|
|
|
|
|
|
|
|
|
As the 12 steps are so often framed in terms of religious/spiritual process, relatively little has been written on them as fostering specific changes in meaning or perception. In fact, where spirituality is lacking, or a readily identifiable higher power is untenable, understanding the steps as providing specific perceptual changes may be extremely useful. Indeed, in the spiritual context the same reframes will help the recovering addict in his or her search for stability.
The heart of this discussion is the question, "What is the conceptual change that must be fostered to accomplish the short term goal appropriate to this stage?" This is rooted in the idea that the steps must ultimately mediate changes in the addict's understanding of the world in order to be maximally effective. For the sake of brevity we will examine only a few of the meanings that can be used to enhance the efficacy of 12 step interventions.
Step 1-- The admission of powerlessness: We admitted that we were powerless over alcohol or addictions--that our lives had become unmanageable.
The 12 step programs begin with the idea that there are substances, practices or ideas over which the addict has lost control. Indulgence in them inevitably leads to a downward spiral of abuse and loss of control. This perspective gives rise to the disease concept of addiction.
The disease concept holds that addiction is a progressive and ultimately fatal disease. Indulgence in the addictive substance, whether, sugar, abusive behavior, co-dependency, or drugs and alcohol leads to the reassertion of diseased patterns of ideation and physiological craving. From this perspective, absolute abstinence is the only answer.
Insofar as it is only used as a means of impressing upon the individual that there is a physiological and/or psychological propensity for the abuser to lose control over the abused substance, the disease model is quite useful. Some of the older materials from the Hazelden Foundation Laundergan, 1982) rightly referred to the "disease metaphor." Operationally, the disease metaphor represents an initial awareness that there are places, persons, attitudes, behaviors, and substances which I cannot handle and would do well to avoid. It also implies that, just as life has become unmanageable through the addictive substance or behavior, so it might also be restored to sanity through some process including the avoidance of that substance or behavior. The crucial idea here is this: I can't handle it. I shouldn't try and I should also learn to keep my distance. This is a simple and useful message.
So long as the emphasis remains on avoiding the substance the idea retains its utility. Unfortunately there is a tendency to emphasize the disease in such a way that it diverts from the real utility of the model. If we posit an addictive mind set that includes a manipulative tendency, there are fewer excuses that are more accessible than "Poor me, I suffer from a disease."
Among the consistent problems with the disease model of addiction is the temptation for some people to reject the concept outright and for others to attempt to use it in their manipulative strategies. In either case, the individual focuses upon the idea of disease as weakness. On the one hand it is destructive to self esteem--"I am diseased"-- on the other it creates a ready excuse-- "I can't help it, I have a disease." The concept, however, is easily restated in terms of biological propensity which provides neither the excuse to abuse nor the image of disease.
Gregory Bateson has suggested that addiction is more like acclimation to extreme environments than it is to a disease. It is, in fact, an evidence that the individual addict's body is functioning exactly as eons of evolution have determined it should. In fact, from this perspective, the addiction becomes a proof positive of the potential for future healthy behavior.
The argument is this: If you were to travel to the high Andes in South America and immediately encamp at the 10,000 foot level, most lowlanders would experience significant difficulty in breathing. Adapted as we are to atmospheric densities at or around sea level, our breathing would become labored, our hearts would beat more quickly, we would tire easily. After several weeks in that environment, our bodies would change. Our blood would thicken with red corpuscles, our lung capacities would expand, our heart would grow accustomed to the new load. In short, given enough time, our bodies would adapt to the new conditions.
Should we return to the lowlands, our bodies would gradually return to their original state. However, having once adapted to the mountain life, each return to the environment of the highlands would require less and less time for our bodies to adjust. Theoretically, the speed of the adjustment now becomes limited only by the extent of the physiological adaptation required. Each time the trek is made, the body adapts perfectly to its new home.
Addiction is no different. Both alcohol and other drugs represent a change in the body's chemical environment. Once a crucial threshold of interaction is passed the body begins to adapt to the new environment. Each return is characterized by a streamlining of the adaptation until the time comes where the change is nearly instantaneous. This is not disease. It is the body rising to protect itself and adapt to a new facet of the environment. As such, it is evidence of the individual’s capacity to adapt, to change, and to grow (Bateson, 1972; Delozier and Grinder, 1987)
In this light, the addictive process becomes evidence of the capacity to change. While the change that has been learned --the addictive behavior-- is unhealthy in its consequences, it is living proof of the organism's own vitality and capacity to learn. Generalizing from this example, the addictions counselor and the client or offender can now derive hope for future change from the problem itself. If I can learn to be addicted, I can learn to be unaddicted, or at least to change. The successful reframe of the addictive process becomes a tool for future change.
