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“Nothing is so bad that a few drinks won’t make it worst.”
Alcoholics Anonymous
“Successful addiction treatment is dose-related; the more treatment the _ substance abuser gets, the better the results.”_
Alan Leshner
It has long been a well-known axiom in the addiction treatment community that addicts or alcoholics will usually not give up their chemical use until the pain and dysphoria they experience from its continual use exceeds the pleasure or euphoria they derive from its present use. Conversely, the possibility of successful long-term recovery is greatly reduced unless the alcoholic’s newfound life of abstinence is more rewarding than the previous one centered around alcohol use. This reflects an important principle of recovery: alcoholics and addicts will not remain abstinent unless they derive more pleasure from a chemically free life than they did when using. Since attachment theory holds the position that addiction is a compensatory driven compulsion because of the lack of satisfactory attachment experiences, long-term recovery is not possible until the capacity to achieve satisfaction from interpersonal attachments is achieved.
Consequently, a great deal of early addiction treatment is aimed toward monitoring the delicate balance between pleasure and dysphoria. Since most addicts and alcoholics are exceedingly intolerant of delaying gratification and will usually choose any certain source of immediate gratification (i.e., drugs and alcohol) over an uncertain source of probable satisfaction in the distant future. In order to alter this ingrained attitudinal and habitual characterological pattern of behavior, they must first come to realize and accept the premise that their solution is the problem.
Convincing addicts and alcoholics that it is in their best interest not to return to drugs and alcohol is an arduous task. Logic and reason alone will not accomplish this end. The limits of reason and logic was eloquently captured by the German philosopher, Schopenhauer when he wrote, "Hence the uselessness of logic; no one ever convinced anybody by logic; and even logicians us logic only as a source of income. To convince a man, you must appeal his self interest, his desires, his will" (Durant, 1926). Spinoza, addressed this issue nearly two hundred years prior to Schopenhauer when he wrote of the importance of substituting one strong emotion for another in bringing about change. Spinoza knows that passion always wins over reason. “Unless we use reason to help steer our passions to a less destructive action, we will forever remain in ‘human bondage’. An emotion can neither be hindered nor removed except by a contrary and stronger emotion.” (Durant, 1926).
Early Treatment Strategies
Keeping alcoholics sober and addicts clean requires an entirely different set of strategies than getting them to initially stop their chemical use. The expectation that addicts or alcoholics will stay off of drugs and alcohol requires that they come to realize, accept, and experience the benefit of abstinence. Addicts and alcoholics cannot just be convinced that it is advantageous for them to stay abstinent and sober by persuasive reasoning, they must be provided with something else that will sustain them until they achieved enough sobriety to experience this for themselves. One source of something that can sustain them is the regulating power of a strong attachment relationship.
Breaking an ingrained and powerfully conditioned addiction however, usually requires more than the regulatory power of a single relationship and therapeutic alliance. AA and other twelve step programs are sources of powerful persuasions that provide more than just appealing to the addicts and alcoholics to give up alcohol and drugs. AA knows that recovery requires that the substance abuser must also relinquish old sets of attitudes, behavior, and even friends associated with the addictive lifestyle. As AA members tell new members who enter into the twelve-step program, "If you want to avoid a slip, don’t go where it's slippery"; and "If you're serious about your recovery, you have to change your playmates and your playgrounds." To maintain sobriety, the addict and alcoholic must relinquish the regulatory function that their drug or alcohol use previously provided and substitute the fellowship of the AA program as an alternative attachment object.
Addiction Treatment As Α Time Dependent Process
What differentiates early treatment goals from later stage treatment requirements is the stance taken toward abstinence. Alcoholism treatment is basically a very simple two-step enterprise involving strategic shifts related to abstinence. Early in treatment, the task is to get the alcoholic to stop his or her use of substances. Later in treatment, the alcoholic must be prevented from starting again. Closely related to the “keep it simple stupid” (KISS) approach of AA is the need to adapt strategies that match the special circumstances of the newly abstinent alcoholic and addict.
Addiction specialists have been advocating for years the need for differentiating early treatment strategies from later stage treatment requirements (Flores, 1982; Wallace, 1978, Brown, 1985). Effective addiction treatment requires an alteration in treatment strategy when moving from early to later stage treatment. This represents one of the important paradoxes of successful addiction treatment. Clinical interventions that are often successful and necessary in early treatment will prove ineffective if applied unmodified in late- stage treatment. Not only will these early treatment strategies cease to be helpful if applied indiscriminately or unaltered during later stage treatment, they can contribute to a relapse rather than enhance continual abstinence.
