best place to start this presentation is to look at the preamble to Alcoholics Anonymous. Alcoholics Anonymous is a fellowship of men and women who share their experience, strength, and hope with each other that they may solve their common problems and help others to recover from alcoholism. So how do you join Alcoholics Anonymous? Well, the only requirement for membership is a desire to stop drinking. There are no dues or fees. Alcoholics Anonymous is self-supporting through their contributions. It's not allied with any sect, denomination, political group, organization, or institution. Alcoholics Anonymous does not wish to engage in any controversy, and as a result of which it neither endorses nor opposes any causes. Alcoholics Anonymous's primary purpose is to stay sober and help other alcoholics to achieve that same end. The contributions Alcoholics Anonymous has made to many individuals' sobriety has led individuals to cite its contributions. Here we have a quote. Alcoholics Anonymous has been called the most significant phenomenon in the history of ideas in the 20th century. Alcoholics Anonymous is synonymous with 12-step programming. And as an overview, let's begin by noting that decades of involvement through their fellowship shows that the 12-step program really works for people. The spiritual approach of AA and Narcotics Anonymous has indeed helped millions of people who want to stop drinking and using drugs. For many individuals, it remains the most effective way of staying sober. It's also an essential resource for clinicians who similarly want to help their patients. This presentation will discuss the 12-step programming in detail and also how to refer and support your patients as they begin their initial steps on the path to sobriety. The 12-steps are adapted to deal with over 200 emotional problem behaviors. The challenge for both physicians and for many patients is the means by which Alcoholics Anonymous and the 12-step program is integrated into the overall aims of addiction psychiatry, modern neurobiology, and 21st century psychopharmacology. At its best, it exemplifies a comprehensive biopsychosocial approach to the treatment of individuals with substance use disorders. So let's look at a bit more detail at the components that we would ideally like to integrate as best practices for the treatment of substance use disorders. So we have two models here. The first model, Model 1, promotes abstinence, spirituality, self-accountability, and community. It looks at a higher power as a spiritual concept. It looks at faith and it uses the big book, which we'll discuss later, as its authority. Sponsorship, a group conscience, and 12-step programming are seen as the recovery pathway to a life of sobriety. Model 2 is more of a medical model and looks at concepts such as dual diagnosis, medical authority, prescription authority. Science and psychotherapy are the pinions upon which decisions are made. And we have psychopharmacology. These two models need not be polar opposites. And again, in terms of best practices for patients, ways to integrate these two models will no doubt lead to best outcomes for many patients. Estimating the reach and scope of Alcoholics Anonymous membership gives some idea of its gives some idea of its reach and scope. In the United States, it's estimated there are over 51,000 groups with over a million members. In Canada, much smaller, 5,000 groups and nearly 40,000 members. As we turn overseas, we see that there's 656,000 members overseas with 124 groups. It's interesting to note that there are many groups in correctional facilities, both the United States and Canada, nearly 2,500, which gives us an estimated total membership worldwide of nearly 2 million individuals, hopefully benefiting from AA membership. Many individuals find these spiritual aspects of Alcoholics Anonymous a central point that helps comfort and guide them on their path to sobriety. For others, it's a point of contention. We have an AA member here, Ross V., who helps explain the difference between religion and spirituality. Religion is for people who are afraid of going to hell. Spirituality is for those who have already been there. The success of Alcoholics Anonymous has spurred the formation of other groups to help individuals with other areas of concern. So we begin, of course, with Alcoholics Anonymous. Then we have Al-Anon, Narcotics Anonymous, Cocaine Anonymous, Gamblers Anonymous, Overeaters Anonymous, Debtors Anonymous, Man, Sex, and Love Addicts Anonymous, all of which owe much of their philosophical guidance to the original concepts in Alcoholics Anonymous, which of course have been modified for their particular groups. The history of Alcoholics Anonymous reaches back almost a century to 1935 when two individuals who could not stop drinking and saw the carnage it was creating in their life came together, Bill W. and Dr. Bob, managed to stay sober by talking to each other and beginning that first fellowship bond. Bill W. and Dr. Bob decided to share their experiences, what they learned, with other individuals with an alcohol use disorder. And they did that in June of 1935. Based on their experiences, you see that in 1936, they reported five individuals on the