The 12 steps unchanged after 74 years

September 30, 1939, the popular weekly magazine, Liberty, gave many Americans a first taste of the now famous 12 steps. Many self-help groups today employ the 12 steps that originated in the book, Alcoholics Anonymous, published five months earlier. The group named after the book remains the most successful organization in handling the disease of alcoholism today.

The Substance Abuse and Mental Health Services Administration (SAMHSA) in 2008 reported an annual average of five million people 12 and older attended a group self-help meeting in the prior 12 months. One third also went for one-to-one counseling or group therapy. Because 12-step groups are so widespread, most one-to-one counseling and group therapy is based on the 12-steps and those counselors encourage participating in 12-step group self-help to boost sobriety. In fact, the National Treatment Center Study Summary Report from the University of Georgia found 90 percent of 450 treatment centers are based on the 12 steps, while 10 percent rely on “Behavior Therapy.”

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) seems to endorse the 12-step approach in group therapy as well. In 2008, it found Behavioral Therapy less successful than 12-step methods. “Individuals in 12-step oriented therapy have increased subsequent AA participation and it is the AA involvement that leads to better outcomes by buffering the effects of social pressures to drink. AA exposes a person to a network of people who have a goal of sobriety and support one another in achieving that goal.”

Group therapy requires signing up and showing up. Group self-help like AA requires only showing up. One thing to note though, if it is confidentiality you seek, one-to-one counseling is the only route 100 percent confidential. Anonymous is not a synonym for confidential. Ask yourself, though, does recovery really need to be confidential? Far too many get ticklish about talking “publicly” about their shame and other stressors. The alternative is not talking. And that leads to relapse. A twelve-step meeting is not the town newspaper. Even if it was, some alcoholics’ under-the-influence feats were more public than anything they’d say in a group self-help meeting ever would be.

These are safe venues in which to communicate. They consist of people who share the exact same struggles. Talking things out among them is cathartic. You don’t need to talk about every confession you have. You don’t get style points for deeper traumas. You do get style points for creating a climate of trust by putting on the table the things that are giving you challenges in sobriety. Those with drinking problems risk reaching out because they need a new label, a new place to belong, and there is safety among others who are also trying to shed old labels and stressors. If You’re Not Normal is the three-word death sentence to recovery, Me Too is the two-word pardon alcoholics get at 12-step meetings.

Even if an alcoholic does not ever buy into the 12 steps as a design for living, they are suggested, not required, for membership. “The only requirement is a desire to stop drinking,” the literature says. Twelve-step meetings are places to be among others who feel the same, wore the same masks, suffer the same struggles and have a desire to communicate rather than drink over them. “The most desperate need of mankind today is not a new vaccine for any disease or a new religion or a new way of life,” wrote Taylor Caldwell in the novel The Listener. “His real need, his most terrible need, is for someone to listen to him, not as a patient but as a human soul.”

Everyone, no matter how gifted, healthy or wealthy, encounters an issue that baffles them or breaks the spirit. Twelve-step groups are where alcoholics can communicate the baffling and the spirit-breaking. What all are trying to do together is acquire back self-esteem.

There are alternatives to 12-step groups, such as Self-Management and Recovery Training (SMART) and Women For Sobriety (WFS), however none have the track record of success AA boasts, and none are as widely available.

The Higher Power thing is tough for some people to swallow. The 1939 Liberty article had the title “Alcoholics and God,” which AA founder Bill Wilson disliked because he knew some people would object to the still-new program when positioned that way. And some still reject the program's spiritual bent.

Some people stay away from 12-step meetings because they don’t see themselves in the people around the tables or hear their stories told in the tragic stories of others. That is the point in going: To make sure you’re communicating what is stressing you before you go back to the drinking and become those tragic stories.

From a strictly medical standpoint, alcoholism is remarkably easy to arrest. It’s a lot less complicated than arresting cancer or diabetes. Abandon the bottle long enough and detox and biological functioning returns to something close to normal in a few weeks or months. From that point on, it is a matter of not going backward. That’s the drawback to having a disease that can be arrested but not cured: While it is under control it’s all too easy to forget what life was like when it wasn’t. Twelve-step groups remind alcoholics what it was like. Without the stigma.