As long as the alcoholic remains attached to alcohol, he will not be able to establish a therapeutic alliance. Sometimes creating the capacity for attachment requires nothing more than taking advantage of a well-known fact about attachment: an individual's attachment system opens up during a crisis. Substance abuse and urgent circumstances usually go hand in hand. If the group leader is patient and does nothing to interfere with this process, the consequences of a substance abuser's drinking and drug use eventually will provide them with a favorable therapeutic opportunity. Attachment theory reminds us that attachment systems open up during a crisis. AA refers to this as _ hitting bottom_ .
_ Most of his adult life, Bob had consumed alcohol regularly without much difficulty. However, soon after his fortieth birthday, Bob's drinking escalated and he began to experience blackouts and job related difficulties. His family became more alarmed and encouraged him to seek help. He reluctantly agreed to "try therapy" and attempted to control his drinking for the next two years with disastrous results. He saw three different therapists during this time, terminating therapy each time after a few sessions, complaining "1 just don't feel connected to them and I don't like them fawning over me." Eventually, he lost his job and his wife threatened divorce. Bob reluctantly agreed "to try therapy", but quickly gave up on the sessions complaining, "I'm not like them, I can't stand their self-pity." Following a severe drunken binge that left him devastated and defeated, Bob readily agreed to seek treatment. During the initial interview and his first group session, Bob showed a dramatic shift in his willingness to "let others help me with my problem." He told the group "1 have to swallow my pride, admit I am like you, and stop acting like I don't need anyone." Over the next six weeks, he proceeded to become very attached to the group and after treatment stayed active in aftercare and AA._
John Wallace (1978) was one of the first to write about alcoholism treatment as a time dependent process , reminding us that what an alcoholic needed during the early stages of treatment was far different than what they needed later in treatment. Currently, most addiction treatment specialists (Kaufman & Roeux, 1988: Washton, 1992) hold to some variation of the recommendation that treatment strategies be adapted to fit at least three distinct phases of treatment: (1) achieving sobriety; (2) early recovery or abstinence; and (3) advanced or late stage recovery. Applying these recommendations to attachment theory, three primary stages of treatment need to be followed.
1.) Since substance abuse is an attempt at self-repair, which exacerbates the individual’s already impaired capacity for attachment and intimacy, abstinence and detachment from the object of addiction is required before the individual can make an attachment to group or establish a therapeutic alliance.
2.) Early treatment strategies require adaptation in technique so that gratification, support, and containment are given priority because these strategies maximally enhance attachment possibilities.
3.) Once abstinence and attachment to the recovery process is established, deficits in self and character pathology must be modified. An essential part of this stage of treatment requires the patient develop the capacity for conflict resolution in a non-destructive manner while becoming familiar with mature mutuality and the intricacies that define healthy interdependence and intimacy.
Early Treatment Issues
An approach that is very effective with a non-addicted patient might be totally inappropriate for someone who is addicted, especially the early stages of recovery. It is important to remain aware that many alcoholics and addicts have rather sophisticated defenses that serve the primary purpose to protect their attachment to substances. Unlike non-addictive patients, who pursue treatment of their own free will and are actively seeking help in of their symptoms, most addicted patients come to treatment under pressure or duress and want to convince the therapist that there has either been a horrible mistake made with their referral for treatment. They might well try to steer the therapist toward the “real problem” (i.e. a wife or boss who’s always hounding them about one thing or the other). This problem may well be sincerely formulated in the substance abuser’s mind as the root cause of their excessive use of substances. Secretly, the substance abuser hopes that once this root cause is discovered, he or she will be able to return to the normal use of chemicals. Because drinking or drug use is frequently the only pleasure they derive out of life, it is an attachment relationship that must be protected at all costs.
Most approaches to early stage addiction treatment take the position that the primary emphasis must be on abstinence, relapse prevention, and managing the cravings stirred up by conditioned responses to external cues (Brown & Yalom, 1977; Brown, 1985; Flores, 1996; Kemker, Kibel, & Mahler 1993; Matano & Yalom, 1993; Khantzian, Halliday, and McAuliffe (1990; Vannicelli, 1992). These approaches recognize the fragility of the addict’s early recovery and adaptations in technique must be initiated to take these vulnerabilities into careful consideration. Careful consideration is also given to providing enough emotional gratification to keep alcoholics and addicts in therapy while helping them accept their diagnosis and “acculturating them into the culture of recovery” (Kemker, Kibel, & Mahler, 1993).
