long run.