path to sobriety. A year later, 15. Another year, 40. And by 1939, 100 had recovered. In 1939, the big book was written by Bill W. with the help of three groups and became the source of inspiration and structure for Alcoholics Anonymous. Alcoholics Anonymous did not shun those individuals that did not have an alcohol use disorder. And from the beginning, there was cooperation with professionals. One of its slogans, AA wants to be friends with its friends. Roughly four days after Bill W. and Dr. Bob began their momentous journey on the path towards Alcoholics Anonymous, research began to elucidate some of the strengths of this programming. As reported by Vallant in 1983-1995, AA was considered the most effective way for alcoholics to maintain long-term sobriety. Alcoholics Anonymous and Narcotics Anonymous were considered and are considered compatible with the treatment of all medical and mental disorders. AA and NA should be considered as part of a comprehensive approach to the treatment of substance use disorders. Throughout this presentation, the terms program and fellowships are used quite a bit. So the question should arise, is there any difference between these words, program and fellowship, when it comes to 12-step programming? Or are they simply synonymous and casually used interchangeably? Well, there is a difference between the two terms, and let's take just a moment to explain how they differ. When it comes to a program, what we're talking about are the prescribed beliefs, values, and behaviors as envisioned in the 12-step organizations. They are the so-called 12 steps. Alternatively, fellowship is the practice, activities, and experiences that an individual will go through in a 12-step organization that includes such things as their community service, helping others, sharing through meetings and other formats. Working the steps is another example. As might be imagined, going to meetings is a critical component of the 12-step fellowship. Acceptance of newcomers hopefully is warm and genuine. And the core activity in a group meeting is the sharing of experiences buttressed by strength and hope, underlined by honesty, open-mindedness, and a willingness to change. If there is one word that best describes 12-step programs, it should be emphasized that they require action. Action is a key component of all 12-step programs. You and your patient have developed an individualized treatment plan. And as one component of that treatment, you're encouraging your patient to attend an Alcoholics Anonymous meeting. So here are some practical advice you could provide your patient to help encourage and support them as they make that important step. Your patient should go early and stay after the meeting to talk with others who are setting up and cleaning up after the meeting. These individuals accomplishing these tasks are considered the home group members. Speaker meetings are good places to start. One speaker will share his or her experience, their strengths and hopes, their motivations. Your patient should not feel any pressure to speak at these meetings. If your patient is particularly nervous about attending a first meeting, which is, of course, understandable, suggest they go with a friend or relative. If the friend or relative doesn't have a problem with drinking, they will need to go to what is called an open meeting. If your patient goes to a discussion meeting and is not ready to speak, they can pass and await for a time where they're more comfortable. Encourage your patient to try several meetings as a speaker, a discussion group, a step study before deciding that Alcoholics Anonymous may not be a good fit for them. So your patient returned a few weeks later and had done exactly as you had suggested. They had attended several different types of meeting and now they were comfortable with a particular group. This is their home group. This is the meeting the person will go to essentially every week. Home group members help set up the meetings, chair the meetings, the organizers. Now being part of a home group has other important components. It introduces the concepts of service and responsibility. And, of course, from a social sense, it can serve as both an extended family and a recovery support system. Members may also share their phone numbers, which, of course, can allow the individual to reach out to someone if there is an imminent risk of relapse. Choosing a sponsor is a very important task that all new members to a fellowship program will want to undertake. A sponsor, at least in military departments, is like a battle buddy. Now until a sponsor or permanent sponsor is acquired, you can ask for a temporary sponsor. That individual will introduce your patient to the fellowship and accompany them to meetings. Now, as you may be getting a glimmer, the main task of the sponsor is to help the patient work the steps and develop a personal program of recovery that's tailored for their needs. It's also important to note that having a sponsor, a battle buddy, significantly reduces the risk of relapse. And a sponsor will share their experiences, and they will help the newcomer to work on being honest, open-minded, and willing. And again, the acronym HOW can help bring those