The significance of the acceptance of the diagnosis and the acculturation into AA is an issue often ignored by those whose interest in addiction is only passing or purely academic. Addicts and alcoholics struggling with their disease don’t have the luxury of taking this matter lightly because for them, it is literally a matter of life or death. For instance, Wallace (1984) sees the ideological base of AA providing a crucial component in the alcoholic's and addict's recovery process. In fact, he contends that the alcoholic and addict need AA's t biased view of reality. "The alcoholic can ill afford the dispassionate, disinterested, and indeed, almost casual play upon words and le inquiring academic intellectual" (1975, p. 7). Wallace strongly feels that the chemically dependent individual recognizes intuitively the need for a stable and enduring belief system if he or she is stay sober and clean. Wallace has more difficulty in comprehending and discerning the equally biased view of reality of the academician. Wallace writes that:
“Hidden neatly beneath the rhetoric of science and scientism are the actualities of dreadfully inadequate personality measuring instruments, inappropriate sampling procedures, inadequate measuring operations, improper choice of variables for study, grossly violated statistical assumptions, data gathering, recording and analyzing errors, and so on and so forth. Is it any wonder then that the most outstanding quality of most academic research is now you see it, you don't? Are we really amazed to find sober alcoholics clinging to their belief systems like drowning poets to their metaphors in a sea of confusion?” (1975, p. 7)
The art of treating addiction is to overcome the enormous denial and resistance--whether it be passive or active--that most alcoholics and addicts possess. Such a stance in treatment raises many important ethical and therapeutic issues. However, a therapist cannot afford to stand back and take a stance of therapeutic neutrality, because time, the severity of the chemically dependent patient's condition, and his/her lack of motivation interferes with the typical evolution of psychotherapy that usually takes place with most non-addicted patients. Treating the chemically dependent patient requires therapist to make a dramatic shift in focus and utilize techniques with which they usually have had little training or experience.
Working with alcoholics and addicts therefore requires a therapist to re-evaluate many of the conventional and unquestioned assumptions about psychotherapy. While all competent therapists know that it is important not to make decisions for patients and that a therapeutic alliance should never be compromised at any cost, it is crucial to evaluate this stance when working with an alcoholic or addict currently struggling with decisions about abstinence in the early stages of their recovery. As Shore states, "Therapists who remain inflexibly supportive while alcoholics continue to kill themselves by drinking need to reconsider the moral repercussions of their position" (1981, p. 13).
Wallace also recognizes the importance of helping individuals achieve a self-attribution of alcoholic and, hence, an explanatory system for their behavior. Treatment from this standpoint is very much the teaching of an ‘exotic belief" whose true value of actually describing what has occurred to individuals because of their addiction is held as irrelevant. Its true value is determined by the fact that it:
(1.) Helps explain the past in a way that gives hope for the future.
(2.) Provides a way for alcoholics and addicts to cope with their anxiety, remorse, and confusion.
(3.) Helps them with a specific behavior--staying sober or clean and working the twelve steps of the twelve-step program--that will change their lives in a desired direction.
As Wallace says, alcoholics and addicts have a lifetime of sobriety in which to recognize and figure out that not all of their personal and social difficulties are the result of their substance use.
Gratification versus Frustration
The degree to which the therapist frustrates or gratifies the patient is one of the most consistent dominating themes presenting itself in the treatment of addition. Alcoholics and addicts demand and require certain levels of gratification if they are going to be able to tolerate the relinquishing of their primary source of gratification--namely, alcohol and drugs. Self-psychology's perspective on this issue is most useful in helping the therapist determine when and how much gratification is necessary when treating the addicted patient. Addiction, as self -psychology defines it, is the result of deprivation of developmentally appropriate needs for gratification. Alcohol, drugs, food, sex, and other forms of potentially addictive behavior are attempts at self-repair. The addict and alcoholic tries to acquire externally what cannot be provided internally because of defects in psychic structure. This is not to imply that therapists should "love their addict or alcoholic into health." Not only is this impossible, it is counter-therapeutic since this is what the addict or alcoholic has been trying to do symbolically with chemicals. Rather, the addicted individual needs to learn how to tolerate frustration without immediate gratification since it is through managing tolerable levels of frustration that psychic structure is laid.
