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Category Archives: Essays

Alcohol in the Third World

THE MOST SENSIBLE THING IS NOT TO DRINK

By Shanthi Ranganathan

Abstinence from alcohol is a value which is deeply rooted in Indian culture and religion, and as such is the only approach to drinking that could be called “sensible” in this country. Hinduism has the largest following in India, and in the Hindu scriptures drinking is referred to as one of the five heinous crimes, which include murder and adultery. According to the laws of Manu it is a sin to consume alcohol, and the only way to atone for it is to have the image of a liquor bottle branded on your forehead. The ancient Tamil poet, Thiruvalluvar, whose work entitled THIRUKURAL offers some foundations for ethical values in society, also condemns alcohol, calling it a social evil and equating a drunkard to a dead body.

The Indian Constitution strongly endorses the principle of prohibition, a concept that was first introduced by Mahatma Gandhi, and total prohibition throughout India was imposed in 1977. It only lasted for two years but the State of Tamil Nadu was “dry” for a total of 23 years, and the State of Gujarat still is. In addition, some states have partial prohibition in the form of a ban on “country liquor”. Even today it appears that most Indian women favour total prohibition, and politicians often advocate some form of it to win their vote.

It is illegal to advertise alcoholic beverages in India, and they do not have a cultural role to play in religious and social activities. Thus it could be said that there is quite a strong “supportive environment” for abstinence here. The modern trend towards serving alcohol at parties reflects the influence of Western culture and is limited to small pockets in urban areas. The large majority of Indians still live in the villages. Furthermore, annual per capita income in India is less than US$ 160, which means that alcohol is a luxury few can afford. For most, it can only be bought at the expense of basic necessities.

Not surprisingly for a country in which the doctor-patient ratio is 1 to 2310, the health services are focused on providing bare essentials such as immunization. When questions of alcohol consumption do arise, the answer is usually simple: “Don’t drink”. Religiously, culturally, socially and economically it is the only answer that makes sense. In other words, for an average Indian abstinence in not a matter of choice but an imperative.– Shanthi Ranganathan

Mrs Ranganathan is Honorary Secretary of the TT Ranganathan Clinical Research Foundation, at TTK Hospital, 17 IV Main Road, Indira Nagar, Madras 600 020, India. Excerpted from WORLD HEALTH FORUM (World Health Organization) Sept. 1994.

Alcohol: a “Gift” of Christianity and European Influence
(Original title: LIVE SENSIBLY, THE REST WILL FOLLOW)

By N.N. Wig

My own experience in India and later in many countries of the Eastern Mediterranean Region, has amply convinced me that alcohol drinking has a different meaning in different countries and also within different communities in the same country. The three major religions with which I have some familiarity, Christianity, Islam and Hinduism, seem to have differing views on the subject. While excessive indulgence in alcohol is condemned by all religions, Christianity seems to be more liberal in accepting its use for social purposes while Islam totally rejects it. The Hindu position lies somewhat in between. Their scriptures generally disapprove of alcohol consumption but seem to condone its occasional use by certain classes of people such as kings, nobles, warriors and manual workers but prohibits its use for priests, students and those seriously following a religious way of life.

When the British and other European colonial powers came to India in the eighteenth and nineteenth centuries, cannabis and opium probably enjoyed more popularity as the drugs of recreation than alcohol. However, under the patronage of British rulers, the popularity of alcohol started increasing. In the public’s mind, alcohol soon got associated with the Western way of life. In the days of the freedom struggle in India, the opening of liquor shops by British rulers was seen as a form of exploitation and was strongly resented. At the time of Independence in 1947, India boldly wrote in the directive principles of State policy in the Constitution that “the State shall endeavour to bring about prohibition of the consumption of intoxicating drinks”. Unfortunately, even the written provision in the Constitution of the country has not been able to prevent the rapid increase in the consumption of alcohol in India during the last few decades.

