Integrating 12-Steps and Psychotherapy

Helping Clients Find Sobriety and Recovery

Kevin A. Osten, Robert Switzer

• Publisher: SAGE Publications, Inc
• Year: 2013
• Print ISBN: 9781412998987
• eBook ISBN: 9781483320618
• Edition: 1
• Topic: Education
• Subtopic: Education Counseling

Integrating 12 Steps and Psychotherapy: Helping Clients Find Sobriety and Recovery presents a practical and applied approach to working with substance dependent clients. Designed to be accessible to a wide and multidisciplinary audience of helpers at all skill levels, this text helps future practitioners fully understand the clinical challenges with substance dependence, adjust their thinking and technique in order to match their client?s phase of recovery, and optimize client retention and treatment outcomes. Utilizing educator, training, and practice perspectives, authors Kevin A. Osten and Robert Switzer explore relevant theory and techniques in integrating 12-Steps across a broad range of clinical issues including: the assessment and treatment of resistant and ambivalent pre-recovery clients; boundary setting, undoing antisocial adaption; processing counter transference reactions; and the intersection between biological functioning and ability in early recovery.

1

An Integrated View: Comparing 12-Steps and Psychology

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A NOTE ON LANGUAGE

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As with any field, this area of work has its own specific terminology. For the purpose of this book, the terms substance dependent, chemically dependent, alcoholic, and addict will be used interchangeably to describe clients who meet the Diagnostic and Statistical Manual Fourth Edition’s (DSM-IV) criteria for someone who is substance dependent. Also, please note that we, the authors, firmly hold onto the belief that a-drug-is-a-drug-is-a-drug. Or, in other words, the process of substance dependence is equivalent across individuals regardless of the substance or substances involved. Although there may be some specific differences related to different intoxicants (for example, alcoholics are more likely to have memory loss), in all but a few ways addicts think and behave similarly, whether they are dependent on alcohol, cocaine, methamphetamine, or opiates. Thus, unless otherwise explicitly stated, we are speaking of the substance dependent person in general, not those dependent on a certain substance or class of substances.

A NOTE ON THE PROCESS OF RECOVERY

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There are many means and methods that an addicted person can utilize to overcome their addiction. Despite deeply held beliefs by many, there is no “right way” to recover from substance dependence. Although research and clinical experience provide clinicians working with this population some guidance, finding the right combination of recovery techniques, skills, and beliefs sometimes resembles throwing a bunch of spaghetti against the wall and seeing what sticks. Our examination of how therapy can enhance the work of a 12-Step Program (and vice versa) metaphorically amounts to one option or strand of spaghetti smattered on that proverbial recovery wall.

Even within a specific recovery approach such as a 12-Step Program, there is no set timeline for an individual to work the Steps. The sponsor (someone who is sober, involved in 12-Steps, and willing to mentor others) generally sets a suggested timeline for their sponsee (the term used to denote the sponsored person) to complete the work for each Step. Depending on the sponsor’s style, this can be a very rapid process (all twelve Steps completed in about a month) or a much more relaxed pace (all twelve Steps taking several years to complete). Our experience is that most of our clients have a longer versus shorter timeline of working the Steps; often the first three Steps seem to involve a fair amount of trial and error, requiring a year or so. Also, a relapse (a very normal occurrence) almost always brings the sponsee back to Step One—no matter how far along they were in the Step process. A relapse is defined as the act of using an intoxicant after the decision for abstinence has been made and a period of sobriety achieved.

Added to the above, we find that groups of Steps seem to hang together, both conceptually and in practice. For these reasons, and for the sake of simplicity for this text, we adopt the following “timeline” of recovery stages:

1. Pre-Recovery (prior to any sustained effort at abstinence)
   a. No Step work
   b. If client is in therapy, therapists begin introducing 12-Step concepts without utilizing traditional 12-Step language
2. Early Recovery: 0 to 12 months of recovery
   a. Steps 1 to 3
3. Middle Recovery: 12 to 24 months of recovery
   a. Steps 4 to 7, when appropriate, combined with ongoing work on Steps 1 to 3
4. Longer-term Recovery: Greater than 24 months of recovery
   a. Steps 8 to 12, when appropriate, combined with ongoing work of any previous Step

This book focuses on the pre-recovery and early recovery stages. Later volumes will explore middle and longer-term recovery stages.