It is here that the concept of optimal frustration captures the necessary stance of the therapist when working with alcoholics and addicts. Too much anxiety interferes with the necessary trust and safety required for openness, exploration, and the revealing of one's self to occur. Optimal gratification means that the therapist will provide enough nurturing or emotional responsiveness until the addicts or alcoholics are able to provide it to themselves without returning to old methods of gaining immediate gratification. Early stage treatment with substance abusers will require more gratification than later stage treatment.
The disease concept and abstinence based treatment strategies that dominate the addiction treatment field often seem at odds with many psychodynamic approaches to therapy. Most substance abusers cannot tolerate the frustration and regression that is induced by the more classically influenced psychodynamic approaches to psychotherapy. Addicts and alcoholics, especially those in the early stages of their recovery, respond more favorably to a directive, practical, ‘no-nonsense’ approach than they do to a therapeutic stance that waits for dynamics to gradually develop in therapy. Substance abusers typically do not tolerate passivity or the absence of gratification very well. If therapy is to reach its full potential with this population, it requires active emotional engagement.
Emotional Availability of the Therapist
The beginning phase of early therapy needs to be structured, supportive, and directive. To help the alcoholic or addict accomplish the task of recovery most effectively, the therapist must gear most of his or her efforts towards creating an attachment bond or developing a therapeutic alliance. Therapy works best when it is a vitalizing experience. Substance abusers usually respond more favorably to a therapist who is spontaneous, alive, and engaging than they do to the therapist who adopts the more reserved stance of technical neutrality associated with these more classic approaches to therapy. The more available and engaging therapist can counter the characterological deficits of these patients who constantly have to battle the feelings of boredom, deadness, meaninglessness, and inner emptiness, which threaten to overtake them. The more passive and unresponsive therapist is likely to be experienced by the substance abuser as withholding, timid, dull, or dead. This stirs up unconscious fears of annihilation and nothingness, which are associated with primitive identifications. Transference distortions are thus heightened, which in turn increases resistance.
However, the increased activity level of the therapist does not suggest that he or she be overly charismatic because this can induce fears of engulfment, destructive idealization, competitive distractions, and archaic mergers. Also, this does not imply the therapist gratify the patient in an infantile manner. Not only is this unrealistic, anti-therapeutic, and ultimately impossible, but it also feeds the substance abusers infantile narcissistic grandiosity and demands for immediate gratification. Establishing a climate of optimal frustration provides the delicate balance between meeting the patient's dependency needs until they are able to internalize control over their own destructive impulses and emotions.
Creating the Capacity for Attachment
There is a very subtle interplay between attachment, safe haven, and proximity seeking behavior. Attachment theorists have long recognized an important paradox about attachment: secure attachment liberates (Holmes, 1996). This is as true for the securely attached child as it is for the securely attached patient who has a firm therapeutic alliance with his or her therapist. Just as the securely attached child will move greater distances away from his or her caretaker, taking more risks exploring his or her surrounding environment, the securely attached patient will take more risks in therapy, exploring his or her inner world more readily.
During the later stages of early recovery, helping the addict and alcoholic learn how to negotiate the demands of attachment and mutuality becomes important for another reason. Relapses are always of primary concern during this stage of treatment and are often related to difficulties with affect regulation. Substance abusers are usually unable to use their feelings as signals and guides in managing or protecting themselves against the instability and chaos of their internal world. This disturbance in the regulation of affect manifests as "an inability to identify and verbalize feelings, an intolerance of incapacity for anxiety and depression, an inability to modulate feelings.... and extreme manifestations of affect, such as hypomania, phobic-anxious states, panic, and lability" (Khantzian, 1982, p.590). If they should return to using substances, it will only deteriorate their existing capacity for self-regulation even further.
Alexithymia
Much of the early efforts in treatment need to be directed towards the rudimentarily process of helping the substance abuser facilitate affect-regulation by labeling and mirroring feelings when they occur in treatment. The novice therapist will soon learn that substance abusers require help with becoming acquainted with their feelings. Not only will they have difficulty identifying their feelings; they are notoriously inadequate in communicating them to others. The larger lesson the substance abuser has to learn is that emotions are not only vital to self-understanding, but also crucial to the understanding of other’s feelings and the negotiation of all forms of intimacy in interpersonal relationships.