A similar attempt is made in the basic AA literature where Bill Wilson attempts to redefine alcoholism as an allergy to alcohol. This has two problems. First, it is biologically spurious. While it is obvious that Bill W. intended it as a metaphor, the people who use the image often believe it literally. If they are ever confronted with the truth, this could lead to unnecessary confusion. Second, the allergy metaphor does not provide positive imagery that can be used to reintegrate the abuser into a normalizing self-definition. This is one of the benefits of the acclimation metaphor.
The reinterpretation of urges follows closely upon the redefinition of addictive process as normal biological function. Whereas the common wisdom advises that the addict must fight the urge and that it is somehow wrong to want the drink or the drug, the appropriate reframe reveals the urge as perfectly normal. The urge is further evidence that your body and mind work just the way they are supposed to. Once again, a crucial part of the reframe is to transform the relatively normal craving into an ally for use in the change process.
Recently, a client came to me and complained that he felt bad because he couldn't get the thoughts of drug abuse out of his mind. He often found himself thinking about drugs, and no matter how hard he tried, the thoughts kept returning. He felt terrible.
I responded, "What do you expect? How long have you used heroin?" He reported that he had been using it for 6 months at the rate of $40 or $50 per day, with a much longer history before that. "Well," I said, " for six months you have been anaesthetizing your body, wrapping your mind in a cocoon of quiet bliss, and now, now that you've exiled yourself back into the real world of pain and suffering and real problems, you're surprised that you want to return to the drugged state?" "Wouldn't it be far more surprising if you didn't want it?"
In addictive studies, we have placed great emphasis on the idea of denial. Here is a serious level of denial-- the denial of the relative normalcy of the addictive urge. When the urge is expected and dealt with, it becomes far less powerful.
Step 2- Acknowledgment of a higher power: We came to believe that a power higher than ourselves could restore us to sanity
For some people, a significant problem with step-based programs is the idea of a higher power. For many, the higher power has become associated with the western idea of God. Whether appropriately or inappropriately, committed Christians gladly express their personal faith in the forum of the AA or NA meeting. For addicts who do not share a similar faith, the idea of a higher power often becomes offensive because there is relatively little religion-neutral information that is not drowned out by the almost evangelical fervor of those committed to a higher power associated with a mainline belief system.
The idea of a higher power is, however, easily secularized. At root, even Bill W. and Dr. Bob recognized that the higher power could be something as near and familiar as the program, the meeting, or other external and, presumably, benevolent entities. On a more abstract level the higher power may be understood as the universe whether conscious or unconscious, or Tao, especially the Tao of stepping.
In practice, the 12 step programs are strongly oriented towards standard Western Spirituality. For all of the possible philosophical and logical extensions that can be made from their logic, without a foundation in classic Christian Spirituality it may often be best to move to a different approach altogether.
The idea of a higher power, although drawn from the experience of evangelical Christianity experienced by the founders of AA, is philosophically reducible to the idea that no problem can be solved from the same logical level at which it is formulated. This means that for every problem we face, we need information from someone or something that can look at the entire problem from the outside, from another perspective. Without information from this new perspective, the problem cannot be solved.
In the logic of recovery, the problem formulated in addiction must find an answer in a life that has either overcome addiction or otherwise lives beyond that state. Thus, a higher power may be the combined wisdom as it appears in sponsors and sharing in the rooms. It may represent the communal wisdom of the founders as presented in the steps, traditions, and Big Book. It may as legitimately be a set of behavioral interventions that were otherwise unconnected to the principles of AA/NA but which have a proven track record. Behaviorally, the crucial element in the idea of a higher power is an appeal to an authority that has overcome,or gone through the place where we are now. Freed of our own blindness, the higher power is trusted to provide the wisdom and guidance that is necessary to get us through.
For many African American addicts the redefinition provided by an historical non-American identity in Islam becomes a significant higher power and whole-life reframe. For others, the rigors of a martial arts or a health regimen can serve the same purpose. More conventionally, a return to one's childhood religion provides a perfect psychosocial background and impetus for change.