One of the most treasured AA stories in print says, “Above all, AA taught me how to handle sobriety. I have learned how to relate to people… deal with disappointments and problems that once would have sent me right to the bottle. How do we do it? By sharing at meetings.”
-- Adapted from Every Silver Lining Has a Cloud.

-- From examiner.com (full article)
www.alcohologist.com

SUNDAY SNIPPET August 25

Former boxing champ Mike Tyson's admission that he's struggled with grief and forgiveness in part of his ongoing alcohol rehab points to two of the four key stressors Every Silver Lining Has a Cloud notes as potential barriers to long-term sobriety. Of course everyone, Alcoholic or non-Alcoholic, faces these stressors.  Most handle it swimmingly well, others not so well, masking them with alcohol.  When someone with the disease of Alcoholism encounters something so strong it triggers the stress hormone cortisol, relapse is a possibility.

 

"For those on the outside of the disease, in a way, dealing with a drinking Alcoholic is easier than dealing with a sober one because with a drinking one you know what the problem is. The conversations I had with more than 200 men and women in recovery reveal what the sober Alcoholic’s problems are.

 

When the Symptoms of Sobriety appear, know they are normal responses to cortisol increase traced to these four things we struggle with in sobriety:

Guilt (Chapter Four)

Shame (Chapter Five)

Forgiveness (Chapter Six)

Grief (Chapter Seven)

 

When you take away alcohol, you still have problems—problems that non-Alcoholics sometimes use alcohol to relieve, “treat” or cover up. In an Alcoholic, these four cause relapse. They are the cloud to sobriety’s silver lining. They aren’t simply squishy, intangible emotional qualities for Hallmark cards or spiritual books. Science shows they’re states that have a concrete and measurable effect on our biochemistry.

 

Every Alcoholic has manifestations of these four and needs treatment geared toward these stressors or the treatment fails. No treatment will have lasting success without addressing what causes the Symptoms of Sobriety. To put it another way, it’s well known that high cholesterol levels increase coronary heart disease—heart trouble. Those who have a genetic predisposition for difficulty handling cholesterol frequently can forestall heart trouble with careful eating habits. A person who doesn’t have the problem handling cholesterol doesn’t have the same urgent need to restrict his diet. Eating ice cream or gorging on fries isn’t much of an issue for him but it is for the man who does have the genetic predisposition. And so it goes with Alcoholics who are stuck with a problem handling cortisol. Guilt, shame, forgiveness and grief are a threat to recovery trouble like cholesterol is a threat to heart trouble."

--from Every Silver Lining Has a Cloud: Relapse and the Symptoms of Sobriety, pgs. 33-34

www.alcohologist.com

SUNDAY SNIPPET, June 2

There are several reasons Every Silver Lining Has a Cloud notes in favor of attending some sort of self-help group. Attendance can help stave off relapse, but on a more basic level it provides a place to talk and to be heard and to be understood. It doesn't have to be the 12-steps. There are other alternatives, some are quite effective and might be a better fit given a person's location or belief system. The fact is regardless of belief system, we need a place to talk about The Things We Don't Talk About.

 

 

"I’m no shill for AA. The slogan factory drives me nuts. More about this in a moment. I hate the coffee. The Higher Power thing is tough for some people to swallow. Some people stay away from 12-step meetings because they don’t see themselves in the people around the tables or hear their stories told in the tragic stories of others. That is the point in going: To make sure you’re communicating what is stressing you before you go back to the drinking and become those tragic stories. You go because you don’t want to become The Alcoholic You Don’t Want To Be.

 

I screwed that one up, big time.

 

When I first went to a 12-step meeting, I was Alcoholic. No Doubt About It. But I didn’t hear myself as I presently was in the stories. I heard the horror stories. I was a functioning, maintenance drinker with a great job, two cars, etc. I didn’t have this low bottom I heard in the other stories. So I walked away, not realizing that that day could have been my bottom. Their stories of grief and shame weren’t me. I had great empathy for their ordeals. What I failed to see was that they were a gift, showing me where I was headed, not where I was. That these ordeals of theirs were mine if I didn’t make that day my bottom. They were the Alcoholics I Didn’t Want To Be.