PURPOSE OF THIS BOOK

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There has been a long history of disconnection between a 12-Step approach to substance abuse and the psychotherapy approach. For many psychologists, substance abuse and addiction are often mentioned little, if at all, during their training. Frequently, psychologists are told during their early training that substance dependent clients may benefit from a referral to a 12-Step meeting. Chemical dependency is often given the attention one would give to an afterthought. As an example, during our training, not one class focused on 12-Step Programs, how they worked, and how psychotherapy could be used to enhance the involvement and benefit of clients in 12-Step Programs and vice versa. Instead, these clients and their substance abuse were often discussed as an artifact of an underlying psychological process. From this viewpoint, their drinking and drugging were the consequence of low self-esteem, self-destructive patterns, or disrupted early relationships. At no point were the authors educated about ideas common to 12-Step Programs: where substance abuse becomes a compulsion, where a person loses control, where a successful treatment must begin with some sobriety, and the reality that for many clients their substance abuse often becomes their focal issue. As a result, there is little reason to question why many of our colleagues feel unprepared to treat most substance dependent clients given this accurate assessment of the clinical training for many psychologists and psychiatrists!

In psychology, counseling, and social work, master’s level clinicians often are required to take at least one class on addiction. Unfortunately, one course typically cannot address much of the field of addictions, including the pharmacology of the substances of choice, diagnosing substance disorders, behavioral addictions, clinical techniques such as Motivational Interviewing, self-help programs such as 12-Step, and family systems. As one course of study does not prepare clinicians adequately for working with any particular diagnosis, so the same is true when studying addictions.

Thankfully, some schools are offering concentrations in addictions in which both master- and doctoral-level students are able to take a series of courses that explore each of these topics more in depth. However, we have found that 12-Steps continue to be addressed in a peripheral manner; one that considers the work clients are doing in this type of Program to be something that occurs outside of therapy. Our position, and the reason and purpose for this text, is to demonstrate and provide instruction on how therapy and 12-Step Programs can work in conjunction with each other.

We see a real danger in clinical practice resulting from the lack of training of clinicians in substance abuse or dependence. For some clinicians, this deficit can have devastating consequences for their clients. Let’s look at a case example to illustrate this problem.

John arrived in my office with four months of sobriety from alcohol. He had previously been seen by multiple psychiatrists, including at least one who was very well-known and respected. John had also been treated as an outpatient at several reputable hospitals. At the start of his treatment, John was on four different psychotropic medications, including two mood stabilizers, an antidepressant, and an anxiolytic. John described himself as such “a zombie” from these medications that he could no longer work, yet he was adamant that he had to take the medications because he had a Bipolar I disorder. An initial history revealed a pattern of symptoms consistent with this diagnosis, including hallucinations, as well as episodes of mania and severe depression. However, on closer inspection it appeared that these symptoms were not due to a mood disorder. Instead, they seemed to correlate with a pattern of intoxication and withdrawal symptoms in someone who was dependent on alcohol.

After a referral and several consultations with a psychiatrist, all of John’s medications were stopped and he began attending 12-Step meetings. For the next four years, John’s treatment included meeting attendance and psychotherapy and not once during this time did he present with an episode of a mood disorder, either depressive or manic. In repeated discussions with John, it seemed likely that none of his prior providers had considered that his alcoholism was mimicking a bipolar disorder, and they apparently had not evaluated him for such a possibility. Lacking this crucial perspective, they medicated him to the point that he had lost his job and was no longer able to function.

The educational deficits of providers may also explain much of the distrust that those involved with 12-Steps have for many mental health providers. Again and again, our clients have told us how others in their 12-Step meetings have expressed concerns and doubts about them seeing a psychotherapist. With further exploration, these fears often boiled down to expectations that clinicians would not support the work of a 12-Step Program or, even worse, would undermine and contradict sponsors and even the Program itself. With many of our clients, we prove that not only are we knowledgeable about a 12-Step approach, but that therapy can serve to enhance the 12-Step work. And make no mistake, this work needs to be done.