It seems that most of the developing countries in Asia and Africa have had a similar experience in the matter of alcohol consumption during the last hundred years. Originally, alcohol was not such an integral part of the social scene in most of the countries of Asia and Africa as it was in the Christian communities of Europe, but now it has become very much associated with the concept of “Westernization” and “modernity”. Condemned and regarded as something alien to local cultures a century ago, it is now fast becoming “the in thing”, a sign of social sophistication and a symbol of prestige. Most of the developing countries have now set up their own breweries and distilleries, and the tax on alcohol is a major source of revenue for many of them. High-pressure advertising by the alcohol companies further speeds up the trend.

Barely three decades ago, less than 1% of the cases in psychiatric wards were admitted for alcohol-related problems; now the number exceeds 20% in most of the major psychiatric centres. The position in many newly independent countries of Africa is equally bad or worse.

Thus, in spite of the past social stigma and serious cultural reservations, the use of alcohol has gradually spread to most of the communities in developing countries, except perhaps in the Islamic countries of the Middle East. Since there are no previous cultural norms in this area to refer to, there are no clear social guidelines about when, where and how much to drink. We are witnessing a bewildered social response, usually of an extreme kind. While reformers keep urging a total ban on alcohol, the common people are drinking more and more. Also, people are drinking not so much for social enjoyment as to get intoxicated. It is in this context that I see the relevance of the concept of “sensible drinking” in developing countries–an idea whose time seems to have come. The rapid social change has already overtaken us. The old debates and old solutions have become irrelevant. The first battle to be won in developing countries is to accept the reality of alcohol drinking in our societies, so that we can approach it realistically.

The choices are very hard for developing countries. Any general condonement of drinking alcohol seems sure to increase the number of heavy drinkers. On the other hand, it is equally dangerous not to educate our youth about how much to drink, when we know that very soon they are likely to drink recklessly, especially if uninformed about the consequences. The solution is somewhat similar to the dilemma of sexual education in AIDS programmes. Sexual education may encourage promiscuity and disrupt traditional societies but unsafe sex can lead to the death of our children.

Before we move further in popularizing the concept of sensible drinking, there are many hard questions to answer. Can we isolate drinking behaviour from other personal behaviours? In non-European cultures, in popular imagination, alcohol has become linked with other features of Western lifestyle which give high priority to the pursuit of personal pleasures in life, personal freedom in sexual matters, unlimited consumption, assertiveness in social relations, etc. Can we put a control on drinking behaviour without controlling other aspects of human behaviour? Furthermore, should drinking of alcohol be left only to the discretion of the individual as a private matter or should society set the norm? How much alcohol is good for the individual? Should this be governed by rules made by science or by rules made by religion?

Obviously the answers to such questions will vary according to different cultural perceptions and expectations. Islam has already taken a clear position in this regard. Other cultures have to evolve answers depending on their past history and traditions. Ideas like “sensible drinking” will succeed only if they are conveyed as part of larger programmes of public policy and health education in which moderation in all spheres of human behaviour is accepted as a basis for healthy life, and where the growth and happiness of other members of society are seen to be as important as one’s own. In the matter of personal behaviour, probably science alone cannot set all the rules. Sensible drinking can only be a part of sensible living.

Dr Wig is former Professor of Psychiatry at the All India Institute of Medical Sciences, New Delhi, and former Regional Adviser in Mental Health at WHO’s Eastern Mediterranean Regional Office. His address is 279 Sector 6, Panchkula, Haryana 134109, India.

The Alcoholism Revolution

By James R. Milam, Ph.D., Clinical Psychologist

From: Professional Counselor, August 1992.

This conformity makes them not false in a few particulars, authors of a few lies, but false in all particulars. Their every truth is not quite true…so that every word they say chagrins us and we know not where to begin to set them right. — Emerson

No problem in America has been more costly in lives, misery and money than alcoholism, and no problem has generated more stubborn conflict and confusion in all areas of society. In a historic development during the 1970s, the intense focus on alcoholism research exposed the underlying polarity, the clash of irreconcilable premises that has always generated so much conflict. Although not yet widely known, by the early 1980s this root conflict had been resolved by a scientific and professional revolution, a paradigm shift.