concepts to mind. Now, one of the phrases that's common among individuals attending an Alcoholics Anonymous or their 12-step program is the concept of working the steps. Now, this was originally discovered through empirical research to help individuals that were hopeless and had a chronic alcohol use disorder. But it's also been found that working the steps is useful for other compulsive behaviors other than alcohol or drug use disorders. So we've repeatedly mentioned the 12-step program. So what exactly does that mean? What are these steps? So now let's take an in-depth look at each one, step by step, and of course, beginning with step one. We admitted we were powerless over alcohol or drugs, that our lives had become unmanageable. Step one addresses a critical psychosocial concept of denial. It helps promote honesty and self-reflection. It helps the individual identify themselves as an individual with a substance use disorder. So step one, the principle involved is honesty. The second step, the individual comes to believe that a power greater than ourselves could restore us to sanity. What does that mean? It means that the person recognizes that they need help. I alone can do it, but I can't do it alone. Sanity is the recognition that continued use of alcohol or other drugs will have continued negative effects, and it helps open the person again to internal experiences and self-reflection. Step two's principle is hope. The third step in the 12-step program made a decision to turn our will and our lives over to the care of God as we understand him. Now, again, one of the points of contention for some individuals is that it can be difficult for atheists and or agnostics. It's useful to reframe this by thinking of an accepting and loving life force. Step three involves letting go. It weakens the grip of obsessions, craving, worries, and resentments. And step three's principle is faith. Step four is an important one. Here, the individual makes a searching and fearless moral inventory of themselves. It's done by many individuals as a fundamental part of psychotherapy. And through the process, it may arouse guilt and shame and grief and other powerful negative emotions. And here is where the individual's sponsor may be particularly helpful as they work this step. Step four prepares the person for honest sharing in human relationships. And the principle involved in step four clearly involves courage. Step five involves admitting to God or to a higher power, to ourselves and to another human being the exact nature of our wrongs. As you might imagine, this arouses shame and anxiety and perhaps reactions of anger or rejection. It's usually an invitation to involve one's sponsor or a home group member or clergy person. And great relief is involved when that reaction is not rejecting or punitive. Step five, as the individual works this particular step, helps develop honesty with oneself and others. And the principle involved in step five is integrity. Step six builds on step five. We're entirely ready to have God or a higher power remove all these defects of character. Simply getting ready to have a higher power, something other than oneself, removes selfishness, dishonesty, impulsiveness, and blaming. And the principle involved in step six is willingness, the willingness to look deeply at one's self. Step seven involves humbly asking him or the higher power to remove our shortcomings. In essence, the patient is asking and hoping that it can be recognized as fact that they are a valuable human being who needs help. Step seven addresses antisocial, narcissistic, avoidant, borderline personality disorders as they slowly subside and perhaps disappear. Step seven, in its humble request, involves the principle of humility. Step eight can be particularly difficult and challenging because it requires the individual make a list of all persons they have harmed and become willing to make amends to them all. It can be painful, but it can be a valuable step in repairing relationships damaged by the consequences of a substance use disorder. Again, a sponsor can be very helpful in working through this step. And as step eight imagines, it's an essential part of developing and deepening the capacity for empathy. It helps develop the skill that is necessary to maintain relationships. Step eight's principle, love and reparation. Step nine continues the challenging work that was undertaken in step eight by moving towards action. Step nine envisions the individual making direct amends to such people wherever possible, except when to do so would injure them or others. Step nine clearly can arouse anxiety, which may be extreme and make difficult the accomplishment of step nine. Again, a helpful sponsor can help get over this rough spot. Step nine restores the balance of justice. And as a consequence, the principle of step nine involves amends and restitution. Step 10 is another one in the relentless pursuit of looking at one's self. Step 10 requires the individual to take a personal inventory and when they're wrong, promptly admit it. This requires self-observation, problem-solving, and perhaps above all, honesty with oneself and others. It sets the stage for redeveloping both intimacy and