 

At the dawn of AA in the 1930s, the makeup was men and women with low, low bottoms. Over the years, that changed mainly because those who had hit low bottoms were able to raise the bottom to a level where it applies to Alcoholics-in-training like me who hadn’t had a low bottom. Yet. I failed. I didn’t listen . . . there’s that communication thing again . . . to what they were saying that they, too, were one day in the same shape I was. And then I became the Alcoholic I Didn’t Want To Be a few years down the road. While we have to talk about the stuff we don’t talk about, it pays to listen. A lot. I go to 12-step meetings for this, but there are other options out there, too. Use them. Most are free.  All are free of excuses not to attend."

--from Every Silver Lining Has a Cloud: Relapse and the Symptoms of Sobriety, pgs. 104-105

www.alcohologist.com

 

SUNDAY SNIPPET, May 26

One of my favorite sections of Every Silver Lining Has a Cloud is the chapter on a major stressor for Alcoholics: Forgiveness. Not one of us expects a shrine built on our behalf just because we quit drinking. Some people, however, are hell-bent on never letting us move on.

 

 

A healthy recovery is going to rely upon you forgiving other people, too. We Alcoholics really suck at this. We grip resentments like a chubby trick-or-treater grips a bag full of Snickers. We have to—have to—knock that off and forgive, even the people who are downright hostile toward us.

 

You will be able to initiate the process with someone by whom you feel hurt in about two-thirds of the situations. Most of your injurers are not going to come knocking on your door seeking a clean slate for judging you, and the other third are likely to have slammed the door on you and moved on from your drama. Remember the “full” line you passed.

 

Forgiveness isn’t a pardon, releasing a person from accountability for the injury they caused. Pardon, a la President Ford pardoning Nixon, assumes one person has authority over another. Forgiveness isn’t forgetting either. Author Beverly Flannigan (Forgiving the Unforgiveable, Macmillan Publishing, New York 1992) says you have to remember to forgive someone. “To forgive, one must remember the past, put it into perspective and move beyond it. Without remembrance, no wound can be transcended.”

 

To transcend or close wounds with the two thirds who haven’t slammed the door to you, forgiveness is a transaction. The Transactional Model follows a sequence described in 1953 by J.A. Martin (“A Realistic Theory of Forgiveness,” in The Return to Reason, Henry Regnery Press, Chicago).

A) Injured accused injurer

B) Injurer admits it

C) Injured gives reasons he feels violated

D) Injurer admits he was wrong

E) Injured punishes

F) Injurer takes it

G) Injured seeks assurance it won’t happen again

H) Injurer promises

I) Injured accepts the promise and requires nothing further

J) Injurer trusts forgiveness is permanent

 

That’s pretty civilized, optimistic and tidy. And it works. You’ve probably practiced the model without the extensive analysis since you played in a sandbox. But the model is hardly realistic when you encounter the kind of bitterness and stigma Alcoholics face. The emotional sensitivity Alcoholics have in common doesn’t help, and creates an imbalance in the model because the belief systems of injurer and injured are out of whack. Steps C and D can become a snarl when one side doesn’t accept the difference between drinking problems and problem drinkers. If the bitterness persists, you may have to walk away with the satisfaction that you tried: You attempted the transaction.

 

There’s hope still, even when the Transactional Model fails or is inappropriate because someone slammed the door on you and is long gone, unable to participate in the transaction. They’re gone believing they have been injured. Without the opportunity to confront the injurer, you’re pretty much left to repair the damage and wipe the slate clean by yourself.

-- from Every Silver Lining Has a Cloud: Relapse and the Symptoms of Sobriety, pg. 68-69

www.alcohologist.com

 

SUNDAY SNIPPET, May 19

Denial is a word tossed around liberally when it comes to the disease of Alcoholism. It's most often a reference to the very early phases of the drinking when the drinker denies (to himself) he has a problem when it is obvious to those around him he does have a problem. To get to any level of sobriety, an Alcoholic has already tackled that form of denial. What this excerpt from Every Silver Lining Has a Cloud addresses is a different form of denial that rears its head during recovery: The denial that life has, or has to, change because we lost something. It is a stage of the grief process.