This paper describes the polarity and the shift to the new model that is transforming our entire view of alcoholism (and other drug addictions). I have adapted the terms “psychogenic” (of psychological origin) for the old paradigm and “biogenic” (of biological origin) for the new.

The psychogenic model is based on the nearly universal belief that alcoholism is a symptom or consequence of an underlying character defect, a destructive response to psychological and social problems, a learned behavior. The biogenic model recognizes that alcoholism is a primary addictive response to alcohol in a biologically susceptible drinker, regardless of character and personality. It will help at the outset to realize that compromise is not possible, that the two are not complementary but mutually exclusive alternatives, like a perceptual figure-ground reversal.

The contrast between the two paradigms can be illustrated by Robert Louis Stevenson’s classic parable of addiction, “Dr. Jekyll and Mr. Hyde.” In the psychogenic view, the insane, murderous Hyde is the real person, with Jekyll merely a facade. It taps deep currents in American thought–the notions of original sin and the Freudian Id–that beneath the inhibiting veneer of civilization man is inherently evil. Alcoholism merely releases this deeper ugliness by removing the inhibitions. In vino veritas [in wine is truth]. The task of therapy is to engage and civilize Hyde. Treatment fails because the contemptible Hyde is willfully incorrigible. He deserves the stigma and scorn of society.

Within the biogenic paradigm Jekyll is the real person, Hyde a neuropsychological distortion created by the addictive chemical. Hyde exhibits the same kind of deterioration of personality and character as victims of such other progressive brain pathologies as brain syphilis or a brain tumor. Body, mind and spirit (including will-power) are biologically compromised and subverted to serve the addiction. Given time for the healing, in alcoholism the brain syndrome is reversible. The task of therapy is to restore Jekyll to sanity and selfhood, and to start him on a path that will preclude a return to the addictive, transforming chemical.

Although it is conformity to the psychogenic belief that continues to distort and falsify all scientific and clinical knowledge of alcoholism, as the given truth throughout history it has had the advantage of being invisible, of not appearing to be a belief system at all, but simple reality. This was the fatal flaw in the Jellinek “disease concept” of alcoholism. For all his helpful descriptions of the progression of the disease, he endorsed the false belief that alcohol is primarily a sedative drug, and that alcoholism is caused by excessive “relief drinking,” drinking to relieve psycho-social stress. Thus, as a secondary consequence or symptom, the biology of alcoholism could be largely ignored by the establishment in its diligent search for the presumed primary psychiatric cause of the relief drinking.

Following Jellinek, many leading proponents of the disease concept still try to have it both ways, to assimilate the fragments of biological knowledge within the lingering psychogenic hegemony. This conformity necessarily condones the misinformation that continues to tear the country to pieces and helps to delay the emergence of the biogenic paradigm.

RESEARCH

By 1960, research studies had determined that the rate of mental illness among predrinking alcoholics was the same as among nonalcoholics. During the 1960s and 70s, a great many additional research studies confirmed that the defective character, the mental illness of alcoholism, is not primary, or underlying, or a “dual diagnosis,” but the neuropsychological consequence of the alcoholism.

When controlled for heredity (abundant independent evidence makes this mandatory), no predrinking psychological or social variable of any kind could be found to correlate with later alcoholism–not child abuse, depression, antisocial attitude, poor self-image, or any other. These problems are familiar consequences and complications of alcoholism, but research clearly showed they are not contributing causes or “risk factors.” Also, the persistent belief in an “alcoholic (or addictive) personality” was found to be false.