Just as in John’s case, some clients are misdiagnosed and improperly treated, but the reverse mistake is also made. Clients who have severe emotional problems are not referred to therapy or a psychiatrist by those in 12-Step Programs, even though these individuals desperately need the treatment. Repeatedly, clinicians who specialize in addictions treat psychotic clients who have been told by their mentors in 12-Step meetings that they should stop taking all psychotropic medications, including antipsychotic medications. The consequence of following this advice, even though it is given with the best of intentions, sadly can lead to continued mental health problems for the client, which can also lead the client to relapse in order to self-medicate their psychological symptoms in the only way they know how.

Ultimately, this books aims to assist clinicians in their efforts to assess and treat chemically dependent individuals, and is especially directed toward clinicians who are essentially naive about providing treatment (psychotherapy with 12-Step competency) for these clients . This book recommends a treatment that is consistent with 12-Step meetings and its philosophy, but also with the concepts of psychotherapy. It aims at empowering clients’ efforts toward sobriety and recovery, by supporting and reinforcing their efforts in the Program while helping them to fully integrate those changes into their functioning life. At the end of reading this text, students and clinicians alike will understand the core concepts of 12-Step Programs, learn ways of utilizing the language of those core concepts in therapy, and be able to integrate basic psychological assessment and treatment of substance dependent individuals within a 12-Step frame of the first three Steps.

Please understand, this book is only a general introduction to working with addictions. There are many related topics a clinician should master prior to considering themselves adept with this client group. One of these topics is behavioral addictions, also called process addictions, such as gambling, sexual, or eating addictions. Although many of the concepts we discuss here are directly applicable to those with behavioral addictions, the treatment of these disorders is not a focus. Also, we are not focusing on specific issues related to multicultural psychology or working with specialized populations. All of these topics may be addressed in future volumes, but for now, the focus is on a more generalized approach to working with the chemically dependent.

Finally, please note that this book is about those who meet the aforementioned criteria for substance dependence. Only a little time will be spent focusing on those who remain at a level of substance abuse. Many of the techniques discussed here can be useful with those who are at a level of abuse, but in many ways this is a related but separate disorder. As such, the treatment of abuse extends beyond the scope of this text. It is recommended that any reader who wishes to work with substance-abusing clients obtain additional training beyond this text.

A BLENDED APPROACH: INTEGRATING 12-STEPS AND THE PSYCHOLOGICAL UNDERSTANDING OF ADDICTION

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Context Is Everything: A Primer on the Etiology of and Use of the DSM-IV

The notion and use of assessment in psychotherapy is not without controversy. Some schools of thought, in particular cognitive-behavioral approaches, see assessment as a crucial part of treatment as it informs the clinician what interventions should be provided, as well as giving a benchmark where the effectiveness of treatment can be measured and proven. Philosophically, this approach is very similar to the medical model as described by R.D. Laing in 1971 (Laing, 1971). In the medical model, disease is seen as a result of a disruption of the normal physical functioning of the body, resulting in symptoms. The disease process must be identified or diagnosed through the examination of the person and their history, and it is this diagnosis that guides the treatment. These treatments are then applied in the hope of achieving a cure, thereby signaling the end of the disease process. The DSM-IV operates under this model.