Alexithymia has been identified as a characteristic pattern indicating an inability to name and use one's emotions. The alcoholics’ and addicts’ inability to verbalize feelings leads to the somatization of affect responses. Consequently, the substance abuser is confronted with sensations rather than feelings. Such physiological sensations are not useful as signals, but remain painfully overwhelming. Painful affective states call attention only to their discomfort rather than to the "story behind the feelings." Substance abusers possess a striking inability to articulate their most bothersome, and important feelings. Many, if not all of their feelings translate into somatic complaints about physical discomfort and craving. Alcohol and drugs are used to block the affect, preventing the substance abuser from interpreting and attending to the signal. Krystal ( 1982) says this results in, "a diminution in the capacity for drive-fantasy. Thinking becomes operative, mundane and boring. The capacity for empathy with development of utilizable transference is seriously diminished” (p.614).
The recent work of attachment theory and self psychology have taught addictions specialists that dysfunctional attachment styles interfere with the ability to derive satisfaction from interpersonal relationships and contribute to internal working models that perpetuate this difficulty. Experiences related to early developmental failures leave certain individuals with vulnerabilities that enhance addictive type behaviors and these behaviors are misguided attempts at self-repair. Deprivation of age appropriate developmental needs leaves the substance abuser constantly searching for something “out there” that can be substituted for what is missing “in here”.
The following vignette illustrates the futility of attempting therapy with a practicing alcoholic. Their attachment to substances will interfere with their capacity to establish or maintain a therapeutic alliance.
_ Mike, a 52-year-old addict and sexual abuse survivor, had been in and out of treatment and Alcoholics Anonymous for nearly thirty years with little improvement or success. The only long-term relationship he had maintained during this period was a 25-year marriage to a suffering wife who derived great pleasure in reminding him how miserable he made her life. Despite frequent recommendations that they seek couples therapy, she refused saying “she was not the problem, he was.” A severe and persistent introject of self-blame resulting from his sexual abuse prevented him from establishing anything other than sado-masochistic relationships. Following a severe weekend binge that nearly killed him, Mike was eventually persuaded to enter a therapy group. After putting together three months of abstinence, Mike began to gradually become more attached to the group. With the help of the other group members, he began to explore the destructive nature of all his relationships, especially the one with his wife. It soon became apparent that “Saint Sally” could only contain her position of goodness as long as Mike held on to his position of the “bad one”. As Mike became more attached to the group and developed new relational configurations, his wife became more depressed and eventually sought individual therapy. During the next three months Mike continued to show marked improvement, staying sober and developing a new and important role in the group. Anytime the group would drift into superficiality or evasiveness, he would assume responsibility for keeping the group on task and encouraging the members to stay serious about recovery and remaining honest with each other. All this abruptly changed one night when Mike, distressed and devastated, announced to the group that his wife just had been diagnosed with breast cancer. In the middle of an angry confrontation, she blamed him for her condition and screamed at him, “Your drinking caused me so much stress that I got cancer, this is all your fault!” Despite the absurdity of her accusations, Mike’s nascent developing “good self” could not tolerate her verbal onslaught. Within two weeks, he relapsed. Following the relapse, his demeanor and relationship with the group and its members change dramatically. He became more withdrawn and emotionally detached from the group, missing more and more sessions. Whenever he did show up, he either was bored or surly, and frequently critical of group members, telling them “to stop whining and feeling sorry for themselves.” The exuberant and involved individual had now been replaced by a detached, disparaging man who was self-absorbed and showed complete disregard for other’s feelings or difficulties. The group tried unsuccessfully for the next two months to restore their relationship with him and encouraged his return to AA and abstinence. He gradually drifted out of the group and returned to his old relationship with his wife who also had stopped individual therapy._
Trauma Bonding
As long as the alcoholic remains attached to alcohol, he will not be able to establish a therapeutic alliance. Sometimes creating the capacity for attachment requires nothing more than taking advantage of a well-known fact about attachment: an individual’s attachment system opens up during a crisis. Substance abuse and urgent circumstances usually go hand in hand. If the therapist is patient and does nothing to interfere with this process, the consequences of a substance abuser’s drinking and drug use eventually will provide them with a favorable therapeutic opportunity. AA refers to this as hitting bottom. The art of successful early treatment with the addicts who refuses to accept their diagnosis or the alcoholics who remains in denial is to gently encourage them to look at the consequences of their substance use without damaging the therapeutic alliance. Take every opportunity to “reframe” the problem they present to help them see that most of their difficulties are the result of their chemical use. The basic thrust of addiction treatment is to get the substance abuser to perceive and understand the relationship between their present difficulties in their life and their drug or alcohol use.