The search was broadened in the vain hope of finding some other kind of evidence to validate the psychogenic paradigm. None could be found. Responsible drinking could not prevent alcoholism, and alcoholic drinking could neither be learned nor unlearned. All prevention and treatment efforts to modify the alcoholic’s progressive response to alcohol failed.

Deep, broad, and powerful vested interests in the philosophy of environmental determinism were increasingly threatened by the mounting evidence against the psychogenic paradigm. In their desperate effort to forestall its collapse, defenders of the paradigm resorted to an increasingly blatant double standard, a kind of artificial life support system. Editors, reviewers, critics, and other guardians of the academic alcoholism literature increasingly rejected, distorted, minimized, lacerated with extreme criticism, and ignored–one at a time–the thousands of research and clinical reports that, only when allowed to freely come together, form the biogenic paradigm, a complete definition and explanation of alcoholism.

In contrast, thousands of inadequate, shoddy, or even fraudulent studies were uncritically approved and widely cited if they but seemed to support the psychogenic premise. As an aid in warding off the troublesome biogenic research evidence, alcoholism was renamed “alcohol abuse,” a psychogenic term of moral censure. The word “addiction” was then degraded and stripped of its profound biogenic meaning by applying it to all manner of excessive or repetitive behaviors. Of course it became impossible to identify or diagnose alcoholism and many researchers resorted to drink counting instead, with arbitrary amounts of consumption to identify alcohol “abusers.” Alcoholism was trivialized out of existence as the academic literature became a literature not about alcoholism but about itself.

In spite of this concerted attempt to disguise the fact, by the early 1980s the psychogenic premise had been totally discredited and dismantled by legitimate research. This is the documented conclusion of, among others, one of its most distinguished former advocates, philosophy professor emeritus Herbert Fingarette. It is only from the biogenic perspective that his landmark contribution can be fully appreciated.

In 1988, in his notorious book, “Heavy Drinking,” Fingarette declared, from within the psychogenic paradigm, there is no such thing as alcoholism. In his world he was right. The biogenic model has never been assembled within the academic alcoholism literature because it is impossible to do so. Its parts are either distorted or missing. With no direct clinical experience of his own, Fingarette’s 15 year investigation was limited to what he found in this mandarin literature, and he didn’t find alcoholism. He unwittingly wrote the obituary not for alcoholism but for the psychogenic paradigm in which alcoholism in fact does not exist.

There is wry humor in this whole academic spectacle. It has been a kind of acting out on a grand scale of the old joke about the specialist: one who learns more and more about less and less until eventually he knows everything about nothing. But these misguided academic reveries have had devastating effects on public understanding of alcoholism. For example, with Fingarette as its official consultant on addictions, the United States Supreme Court wistfully argued in 1988 that “…apparently nobody understands alcoholism…it appears to be willful misbehavior.”

Overshadowed by the multitude of researchers who were busy confirming that the psychogenic paradigm is devoid of any data base, many others were quietly compiling evidence that alcoholism is a primary, biogenic disorder. However, the task of assembling the biogenic paradigm is elusive and difficult because not only the academic literature but the whole of society has been limited by the psychogenic view. It is impossible to see out of it. As Thomas Kuhn explained, and Fingarette demonstrated, a new paradigm and its supporting evidence are invisible from within the old. Be forewarned that because the dominant premise is false, “…every truth is not quite true.” It is impossible to assemble this myriad of half-truths into a coherent perception of alcoholism.

To discern the biogenic model, a substantial amount of valid research evidence and clinical knowledge must be winnowed from the psychogenic chaff in the alcoholism literature, and gleaned from original sources scattered throughout the life sciences. It can then be transformed and assembled in the new biogenic configuration, much as all knowledge of geography and navigation were transformed for the earth to become a globe after being flat for so long. No flat fields were lost, but it was necessary to ignore them long enough to form the new model. Once the global perception came together there was a certainty and finality about it, which to those still in the other paradigm seemed totally unjustified by the obvious facts. It couldn’t be helped. The flat earth was gone.