Each edition of the DSM, beginning with the third edition, has taken a syndrome approach to understanding diagnoses. This means that the diagnoses are based on a collection of symptoms that are seen as tending to occur together. Each DSM diagnosis is a grouping of symptoms that are most frequently observed in that particular troubled population; for example, symptoms of depression. The DSM does not generally identify the cause, best treatment, or prognosis for each diagnosis. In fact, the DSM quite explicitly does not attempt to do so. To quote the American Psychiatric Association (APA), document, “A Research Agenda for DSM-V,”

In the more than 30 years since the introduction of the Feighner criteria by Robins and Guze, which eventually led to DSM-III, the goal of validating these syndromes and discovering common etiologies has remained elusive. Despite many proposed candidates, not one laboratory marker has been found to be specific in identifying any of the DSM defined syndromes. Epidemiologic and clinical studies have shown extremely high rates of comorbidities among the disorders, undermining the hypothesis that the syndromes represent distinct etiologies. Furthermore, epidemiologic studies have shown a high degree of short-term diagnostic instability for many disorders. With regard to treatment, lack of treatment specificity is the rule rather than the exception … few question the value of having a well-described, well-operationalized, and universally accepted diagnostic system to facilitate diagnostic comparisons across studies and to improve diagnostic reliability. However, reification of DSM-IV entities, to the point that they are considered to be equivalent to diseases, is more likely to obscure than to elucidate research findings. (2002, pp. xvii-xix; Reprinted with permission from A Research Agenda for DSM-5, (Copyright ©2002). American Psychiatric Association)

Without doubt, this quote nicely details that the DSM-based diagnostic system is highly flawed. So why do most providers rely on it? The reasons for its utilization are as varied as the psychological profession itself. For many providers, usage of the DSM-IV helps provide a standard language for communication across the psychological/counseling/social work fields, helps organize research, insurance companies require a DSM-IV diagnosis for providers to receive payment for services, and/or it is perceived as better than any alternative system.

There are additional reasons to consider using the conceptual framework embedded within the DSM diagnosis. With respect to addiction; a diagnosis of dependence is useful in that it communicates that a person’s substance use has shifted to a qualitatively different level in comparison to a nondependent substance use or abuse pattern. This is a helpful differentiation for treatment providers. In particular, it is generally recommended that for most substance dependent individuals the goal of complete sobriety is likely the best, if not the only, treatment goal. For those who have not crossed the line into dependence, other treatments that allow continued substance use, albeit at a reduced level, may be an appropriate goal. However, once a client crosses the line into substance dependence, their treatment often shifts as well.

For this reason, until a superior model is accepted the writers strongly recommend that clinicians assess and rely on the DSM-IV diagnoses for substance related disorders. The DSM-V is slated to rework a good portion of the sections on substance disorders. There are current proposals under consideration for the substitution of the term “addiction” for “dependence,” and “use” for “abuse,” along with expanded criteria selection and the addition of a severity index. To date, the permanent adoption of these changes is not final; however, the DSM-V is slated for completion and release in May 2013.

The DSM system is expedient, but the authors also wish to impress on the reader that use of the DSM system can in many ways be seductive and encourage laziness. It is easy to forget the variety of limitations of the DSM system (a lack of proven inter-rater reliability comes to mind); instead, we accept its simplicity and clear-cut decisiveness for efficiency. Haven’t we all heard, at least once, a fellow clinician pronounce that a client is “substance dependent,” as if that somehow clarified the client’s clinical picture? In many ways, that diagnosis in and of itself is of only limited value. Although we concur that there is some useful information that is ...

Table of contents

• Cover Page
• Title
• Copyright
• Brief Contents
• Detailed Contents
• Acknowledgements
• Chapter 1: An Integrated View: Comparing 12-Steps and Psychology
• Chapter 2: Examining the Components of a 12-Step Program: The Benefits and Criticisms
• Chapter 3: A Clinical Perspective on Why 12-Steps Is a Useful Tool for Reversing the Damage Wrought by Substance Dependence
• Chapter 4: A Primer on Therapeutic Practice with Substance Abuse Clients
• Chapter 5: Assessment Considerations and Techniques
• Chapter 6: Therapy Considerations and Techniques
• Chapter 7: Hitting Bottom
• Chapter 8: Substance Dependence—A Relapsing Disease
• Chapter 9: Step One, the Journey Begins
• Chapter 10: Step Two, the Journey Continues
• Chapter 11: Step Three, the Journey Becomes Purposeful
• Chapter 12: An Afterword for Experienced Clinicians Beginning Work with Substance Use Clients
• References
• Index
• About the Authors