 

 

“Alcoholics have a tendency to cling to their denial of their losses, not of their problem. By lingering in the stage, it only makes the cortisol worse. Even though the reason we linger in denial is simply that we don’t want to feel worse, we’re actually feeling worse because of the cortisol. To move away from more of continued Symptoms, the denial evolves into anger. Ashley Davis Prend identifies it as going from “Not me” to “Why me?” and it takes a long time.

 

“On average it takes one to three years to work through the disorganization and anger stage. That’s because you need to process the grief repeatedly so it can sink in, settling on deeper levels of consciousness over time.”

 

Simply put, you’re not going to be pissed off one time for one day, but you’re entitled to it and it is a healthy part of what comes naturally during mourning and recovery. Different anniversaries rekindle the anger. Social losses and financial ones have long tails and breed anger over and over. Impatience sparks the anger, too, because all of us Alcoholics have a little control freak in us.

 

Unfortunately, some of us never get past the anger because that’s where we lapse. We drink at the anger. Or if we don’t drink, we become what’s known as a dry drunk, a bitter and angry person who doesn’t and won’t drink. The dry drunk won’t find recovery, but will maintain sobriety because they cling to the anger. They become dry drunks because of a false sense of power anger provides. It does beat being sad. Sad feels so broken, anger feels powerful, but sadness is the next stage. Rather than moving forward, the dry drunk chooses the power of anger rather than feeling like the ornament at the bottom of the Christmas storage box. They’re usually more of a pain in the ass than they were when they were drinking.”

– from Every Silver Lining Has a Cloud: Relapse and the Symptoms of Sobriety, pg. 79

www.alcohologist.com

SUNDAY SNIPPET, May 5

This week's excerpt goes back to 2010's What The Early Worm Gets, a book in which the genetic and biochemical roots of the disease of alcoholism are probed. A significant body of research in the field of alcohology revolves around neurochemicals serotonin and dopamine, a.k.a. The Big Two brain chemicals.  They control the oldest part of the brain, the part that regulates what we need to survive based on primitive requirements – eat, don't get eaten, procreate. Dopamine tells the body we need something to survive. Serotonin alerts the body that the need has been met. Non-alcoholics have The Big Two in proportion to one another. In alcoholics, the dopamine is overproduced and serotonin never quite overcomes the dopamine to signal that we've had enough of something alcoholics are genetically wired to believe is a survival necessity: Alcohol.

“Alcohol is a central nervous system depressant. Use of alcohol in an Alcoholic will continue on a binge until the central nervous system becomes so depressed you pass out. There is not enough serotonin to tell the body it is okay. The dopamine keeps telling the body it needs more and is unopposed. It is for this reason that an Alcoholic doesn’t know that other people do not feel the way they do when they drink and that non-alcoholics (“normies”) don’t feel the same way an Alcoholic does when he drinks.

 

Non-alcoholics have no idea what it is like, how it feels, to drink alcoholically.

 

To complicate matters even further, some researchers theorize the alcohol molecule itself triggers release of more dopamine. The chemical composition of alcohol is so close to many neurochemicals that it could mimic or interfere with them, especially because alcohol is absorbed directly into the bloodstream at the small intestine without digestion or metabolization.

 

Treating the imbalance balance between dopamine and serotonin is not new ground. It was originally discovered in 1992 that obesity could be managed by combining Fenfluramine (which blocks the brain’s ability to reabsorb serotonin) with Phenteramine (which increases serotonin and decreases dopamine). The Fen-Phen combination also proved effective in treating Alcoholics in 1993. The Fen-Phen combination however proved also to be saddled with side-effects and fatalities and Fenfluramine was pulled off the market.