generativity. And step 10 clearly requires perseverance as its primary principle. Step 11, the individual seeks prayer or meditation to improve their conscious contact with God or their higher power as they understand, praying only for knowledge and will and the power to carry that out. Step 11's emphasis is on developing experiences that one is capable of achieving, knowledge and power for taking responsibility for one's life. Developing one's own experience leads to tolerance for others, and it involves continuing surrender of the person's strong will. The principle involved in Step 11 is an enhanced spiritual awareness. The last step in 12-step programming involves the individual having a spiritual awakening as a result of their transversing the previous 11 steps, and they try to carry their message of hope and action to other individuals with substance use disorders. Step 12 refers to freedom from the bondage of being self-centered, whereas spirituality is the ability to get our minds off ourselves. Step 12 involves action in carrying the message. It's not a sermon or even good advice. It's a personal sharing of the steps and the path that that particular person has followed. So Step 12 clearly involves the principle of service. Interestingly, there is some correlation between the 12 steps with six elements that are important and well-identified in the success of psychotherapy. These six correlations include the release of emotional tension in the context of hope and the expectation of receiving help, the individual identifies with the particular method, the use of suggestion and persuasion, the concept of operant reconditioning and repeated reality testing, and finally, cognitive learning about the basis for one's difficulties. 12-step programming also involves the promises, and they're listed here. We will know a new freedom and happiness. We will not regret the past nor wish to shut the door on it. We comprehend the word serenity and we know peace. We realize how our experience can benefit others. The feeling of uselessness and self-pity will disappear. We will lose interest in selfish things and gain interest in our fellows. Self-seeking will slip away. Our whole attitude and outlook on life will change. Fear of people and economic insecurity will leave us. We will intuitively know how to handle situations which used to baffle us. We will suddenly realize that God or our higher power is doing for us what we could not do for ourselves. Now let's talk about another concept common to Alcoholics Anonymous and other 12-step programs, and these are the 12 traditions. The 12 traditions are to the group what the 12 steps are to the individual. They are the unique set of organizational principles designed specifically to prevent the group from destroying itself. So just as we did with the 12 steps, let's go through the 12 traditions individually so that we understand them and their importance. Number one, our common welfare should come first. Personal recovery depends upon AA unity. For our group purpose, there is but one ultimate authority, a loving God or higher power. Our leaders are but trusted servants. They do not govern. The only requirement for AA membership is a desire to stop drinking. Each group should be autonomous, except in manners affecting other groups or Alcoholics Anonymous as a whole. Each group has but one primary purpose, to carry its message to the individual with an alcohol use disorder who is still suffering. An AA group ought never endorse, finance, or lend the AA name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose. Every AA group ought to be fully self-supporting, declining outside contributions. Alcoholics Anonymous should remain forever non-professional, but our service centers may employ special workers. AA as such ought never be organized, but we may create service boards or committees directly responsible to those they serve. Alcoholics Anonymous has no opinion on outside issues, hence the AA name ought never be drawn into public controversy. Our public relations policy is based on attraction rather than promotion. We need always maintain personal anonymity at the level of press, radio, and films. And finally, anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities. Now again, to summarize how the 12 traditions respect the organizational structure, this slide brings it all together. And you can see that group unity, conscience, membership, autonomy, the primary purpose, non-affiliation, self-supporting nature, non-professional constituents, not organizational driven, no opinion on outside issues, maintaining and respecting personal anonymity, and principles before personalities are the 12 traditions. Let's take another look at the 12 steps. In terms of the aims or the objectives, which those steps hope to accomplish. So steps one to three involve the admission and acceptance of powerlessness over an alcohol use disorder, the unmanageability of their life that has resulted as a consequence, and the surrender of their strong will. Steps four to 10 are involved in an in-depth self-examination, making amends and restitutions. And finally, steps 11 and 12 involve service. Now steps eight and nine involve amends and restitutions after a