Relapse Prevention
The road to recovery requires a careful balance between affect release and affect containment. Since rapid switches in affect-states can be potentially destructive, the substance abuser’s feelings must be delicately managed until they have enough sobriety and emotional stability to tolerate a closer look at them selves. The potential for a relapse is heightened anytime the substance abuser feels too good or too bad too quickly. Feeling too good too quickly is often a signal that the old narcissistic defenses have returned and the substance abuser will soon be thinking, “I got this thing licked, I’m special. I’m different.” On the other hand, feeling too bad too quickly leads to “I don’t give a damn. I might as well be using; this is no fun”, indicating that abstinence has become intolerable and substance use is the only refuge they have from the intense discomfort that dominates their recovery.
While relapse prevention will be a crucial part of the maintenance stage of change, it will be a continual focus after action is initiated to stop using alcohol and drugs. Relapses are inevitable for most, if not all alcoholics and addicts. They can be invaluable learning experiences if properly examined and integrated. Staying closely connected to other recovering addicts and alcoholics in the twelve-step recovery programs will ensure that the learning from relapses does not always have to come at the individuals' own personal expense since they have the opportunity to learn from each other by witnessing each others' relapses. They soon learn that relapses follow a predictable and recognizable pattern. This is vitally important since relapses can often be fatal. The therapist can provide information and direction and explain the typical warning signs of relapse, thus helping prevent or minimize its impact and occurrence. As important as this information is, it does not carry anything close to the impact and emotional learning that comes from witnessing a fellow addict or alcoholic in the early throes of a relapse.
Sam had a little more than three months sobriety and had been doing “ninety-in-ninety” (ninety meetings in ninety days) as his sponsor had suggested. Faithfully following all the recommendations of AA, Sam was actively working the steps of the program, taking it one day at a time, and reading the “big book” of AA. Despite his best efforts, Sam had come off the “pink cloud” high that many alcoholics experience during the early stages of recovery and was experiencing more intrusive thoughts about drinking. He confessed these difficulties one afternoon to his sponsor, who replied, “Well, maybe it’s time you did a little twelve-step work. I just got a call a little while ago and I’m going to see someone who’s in a bad relapse. Why don’t you come along?”
“Twelve-step?” Sam’s voice was full of surprise and concern. “You think I’m ready to help someone else?”
His sponsor laughed. “I think you got this helping stuff turned around. Remember, twelve step work is about keeping you sober, not the other person.”
“What?” Sam stammered. “I don’t get it. How’s doing a twelve-step call going to help me? I --”
“Come along.” His sponsor interrupted. “Maybe you’ll find out.”
They drove to a seedy part of town and parked in front of the dingiest flophouse that Sam had ever seen. Sam followed his sponsor up a creaky set of stairs and down a dimly lit, dark hallway until they found the room he was searching for.
The sponsor knocked on the door.
“Who’s the hell’s there?” A slurred voice croaked.
“It’s me Pete, Bob Cramer.”
“The doors not locked.” The voice responded.
The stench of the room invaded Sam’s nostrils as soon as his sponsor opened the door. Once inside the room, Sam stood transfixed by the sight before him.
There on the edge of the dirty bed, dressed only in his urine stained underwear, sat a disheveled inebriated sorriest example of a man that Sam had seen in years. The poor creature had thrown up all over the front of his stained tee shirt and dry vomit was caked all over his teeth and unshaven face. Cigarette butts and empty wine bottles were scattered around the room. Before Sam’s sponsor or the drunk on the bed could respond, Sam was overcome by a spontaneous response.
Sam pushed past his sponsor, charged across the room and grabbed the man’s hand, pumping his arm in a vigorous handshake. “I want to thank you. Seeing you like this, I know for damn sure I won’t have a drink for at least the next twenty-four hours.”