 

Rats have the same primitive structures in their brains and the same Big Two. Rats who have had serotonin removed from their brains have compulsive sexual activity and eating (Eat, Don’t Get Eaten, Breed) because there is nothing to counter the dopamine surges telling the body a survival need isn’t being met. If you have hunger, fear or an unconsummated sex drive, that represents Big Two imbalance. The imbalance stems from nothing you do or eat. A neurotransmitter responsible for the balance called Gamma Amino Butyric Acid (GABA) is controlled by your genes.

 

The physiological disease has its foundation in the genetic deficiency of the low or missing alcohol metabolism enzyme [discussed earlier in the chapter] PLUS the imbalance between the Big Two. What’s morality or character or behavior got to do with that? Where does willpower begin to fix that? An Alcoholic is no more capable of willing that physiological picture to correction than a starving person can will himself to a full stomach.”

– from What the Early Worm Gets, pages 60-61

Where willpower does come into play is resisting the first drink once sobriety is reached. A practicing alcoholic has no defense against this neurotransmitter imbalance once the alcohol is consumed. Once sober for awhile and the body's tissues have adjusted to not having the alcohol, then a dose of will is needed to keep it that way. An alcoholic has to will something other than the first drink. Once the first drink goes down, those neurotransmitters are still out of whack and there is no way an alcoholic can resist the second drink. Dopamine is running wild, and running the show at that point.  In fact, the low serotonin will make the body crave the second drink or the tenth as much or more than the first one.

www.alcohologist.com

SUNDAY SNIPPET, April 28

For this week's excerpt, I'm sharing part of an early chapter of Every Silver Lining Has a Cloud: Relapse and the Symptoms of Sobriety. Alcoholics drink that first drink for many of the same reasons non-alcoholics do: among the reasons is to relieve stress. Non-alcoholics can stop, alcoholics cannot, after the first drink. Chapter Two covers stress and cortisol and their relation to relapse, plus the new research revealing how the stress hormone alters the perception of and reaction to stress in those with the disease of alcoholism.


"The stressors Alcoholics pile up over periods of sobriety aren’t the small day-by-day stressors like coffee spills on new carpet. They’re the four major category stressors covered in chapters four through seven.  The longer you spend in prolonged stress with the cortisol rioting through you, the more intense your feelings of helplessness and, sometimes, emotional numbness. You at times feel like you’re just going through the motions. Things “normal” people drink to forget. 

 

Adrenals, like the rest of the body, are not designed for prolonged stress according to Dr. Aphrodite Matsakis (I Can’t Get Over It, New Harbinger Publications, Oakland, CA 1992). “The adrenals can be permanently damaged leading to overfunctioning during subsequent stress. If you were subjected to repeated or intense trauma or stress, certain biochemicals may have been depleted.”

 

In a famous series of experiments conducted by Martin Seligman in the 1970s, animals were subjected to electrical shocks they could not flee no matter what they did or did not do (Helplessness: On Depression, Development and Death, W.H. Freeman, San Francisco, CA 1975). They fought at first. Later the animals became listless when shocked. This was phase one. In Seligman’s second phase, the animals were shocked again but could prevent the zap by pressing a button. They didn’t. They were too changed biochemically to take a simple action to end their suffering. Bessel van der Kolk (in Journal of Traumatic Stress, Vol. 1, 1988) followed up the Seligman work and concluded the shocked creatures had the same biochemical imbalances as humans enduring prolonged exposure to stressors. With people though, human nature dictates that we try to avoid or escape anything to do with the stressor. Someone might, for example, avoid driving a car after the stress of a car wreck. That is a single, short-duration stressor. An Alcoholic, like Seligman’s experiment subjects, has multiple stressors of long duration. And you can’t run from them all. Like the two experiments convincingly demonstrated, there’s a point at which we don’t even save ourselves. Alcohol becomes an efficient escape.

 

Initially as we begin abstinence, we’re told to save ourselves from triggers. People. Places. Things. And the things in slogan-happy and acronym-rich rehab we call HALT: being Hungry, Angry, Lonely or Tired. Research demonstrates that those triggers lead to lapse because you are not thinking your clearest thoughts. When your stomach growls the oldest parts of the brain focus your body’s resources on food. If you’re focused on food, you’re not focused on sobriety, the thinking goes. You’re juggling sobriety’s apples and hunger throws you a chainsaw. When you’re tired, your thinking is blunted by your need for sleep. When you’re angry or lonely, you may prioritize resolving those emotions rather than concentrating on sobriety. HALT is a good starting point. The objective is to stay out of harm’s way. Avoid. But the four major stressors knocking our cortisol out of whack and leading to lapse, you cannot avoid. We need to instead alter our reactions to them.”