very detailed self-examination of one's life and the role that the substance use disorder has contributed to. So steps eight and nine deal with the restoration of the balance of justice from the offenses, violations, and betrayals of others that have come about, again, as a result of the substance use disorder. Steps one, three, seven, nine, 10, and 12 all contribute to developing a sense of humility in the individual. Humility is seen as an antidote to the shame, the guilt, the narcissism, the grandiosity, the omnipotence, the immaturity, and the self-will, the very strong self-will. It is a common component in substance use disorders. Now at this point, it's probably useful to, once again, revisit the concept of a power greater than ourselves. Now this concept has been purposely vague. It's an individualized concept, and it envisions that all persons are spiritual but may approach that in different ways. For some individuals, this is a sticking point in membership in a 12-step fellowship type program. But it envisions a personal relationship with a higher power, influence on social interactions, employment and financial issues, spiritual beliefs and values for everyday living. Serenity is an important concept, not just from a philosophical standpoint, but for individuals with substance use disorders. It's a goal, being the capacity to remain serene and peaceful and calm in the face of a catastrophe, however that's defined or experienced by the individual. And so AA, for example, will talk about the serenity prayer. So the serenity prayer goes like this, God grant us the serenity to accept the things we cannot change, the courage to change the things we can, and the wisdom to know the difference between the two. So step 12 involves the spiritual awakening. The individual has come to the point where they can now carry the message to other individuals with substance use disorders, and they will continue to practice those principles in all the affairs of their life. The wisdom Alcoholics Anonymous has learned over the many decades is often distilled into slogans, pithy little sayings that convey a very strong message. There are many of these. For example, the man takes a drink, the drink takes a drink, the drink takes the man. Easy does it, but do it one day at a time. Utilize, don't analyze. And again, principles before personalities. So one of the elements of best practices that clinicians should incorporate involves the use of fellowship meetings or 12-step programming as part of their considerations in developing an individualized treatment program for their patients with a substance use disorder. And as we've gone through, at least having a basic understanding of 12-step programming can help you discuss this with your patients with some authority. Now, there's probably no better way to learn about a 12-step program than to attend one. And clinicians are encouraged to attend open meetings and read the literature. The big book, for example. And while this may not take too much time, it will pay handsome dividends in being able to explain these programs to your patients who, of course, may be quite reticent to attend. But your reassurance, based on your knowledge and experiences, may help overcome that and motivate your patients to at least attend a few sessions to see if it can be helpful. It may take more than a brief comment to encourage your patient to attend a 12-step program. Successful referral requires a bit more effort, but hopefully it will pay off handsomely for you and your patient. The best outcomes can be achieved through a systematic pattern that encourages your patient to attend. The first step should be a detailed discussion about the referral with a prospective AA member or 12-step program member that provides enough details to allay anxieties and provides an opportunity to answer questions. It can also be quite helpful to arrange a meeting time and, if necessary, to arrange transportation or to at least inquire about how the individual will make arrangements to do so. And finally, you or a member of your staff calling the prospective AA member before the meeting can also be an helpful nudge to encourage their attendance. Based on research, it would seem that this approach is the best way to ensure that your patient may actually take that first step in a 12-step program. 12-step programs like Alcoholics Anonymous can help change dysfunctional behavior. For example, individuals with a substance use disorder may benefit by a decrease in their impulsivity. Their antisocial behavior may become more prosocial. Their immaturity through self-reflection may change into a more thoughtful connection with individuals. The common defense mechanisms that are involved in substance use disorders and that are targets of 12-step programming include the very common presence of denial, I don't have a problem with any particular substances, minimization, I can drink if I need to, no problem, projection, it's not my problem, it's someone else's problem, and grandiosity and, of course, acting out, which can be particularly harmful to the individual and to those in their nearby orbit. Individuals that fully embrace 12-step programming may find that many aspects of their