Prochaska, et al.(1994), Peele and Brodsky (1991), and others have asked the significant question, " What better source of recovery information could there be than the large group of recovered substance abusers that have turned from their problems without external assistance?" In their models, the techniques used by the estimated 85% of substance abusers who are self-changers provides a significant source of wisdom. This and similar bodies of collective wisdom may legitimately be thought of as providing the basis for a non-spiritual higher power. In fact, the recently completed and seriously flawed Project Match (Miller, et al., 1995; Peele,1996), found that AA, cognitive interventions, and motivational interviewing were equally outdone in efficacy by groups provided with Prochaska, Norcross, and Di Clemente’s self help book, Changing for Good. Thus, higher powers may even be conceived in terms of systems far removed from standard AA/NA doctrine.
The higher power can be understood in terms of one's higher self. In Joseph Campbell's worldview, following one's bliss, one's innate call in life, can serve some of the same purpose. Here the original impetus towards self-realization leads the seeker into a discipline which is not only inherently self-reinforcing, but carries with it a set of ethical or practical demands which may serve as a positive rule of life (Campbell 1988).
In Jungian psychology the pull towards self realization (or individuation) represents a similar impetus to change. Here, the integration of the Self, often in the context of a call or meaningful life-roll, also takes on the dimensions of a higher power. Jung, in fact, questions whether God is a reflection of the Self, or the Self a reflection of God. Either perspective provides an acceptable means of conceptualizing the higher power.
Personal definitions of higher powers can change over time. Where one begins with the literature or the group in early recovery, as time goes on, one may later develop a strong affinity for a specific philosophical, religious, or ethical system. Working through the steps can often resolve resentments, fears, and reservations that make new ethical commitments possible. Wherever positive direction and tools for personal growth are provided, one may legitimately identify a higher power.
From a completely different perspective, the higher power may be legitimately framed as a confronting reality, one that changes the meaning of life. This reality may be either transcendent good, transcendent evil, or the reality of "bottoming out". In this instance the ideas of powerlessness and acknowledgment of the higher power are closely linked. Indeed, depending upon the individual's experience of the process of recovery the stages of change may be indistinct and not follow a 12-step model at all.
Step 2a-The recognition of the possibility of normalcy: We came to believe that a power higher than ourselves could restore us to sanity
Prochaska, Norcross, and DiClemente have shown conclusively that recovery from addiction is strongly correlated with a shift in emphasis away from the negatives associated with giving up addiction and towards the positive aspects of a sober lifestyle. In their study, Changing for Good, they report that, in the movement from precontemplative denial to action, a stage signaling readiness for change, their subjects made a decisive move from emphasizing the negative aspects of change to an emphasis on the positive aspects of sobriety.
The important lesson here is that change is a positive move, not a negative one. By emphasizing the negative, one succeeds only in eliminating options. Change strategies that emphasize the negative are essentially directionless and literally paint one into a corner. On a practical level, change stated in the positive sets goals that are both accessible and meaningful. A clearly defined goal allows clear choices and the clear statement of stages towards reaching that goal. When goals are stated negatively, "I don’t want to drink and drug any more" they fail to provide a tangible goal. Negative goals allow any answer.
One of the problems that consistently dogs the drug treatment professional is the manner in which he or she is going to deal with slips. Slips, as differentiated from actual relapses are relatively isolated episodes of drug abuse. They may or may not imply serious problems and may or may not signal the onset of a significant relapse. Ideally they are to be reframed as opportunities for learning, yet there is always the fear that doing so can come perilously close to facilitation of drug abuse.
Counselors and therapists who want to remain totally "up-front" with clients often discuss at the outset their expectation that there will be slips. Others, fearful of providing an excuse, do not acknowledge the possibility. In the law enforcement context of mandated clients the problem is especially difficult. At what point does one say enough is enough and impose sanctions without destroying any hope of meaningful treatment. Here, three-strike rules become especially problematic.
Unlike some of the other positions in recovery, the realm of slip and relapse is less amenable to blanket styles and therefore requires serious case by case consideration. Redefining the slip in terms of a learning experience is the obvious and most useful transformation.
The advantage of turning the slip into information should be obvious. All of his or her career, the addict has been taught to hide, ignore or feel guilty for their slips. They may have been threatened with consequences and, true to their addictive process, continued anyway. Now, having failed once again, they expect to be reviled, castigated, or made to feel ashamed. How refreshing for them to find an ally in treatment who seeks information for future empowerment. It is important to remember that many studies have shown that confrontational styles are highly correlated with lessened success in treatment (Peele, 1996). Conversely, positive, self-affirming approaches (efficacy) are highly correlated with success (Miller, et al., 1995).