Similarly, the biogenic paradigm includes and is shaped by all valid knowledge of alcoholism. It has an extremely broad data base. Nothing is forced in or left out to argue about. And because all parts are valid, the whole is also validated by internal consistency. It is not a philosophy or a theory. It is a new gestalt, a compelling total perception.

Data is found in many areas in many disciplines. Both animal and human studies have shown repeatedly that alcohol addiction is hereditary. A number of inborn, predrinking biological differences have been discovered in alcoholics, along with many initial and progressive differences in their biological responses to alcohol. Differences have been found in brain wave patterns, in various enzymes, in nerve transmitters, in liver functions, in alcohol metabolism, and in the effect of alcohol on performance, mood and mental abilities.

The problem is not a shortage of data as frustrated researchers suppose, but the fact that they have not been able to integrate the abundance of scattered data. Both gathered and viewed within the compromising psychogenic paradigm, each cluster of research data stands alone in the scientific literature as an isolated anomaly, barely acknowledged in the academic alcoholism literature. Because it seems so self-evident that psychosocial factors must be contributing causes, even biological researchers still think there must be more than one kind of alcoholism.

Once all biological data is assembled within the biogenic paradigm, it explains why all learning theories have failed to distinguish alcoholics from nonalcoholics, why alcoholic drinking can be neither learned nor unlearned. It is the unconditioned response to alcohol that is different, initially and progressively. Alcohol is selectively addictive, and the selection is biological.

Regardless of why, how, or how much an alcoholic initially drinks, the addiction neurologically augments his original reasons for drinking, pushing him to drink amounts consistent with his rising tolerance, and beyond. In human experience there is nothing unusual about physiological imperatives, like hunger or sex, creating mental obsessions and driving and shaping behavior. There are not two or more types of alcoholism. There are merely different complications and different types of people who are alcoholic, with different levels of concern and strategies of damage control.

All of the psychopathology of alcoholism, as alcoholism, is of neuropsychological origin, but this fact is disguised because alcoholism is never diagnosed until after character and personality are distorted and normal emotions are neurologically augmented to abnormal levels of chronic anguish, fear, resentment, guilt and depression. It is these distortions that clinically identify alcoholism, not the original character and personality.

Most often alcoholism is hereditary, but many individuals become chronic alcoholics through cross-addiction to other drugs (prescription or illicit), or as the result of other brain or liver insults. Whether or not accelerated by the potentiation of other drugs or injuries, organic deterioration causes a loss of tolerance and substantially reduced alcohol intake. To the drink counters, both alcoholics progressing into the more ominous low-tolerance stages of their disease and those who necessarily reduce their alcohol intake while using substitute drugs are cases of “spontaneous remission” or improvement.

In addition to the early acute effects of alcohol–the mind expanding life enhancing stimulation and energy–three kinds of progressive brain impairment participate in the personality and character transformation, while augmenting the strength of the emotions, and of the addiction. Between drinking episodes:

(1) All brain cells are in a toxic, malnourished state. Their detoxification and stabilization takes several weeks of total abstinence from alcohol and all other drugs,

(2) Billions of brain cells are damaged. Repair and healing takes several months of abstinence,

(3) Many millions of brain cells die. The loss is permanent, but during a period of some 4 years of total abstinence surviving cells compensate for those that are lost.

Ameliorating during the first several weeks of abstinence, the three kinds of impairment have a combined effect on overall brain function, producing both first-order and second-order psychological symptoms:

(1) First-order symptoms are the direct neuropsychological disturbances, such as mental anguish, memory defects, mental confusion, disorientation, and emotional augmentation.

(2) Second-order symptoms are the patient’s psychological reactions to the first order symptoms and include fear, denial, projection, rationalization, depression, personality distortion, deteriorating self-image and self-confidence, regressive immaturity and other mental and emotional aberrations.