Character Defects
In addition to the "physical allergy" to alcohol suggested by the disease model of alcoholism, alcoholics are held to possess an alcoholic personality described as immature and self-centered. They are spiritually sick, their naively egotistical and self-centered personalities preventing any but the most artificial and superficial relation to others or to a "higher power. Whereas society has irrevocably linked alcohol to the alcoholic, AA insists upon their separation. AA will argue that individuals are alcoholics whether or not they drink and that their behavior may be that of a typical alcoholic even if they have not had a drink for years. AA is therefore aware that many drinkers, even heavy drinkers, are not necessarily alcoholics. Alcoholism from the program's perspective is a total lifestyle or mode of being and action in the world within which misuse of alcohol is but one component, albeit the most important component. Elimination drinking is an indispensable first concern, but it is just the first step before altering other important aspects of the overall defective lifestyle. It is not uncommon to hear AA members refer to someone who has stopped drinking but still maintains the defective mode of life as being a "dry drunk”.
From this perspective, alcoholism is viewed as more than just excessive drinking. This is why AA believes that alcohol consumption cannot be curtailed without addressing and treating the rest of the alcoholic's personality disturbance. The difficulty that many have with AA's treatment approach centers around the issue of the necessity of total abstinence. While many therapists continue to view alcoholism as a focal disturbance that could be eliminated or cut out as you would cut out a bad spot in an otherwise good apple, that AA views it as the primary issue that must be dealt with first. Abstinence from alcohol is the first step required for breaking the alcoholic style of living. Only after abstinence has been assured can alcoholics learn to focus on changing their characterological personality style.
Within this system, at any given moment, individuals are either healthy or unhealthy depending on which system is dominant. Drinking only encourages the unhealthy lifestyle to dominate the healthy potential within the alcoholic. As AA recognizes, alcoholics are isolated spiritually and can only relate to others on a superficial level. They cannot define themselves because their being is controlled and clouded by their drinking. Their alcoholism makes it impossible to relate to anyone or anything on a meaningful way.
Self-attribution of alcoholism
Next to the importance Thune places on the telling of one's life an AA meeting, he views the constant introduction of oneself as an alcoholic as the next most essential component of the recovery program. Each self-proclamation of "I am an alcoholic" is a constant reminder to AA members that they are just a drink away from being the person they once were. This is a very confusing state of affairs to those whose interest in AA is only passing, superficial, or purely academic. They fail to understand the important significance of this ritual. Critics of AA often take special issue with the insistence that all AA members introduce themselves as alcoholics. Individuals outside of the AA program interpret this as degrading, serving only as a constant negative reminder of the alcoholic’s shortcomings. They do not understand how such a requirement by the AA program can do anything but leave alcoholics feeling a sense of continual debasement and loss of self-respect. To the contrary, AA members who introduce themselves as alcoholics do so for they are conveying an important message to themselves each time they stand up and make such a proclamation. The self-attribution of alcoholic conveys far more information for the alcoholic in AA than it does for the individual outside the program who defines him or herself as someone who once drank too much. The term "alcoholic" signifies everything (self-centered behavior, negative attitude, corrupt values) that sober AA members must guard against if they are to maintain a healthy sobriety. By constantly utilizing the self-definition of alcoholic, AA members automatically imply the opposite, which is everything a healthy, recovering, and sober member of AA must attain. AA members are thus reminded with each pronouncement of themselves as an alcoholic that they are just a drink away from losing what they have become, which is a person whose values, attitudes, and behavior is the direct opposite of that of an alcoholic.
From this perspective, the discovery of personal meaning and the experience of shared narratives between fellow alcoholics serve to firm up the attachment bond. Like with good therapy, newly recovering alcoholics and addicts learns how to make “better sense” of themselves and their substance use. Narratives provide a containing boundary and a sense of continuity across time—a movement from the past, however painful, through the present toward the future. As sobriety is solidified over time, alcoholics and addicts are not only better able to look at the way their substance use exacerbated the difficulties in their lives, but also how their difficulties with attachment contributed to their substance use.
References
Brown, S. (1985). Treating the alcoholic: A developmental model of recovery. New York: John Wiley & Sons.
Brown, S. & Yalom, I. (1977). Interactional group psychotherapy with alcoholic patients. Journal of Studies on Alcohol, 38, 426-456.
Durant, W. (1926). Story of Philosophy. New York: Simon & Schuster.
Flores, P. (1982) Modification of Yalom’s interactional group therapy model as a mode of treatment for alcoholism. Group, 6, 3-15.