Properly handled, the slip becomes an opportunity to clearly observe the process of temptation, choice and failure, identification of triggering events (people, places, things), and the development of a real conscious acknowledgment of the process of "picking-up."(Washton and Stone-Washton, 1993; Rawson, Et al., 1993).
A significant problem with reframing the slip comes out of the the strongly negative character of the classical literature from AA/NA that emphasizes the power and subtlty of the disease. For whatever truth value they possess, the strengthening of faith in the power of the urge and the :disease " can make each slip an inevitable fall. Conscious efforts should be made to limit the power of such suggestions.
It is sometimes difficult to remember that consequences are often lost on addicts. How many times have the warnings of well meaning friends failed to have any result? Why should they start now? From this perspective, the addict, rather than being confronted by another consequence which would feed the old process of denial and flight into addictive process, now receives tools, choice and acceptance. The message is that someone may, in fact, understand.
Many patients complain of the continual rehashing of drug and alcohol experiences in group discussions and how the "war stories" seem to stimulate rather than quell their urges. In these cases, the patient can be given an explanation of the process of desensitization/reciprocal inhibition as it applies to addictive process.
Part of the wisdom of the recovery group is the opportunity it provides to experience minor episodes of temptation and reminiscence without acting on them. In producing this experience the group becomes an exemplar of the desensitization process.
Desensitization is the psychological process of extinguishing or depotentiating a negative or unwanted stimulus. Through this process phobias can be cured and urges can be disempowered. Desensitization works by introducing tolerable amounts of a noxious stimulus into an overwhelmingly positive circumstance. Relaxation is often used with threatening or disturbing stimuli. Once the positive state is entered or made accessible, the problem is introduced at a non threatening level.
In classical form, desensitization follows the pattern of the following story:
During World War II, My father was stationed in Sri Lanka. Unfortunately for a man stationed in a jungle paradise, my father had a fear of spiders. More often than not his fears were manifested in nightmares and accompanied by blood-curdling screams. The camp was regularly awakened by his terrors, and he would awaken from the dream surrounded by fellow GIs. The dream, a recurrent one, took this form: There was a hole in the wall. From the hole there emerged a large black spider with glowing red eyes. As the spider approached, it grew in size and his terror grew. Finally, paralyzed with fear, he would struggle to scream and the dream would end. Having been embarrassed on several occasions by these night terrors, my father undertook a project to overcome his fear. Convinced that if he could drive the spider back into his hole, the dream would end, he performed the following exercise. Sitting in a comfortable chair, he entered a deeply relaxed state and imagined the dream scenario: the room, the wall, the hole. He then imagined the spider, still small as it began to emerge from the hole. Under these circumstances, his level of discomfort was relatively small, so he allowed the spider to emerge far enough to become slightly uncomfortable. He then imagined himself driving the spider back into the hole. With a little effort, the spider fled into the hole and my father was never again bothered by the dream.
Groups ideally provide a place of safety. A place where an individual can express their experience of life and receive support, direction, or understanding. Due to the sharing, the tradition of anonymity, and the fostering of community in NA/AA style groups, individuals should feel a certain degree of support while in the meeting. Moreover, if the individual has developed a network of support, including a sponsor and other allies, these individuals should become a primary setting for the defusing of especially problematic feelings and emotions. When disturbing materials arise, there should be enough support within the group to either allow the individual to express their concerns or to have someone near enough to talk them out.
Proper group process calls for a debriefing or the addressing of the issues of the war story before the group ends. In facilitated groups, it become the leader’s responsibility to move the group into positive discussion of means for dealing with the situations which may have been brought up in the presentation and for eliciting countering strategies for temptations that may have been aroused. In non-facilitated groups, older members should take responsibility for the same kinds of responses. Minimally, each individual should be encouraged to express their misgivings regarding the war story and their personal reaction to it.
These are considerations that need to be discussed with the recovering addict. He or she must be taught how to understand the group and how to use it. Without guidance, which, one would hope, is provided by a sponsor or an old-timer, people often fail to make the connection with the process and are left to tough it out alone (Peele and Brodsky, 1991).
Addictions may be conceived in terms of meaning structures. As meaning structures, addictions and their subcomponents are subject to redefinition. These reframes or changes in the structure of meaning are some of the crucial tasks in guiding an individual through recovery. Through the use of personal flexibility and imagination, the substance abuse treatment professional can reframe the meaning of events and perceptions in such a way as to enhance the process of recovery.
|
|
|
|
|
|
|
|
|