A third order of symptoms is imposed by the psychogenic paradigm, the cultural heritage of both patient and family members, the mistaken belief that the first- and second-order symptoms are caused not by the brain disorder but by an underlying or concomitant psychiatric problem. Both subjectively and to the casual observer, the symptoms are the same. This wrongly places the blame for the abnormal behavior on the person rather than on his organic disease (hence the term “alcohol abuse”) and draws the family into sharing the blame. Third order symptoms include feelings of guilt, shame, remorse, alienation, resentment, helplessness, despair, and depression. Complex states, such as fear, depression, and regressive immaturity are composites of first-, second-, and third-order factors.

When alcoholics quit drinking on their own, as many do, they must live with the cultural stigma and the unrelieved symptoms of anguish, guilt, shame, remorse and depression. In this troubled state, without an enlightened support group, it is not surprising they so seldom achieve a lasting sobriety. These interludes “on the water wagon” between drunks are also included as spontaneous remissions or improvements by the drink counters.

TREATMENT

The attempt to force research findings into the psychogenic mold has been paralleled by a similar distortion and suppression in clinical practice.

Psychiatrists have always been regarded as the ultimate authorities on alcoholism in spite of the fact they have never had academic courses or field training in alcoholism. Their credibility has always depended entirely on the culturally shared premise that alcoholism is secondary to psychological and social problems, areas in which they are qualified.

Surveys during the 1960s found that alcoholics consulted psychiatrists from 40 to 100 times as often as nonalcoholics and were hospitalized some 12 times as often. They were never given a primary diagnosis of alcoholism. There wasn’t a hospital in the United States that would admit a patient under a diagnosis of alcoholism, and health insurance would not pay for alcoholism treatment. Alcoholism recovery rates were acknowledged to be zero for all types of psychiatric treatment. Alcoholic drinking, obvious “psychiatric” disorders, and failure to recover were all regarded as evidence of a mysterious perversity in the patient’s character. Alcoholics were considered hopeless, pending further psychiatric research.

Still under the psychogenic paradigm, the whole of the health care and social service establishment, public and private, continues to be a gigantic revolving door for undiagnosed and untreated, or wrongly treated, alcoholics and drug addicts, who, together with their victims, comprise conservatively 60 percent of all caseloads. The vast majority of all prison inmates are there for crimes secondary to addiction. The annual cost to society of tending to the multiple effects of addiction– rampant “psychiatric” problems, family neglect and abuse, poverty, violence and other crimes, illnesses and organ and system failures, accidental injuries and deaths–is in the hundreds of billions of dollars.

Because psychiatrists and other mental health specialists have such an enormous vested interest in the psychogenic paradigm, it could be anticipated that they would be among the last to discover the biogenic alternative. But this alone does not explain why they continue to be such stubborn believers in the face of the mountain of evidence that they are wrong. Their most stultifying problem is that they are trapped in a vicious circle, a self-fulfilling prophesy, that can only be seen from the perspective of the other paradigm.

Alternate states of being supplant each other. The person as transmogrified, transformed by the brain syndrome, enters treatment alone. The original, authentic person is not present. He or she has been superseded, replaced. All therapeutic dialogs with patients during the first weeks of treatment, until Jekyll is allowed to reappear, are dialogs with Hyde, through his “mask of sanity.”

Within the psychogenic paradigm, both therapist and patient mistake the characteristics of the wretched, contorted self of the brain syndrome for attributes of the real self. After a few days of acute detoxification, this miserable self-image is further authenticated as the focus shifts to psychiatric treatment. The third-order symptoms of guilt, shame, denial, defensiveness, resentment and depression, created by the psychogenic paradigm in the first place, are not dispelled by healing and reeducation, but are reinforced as emanating from deep sources in the patient’s character and personality, an underlying or concomitant psychiatric problem. It’s a self-validating practice. The patient now has an iatrogenic (therapist induced) disease.