Flores, P. (1997). Group psychotherapy with addicted populations: An integration of twelve-step and psychodynamic theory. Binghampton, NY: Haworth press.
Flores, P. & Mahon, L. (1993). The treatment of addiction in group psychotherapy. International Journal of Group Psychotherapy, 43, 143-156.
Fonagy, P., Steele, M., Steele, H., et al. (1994). The theory and practice of resilience. Journal of Child Psychology and Psychiatry 35:231-257.
Grant, I., Reed, R., & Adams, K. (1980). Alcohol & drug related brain disorder: Implications for neuropsychological research. Journal of Clinical Neuropsychology., 2(4), 321-331.
Holmes, J. (1996) Attachment, Intimacy, Autonomy. Using attachment theory in adult psychotherapy. Northdale, NJ. Jason Aronson, Inc.
Kaufman, E. & Reoux, J. (1988). Guidelines for the successful psychotherapy of substance abusers. American Journal of Drug and Alcohol Abuse, 14, 199-209.
Kelly, G. (1963). A theory of personality. The psychology of personal constructs. New York: W. W. Norton & Co.
Kemker, S. S., Kibel, H. D., & Mahler, J. C. (1993). On becoming oriented to inpatient treatment: Inducing new patients and professionals to recovery movement. International Journal of Group Psychotherapy, 43, 285-302.
Khantzian, E. J., Halliday, K. S., & McAuliffe, W. E. (l990).Addiction and the vulnerable self. New York: Guilford Press.
Krystal, H. (1982). Character disorders: Characterological specificity and the alcoholic. In: M. E. Pattison & E. Kaufman (Eds.), Encyclopedic handbook of alcoholism (607-618). New York: Gardner Press.
Kurtz, E. (1979). Not-God: A history of Alcoholics Anonymous. Center City, MN: Hazelden.
Laing, R. (1969). The self and others. London: Tavistock Publications.1-3.
Madsen, W. (1974). The American alcoholic. Springfield, Il: Charles C. Thomas.
Main, M. (1991). Metacognitive knowledge, metacognitive monitoring, and singular vs. multiple models of attachment. In Attachment Across the life Cycle, ed. C. Parkes, et al. London: Routledge..
Matano. R. A. & Yalom, I. (1991) Approaches to chemical dependency. Chemical dependency & interactive group therapy – a synthesis. International Journal of Group Psychotherapy, 41, 269-294.
Parsons, O. A. & Farr, S. P. (1981). The neuropsychology of alcohol & drug use. In S. B. Felskov & T. J. Boll (Eds.), Handbook of clinical neuropsychology (320-365). New York: John Wiley & Sons.
Prochaska, J. O. & DiClemente, C. C. (1992). Stages of change in the modification of problem behaviors. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification, Vol. 28 (184-214). Sycamore, Il: Sycamore Press.
Ryan, C. & Butters, N. (1980). Further evidence for a continuum of impairment encompassing male alcoholic Korsakoff patients and chronic alcoholic men. Alcoholism, 4, 190-198.
Shore, J. J., (1981). Use of paradox in the treatment of alcoholism. Health and Social Work, 38, 11-20.
Vannicelli, M. (1992). Removing the road blocks: Group psychotherapy with substance abusers & family members. New York: The Guilford Press.
Wallace, J. (1978) Working with the preferred defense structure of the recovering alcoholic. In S. Zimberg, J. Wallace & S. Blume (Eds.) Practical approaches to alcoholism psychotherapy. (pp. 19-29). New York: Plenum Press.
Wallace, J. (1984). Myths and misconceptions about Alcoholics Anonymous! New York: AA World Services.
Washton, A. M. (1992) Structured outpatient group therapy with alcohol & substance abusers. In J. Lowinson, P. Ruiz, & R. Millman (Eds), Substance abuse: A comprehensive textbook. (2nd ed), 509-519, Baltimore, MD. Williams & Wilkens.
Wells, H. L. (1982).Chronic brain disease: An update on alcoholism, Parkinson’s disease, and dementia. Hospital and Community Psychiatry, 33(2), 111-126.
Wilkenson, D. A. & Carlen, P. L. (1981). Chronic organic brain syndromes associated with alcoholism: Neuropsychological & other aspects. In Y. Israel, F. Grace, H. Kalent, R. E. Popham, W. Schmidt & R. G. Smart (eds), Research advances in alcohol and drug problems, Vol. 6. NY: Plenum Press.