lives have changed. So 12-step programming may be helpful with the individual becoming more thoughtful, more honest and self-reflective, open to learning and change, which, of course, is a core trait of humility. They become grateful. And again, the common defense mechanisms that may be motivated through active participation in 12-step programming may be altruism, an improved sense of humor, anticipation, suppression, sublimation, and perhaps most importantly, a sense of hope may infuse their life once again. In the most fundamental way, certain conclusions can be stated about 12-step groups. They are normative in that they help members experience, express, and manage feelings in a safe environment, in a nurturing atmosphere. That particular concept results from there being no negative feedback from others, accepting and learning and experiencing. 12-step groups help individuals self-regulate, decrease impulsivity, increase self-efficacy and self-care, and clearly by sharing and listening and through an honest appraisal of oneself, a very important byproduct is an improved relationship through empathy with others. 12-step groups can help the individual find a new purpose and meaning in life. And of course, it goes without saying that the group experience increases the ability to listen, tolerate, and share with others. Over the many decades, there have been a number of negative attitudes that have developed towards 12-step programs. In some circles, 12-step programs are criticized as doing nothing more than creating a new dependency. Others describe these programs as a folk movement, as too religious, or as a cult. Others will say that 12-step programs actually make me want to drink. Or even more critically, they just don't work. 12-step programs have also been criticized for their apparent lack of accountability. After all, they just smoke and drink coffee in their little groups. And the fact that it's non-intellectual and not medically based, of course, generates another line of criticism. Throughout this same time period, some 12-step programs have developed decidedly negative attitudes about the use of medications, often considering them nothing more than a crutch and an easier way to achieve sobriety. Those attitudes also will criticize the use of medications as an impediment to spiritual recovery, and once again, medications foster dependency. It seems reasonable to expect that primary care providers are going to see a large share of individuals with substance use disorders. And with that in mind, one of the ways that they can help motivate individuals to be thinking about treatment is to have 12-step program meeting schedules in waiting rooms. In addition, AA and NA pamphlets may be a source of information that some individuals are willing to take a look at. If you have patients or staff that are in recovery, they can also be a source of motivation for individuals that are in the very early stages of considering a new pathway to sobriety. It's also helpful to encourage staff to attend Al-Anon because it is possible that some staff may have issues working with patients that have a substance use disorder. And it goes without saying that it's imperative that negative attitudes and hostile remarks towards patients with a substance use disorder cannot be tolerated and will certainly be antithetical to best practices. Of course, a really good place to get additional information and materials is to access the organization's websites. And from here, you can get additional information such as meeting schedules, locations and contacts, and literature. And for both NA and AA, the relevant websites are listed on this slide. This slide lists some of the important and classical literature that you can use to learn more about 12-step programs. The first one is the Alcoholics Anonymous, often referred to as the Big Book, 12 Steps and 12 Traditions, Narcotics Anonymous, often referred to as the Basic Text, and you'll see the others listed here. This is just a small sample of literature that you might want to consider. So as we come to the end of this presentation, let's summarize what we've learned so far. Clearly, it should be evident by now that working a 12-step program is not easy. It requires a significant and sustained effort by your patient. It also requires help from others, especially a sponsor and a home group. And needless to say, the dedication required comes in terms of time and energy. Now, what we can hope for when we refer an individual to a 12-step program are two benefits. The first, of course, is sobriety, which sets the stage for improved health, relationships, finances and learning. And secondly, mature 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. It's all about service. And integrity, a sense of wholeness and acceptance of oneself. As we come to the end of this presentation, I want to thank you for your time and attention. And again, on behalf of the American Osteopathic Academy of Addiction Medicine, my name is Dr. Gregory Landy. And thank you once again for your participation in our learning management system.

Alcoholics Anonymous

12-step program

recovery

sobriety

addiction psychiatry

neurobiology

psychopharmacology

substance use disorders