– from Every Silver Lining Has a Cloud, pages 29-30, FIVE STARS on amazon.com 

 

The first drink is the ESC key for the big stressors in the book, even for infrequent drinkers.  Alcohol has managed to remain popular for millennia for that reason despite troubling social or physical outcomes from alcohol misuse. For non-alcoholics, stopping after that first drink, after hitting the ESC key, isn't an issue.  All bets are off for the Alcoholic after the first drink to break the stress.  That isn't to say violence or illness is inevitable for that episode, just that stopping at one is not an option.  Many drinkers have tried and failed that simple test.  After the first one, it's like trying to slam a revolving door.
www.alcohologist.com 

 

SUNDAY SNIPPET, April 21

For this week's excerpt, I'm introducing one of the four stressors related to relapse emphasized in Every Silver Lining Has a Cloud: Relapse and the Symptoms of Sobriety. Shame. The book leans heavily toward the neuroscience and endocrinology fields in parts of the first portion of the book. In this middle section, in addition to being bluntly personal, I turn to many of the established pros in addictions and psychology... men and women who know the stigma the word "alcoholism" carries.


"...That’s just one example of stigma or ignorance leading to the insensitivity behind shame other people bring to our doorsteps or the shame we find when we stand on their doorsteps. In a lot of ways the shame is as pain-provoking as the disease itself, especially when we’re treated this way by People Who Should Know Better. I once thought I had a huge fund of tolerance for people but realized it could be quickly drained once I began dealing with otherwise smart people who say dumb things about Alcoholism.

The shamer may not want me to go to heaven because I’ve got this thing, but I want to go anyway, so who’s the one with the problem? The Person Who Should Know Better. You do not expect them to build a shrine to your sobriety, but it isn’t too much to expect them to let you try to succeed. They are simply not strong enough to accept that negative things can happen in life randomly. It is a part of nature they have chosen to deny. They have a “conflict of visions of reality” to steal from Zen and the Art of Motorcycle Maintenance. (Robert M. Pirsig, HarperCollins, New York 1974) It’s the way people choose to see the world regardless of scientific discoveries.

Stigma is the shadow cast by ignorance, and ignorance about Alcoholism remains very strong in society. A poll cited in HBO’s 2007 series, Addiction: Why Can’t They Just Quit? reported that one half of the public believes Alcoholism is a “personal weakness.” In the face of 56 years passing since the American Medical Association deemed Alcoholism a disease, HALF the population still refuses to believe it is one, and are wed to a 3000-year-old notion that it is a bad person rather than a bad medical condition. Call it lack of training or education to be more diplomatic, but it isn’t going to change by the time you finish this book. According to a truly common way of thinking called the “just world philosophy,” you’ve gotten what you deserved. In a just world, if you are careful, smart and moral you can avoid misfortune; and if you don’t avoid misfortune, you are misfortune. Shame on you.

In 1957 Dr. Jellinek’s disease model of Alcoholism authoritatively ended centuries of false conclusions about Alcoholism being tied to careful, smart and moral. People still have a hard time giving up the idea that it is some sort of problem that can be stopped by just walking in a different direction. They don’t isolate the science from the myth and rhetoric. The prevalence of shaming is a natural human tendency to be subjective rather than objective and that the untrained and closed mind will follow the path of least resistance. The American society shames the Alcoholic, so too must they.”

--- condensed from Every Silver Lining Has a Cloud, pages 53-54, FIVE STARS on amazon.com 

 

It's unicorns-and-rainbows thinking for those in recovery to try to overturn the stigma that is rooted so deeply in our culture. What we can do is learn to live, live well and live sober around it. It's a key to long-term recovery.

www.alcohologist.com