The psychiatrist will be addressing Step 1 automatically in the assessment, using DSM-5, which separates alcohol use disorders into mild, moderate, and severe. If the patient has mild or moderate addiction, AA might not be appropriate, said Nowinski.
Nowinski has worked on treatment strategies for alcohol-dependent individuals, but there are people who are “almost alcoholic” (the title of a book he co-authored) who may need to get back to less risky drinking. While TSF is for severe alcoholics, there are people who are “high-functioning alcoholics.” Imagine a woman who drinks 3 to 4 drinks a day—this is too much, and adversely affecting her health, but AA is not for her. “In that case, the psychiatrist can ask, ‘What is your daily drinking routine; how can we change that?’” It may include drink refusal skills, not going out to bars after work as much, or other approaches. “But they haven’t experienced the kind of consequence that people going to AA have,” said Nowinski. “They might feel that they don’t belong there.” On the other hand, there are people with moderate (not severe) drinking problems who go to AA because they really do want to stop, he said.
The message at AA meetings is going to be one of abstinence, not cutting back—even though there are clear benefits to drinking less. But for patients who are not committed to stopping altogether, they could practice what Tonigan calls “sobriety sampling,” which can help patients who don’t really want to be in treatment and don’t have an abstinence goal. “We ask them, ‘How long could you try being abstinent?’ And if they say 1 day, we say, ‘Could you try 2 or 3 days?’” Once they try 2 or 3 days, they come back and report that their lives are already getting more stable, said Tonigan. “If you tell them it has to be for the rest of their lives, that’s overwhelming.” And this is built into the AA philosophy, which has as one of its most beloved slogans, “One day at a time.”
People with addiction tend to discount future rewards, researchers have found. While people who are not alcohol dependent could say they don’t want that extra drink because they don’t want a hangover the next day, the alcoholic would be more interested in the immediate reward. And eventually, that alcoholic would simply drink the next morning as well to feel better, at this point not being able to cut back at all.
For patients who do want to continue to drink, but who want to cut back, Tonigan thinks a group like Rational Recovery, which is more tolerant of ongoing substance use, might be more appropriate.
For patients who have read magazine articles and books denigrating AA, Tonigan, who worked with motivational interviewing founder William R. Miller, PhD, said don’t argue. These patients may say, “Why should I go there? It’s a crazy society of people who pray to God.” The best response, said Tonigan, is “Yes, I understand what you’re saying, but on the other hand, some people aren’t aware that there are more than 650 empirical studies on 12-step programs, and in general we find people do much better on attending these programs.”
Which steps work?
For years, Tonigan and co-researchers have been trying to find out which steps AA members have completed. They found that in essence, people were working on parts of the steps, usually without completing all of them. It turns out that the steps people have completed doesn’t predict outcome; rather, continuing to work on them on a regular basis is the key. “That’s pretty shocking, because the steps are supposed to be the active ingredient of AA,” said Tonigan. “But what we do find is that working the steps helps someone have a spiritual awakening, and that is what is mobilizing the change.”
Instead of focusing on the steps themselves, psychiatrists can just encourage people to take part in the “prescribed behaviors” of the steps, said Tonigan.
Joining the human condition
David Sack, MD, is an addiction psychiatrist who has been in practice more than 30 years, and he has found that 12-step programs help patients with everything that therapy and medications don’t address. Most patients with substance use disorders have co-occurring disorders such as depression, bipolar disorder, anxiety, or schizophrenia, he says. One of the biggest problems for people in early recovery is impairments in working memory. “They lose the ability to plan, to remember what they want to do and when they want to do it,” he said. “But in the Twelve Step program, the message over and over is, ‘One day at a time, one step at a time.’” This is important to these patients because they can become overwhelmed and panic, he said. The Twelve Steps program helps patients develop a strategy around getting back to work and getting stable.
Secondly, the Twelve Steps program is very good at the issue of shame, said Sack, who is also president and CEO of Elements Behavioral Health, an addiction treatment chain. “Most people in early recovery are forced to confront all the things they did when they were using,” he said. The fourth step helps them process what they did to their loved ones or their co-workers. “They write it down and tell it to another person, and then they see that the world doesn’t end,” he said. “The fourth step has tremendous curative power.” That shame, when not released, is one reason that people relapse early on in recovery, said Sack. “They’re frightened, they don’t think they can join the human condition.”
AA meetings can be remarkably helpful in teaching patients how to imagine something good in the future, which can help forestall relapse and strengthen recovery. Sack related the story of one patient who was dutifully going to AA but didn’t feel it was helping him much—something happened at a meeting that changed everything. “He told me, ‘I’m sitting in this room, I don’t know why I’m there, and I’m listening to these stories, and one day my ears perked up. I was listening to this guy who sounded just like me—drinking, cocaine, shooting up, detox—and then at the end of his sharing, he said that then he got clean, and he has a house, a car, and his car sounded great, and he has this wife and she loves him and they have dinner together—and I wanted those things too. I didn’t really care about being sober, but when I heard that, I said that’s what I want.’”
That “sharing,” as telling your experience in AA is called, is what allows new patients to see that things can get better, which can decrease their impulsivity, said Sack.
Finally, it’s important to know that nobody has to say anything at a meeting. “You watch other people say things, and they get a round of applause,” he said. “The meeting shows it’s safe to share.”
Of course, it’s also safe to share in the psychiatrist’s office. But Twelve Step 5 groups and AA members are there the rest of the time, even at 2:00 in the morning when your patient may need support. This is a free resource with some good evidence to back it up. The TSF prescription may be just what many patients need.
For the Twelve-Step Facilitation Therapy Manual, go to: http://pubs.niaaa.nih.gov/publications/ProjectMatch/match01.pdf
For more up-to-date information, go to: http://www.aa.org/pages/en_US/information-for-professionals