By locking the patient into this mistaken identity, the therapist creates the chronic psychiatric problem that he then thinks he has merely uncovered. Therefore the dual diagnosis rate is very high, and the recovery rate is near zero. Of course, the patient gets the blame for the treatment failure, the continuing “willful misbehavior,” and the therapist feels justified in his contempt for these uncooperative patients.

In a sense, the recovery rate is worse than zero as many alcoholics die of the iatrogenic disease. They are destroyed by the potentiation of their alcoholism with routinely prescribed addictive drugs, in combination with psychotherapy, which converts the otherwise reversible organic insanity into a hopeless “mental illness” (Judy Garland, Marilyn Monroe).

The biogenic approach is entirely different. By the 1940s Alcoholics Anonymous had clearly demonstrated that alcoholics could stay sober and be restored to sanity with continued total abstinence from alcohol and all other addictive drugs. Special treatment programs came into being to meet the need that AA was not designed to address, the need for control and professional treatment during acute detoxification and the troublesome early weeks of recovery.

The therapist is a kind of mid-wife in the rebirthing of the patient into sanity and true self-hood (Jekyll). With medical management, directive counseling, appropriate nutritional therapy, regulated rest, moderate exercise, and complete reeducation to the neurological origin of the “mental illness,” within a few weeks the brain syndrome and the craving subside. Understandably, in varying degrees all patients experience a crisis of identity during the transition into unfamiliar self-hood. Patients are extremely unstable, biologically and psychologically, during this period. The four-week inpatient program evolved to facilitate the healing and to protect patients from an otherwise high probability of relapse during this period. There is no attempt to reform or to do psychotherapy with the fading, counterfeit self (Hyde). Like a bad dream, it is discredited as “unmanageable” (AA’s first step), left behind and disowned by the patient as not-self (Betty Ford, Elizabeth Taylor).

Restored to sanity, and reeducated to the permanent nature of addiction and how to recover, the alcoholic for the first time has a valid moral choice. He can see that he has a moral imperative to live the way of life that will assure his continued sobriety and recovery. He must understand why he cannot rely on willpower alone. Willpower is a fickle servant that can be quickly redirected at its biological source to serve an awakened Hyde instead of Jekyll. As patients stabilize in sobriety they are ushered into Twelve Step programs for long term sobriety maintenance and self- realization. It is this unbroken sequence that works so well with both alcoholism and other drug addictions.

There is no question that in early recovery patients must face the very depressing psychological and social damage caused by alcoholism–their own and often their parents. But this is reality, not mental illness. With proper addiction treatment, and continuing in health and sanity within a Twelve Step program, patients can cope with the damage and outgrow it. Reality centered counseling and other ancillary services may be needed or helpful during this difficult period. As with all other chronic diseases, even with the best of treatment relapses are often part of the recovery process. Nonetheless, with this treatment model the addiction recovery rate is high, and the actual rate of mental illness, the true dual diagnosis rate, is low, around 5 percent.

From within the psychogenic paradigm the special treatment model is incomprehensible, and the sequence seems arbitrary. Both AA and treatment programs have been endlessly misrepresented in the academic literature. AA is not a “treatment program,” and the special treatment programs are not “Twelve Step programs.” While AA properly stayed true to its original nonprofessional form, by the 1970s, after several decades of evolution, the treatment programs had become fully professional, multidisciplinary, and highly cost-effective.

Both the form and content of treatment evolved out of trial and error experiences of tens of thousands of professionals treating hundreds of thousands of patients in thousands of treatment programs over a period of several decades. Born of the psychogenic paradigm and guided by Jellinek, the movement of these programs toward the biogenic model was not by central control or conscious design, but by the grass-roots discoveries of what worked and what didn’t work in producing recoveries. Those who have more coherently grasped the biogenic paradigm have been rewarded by a quantum improvement in the rate and quality of recoveries.

Nothing is arbitrary. The common sequence of four weeks minimum of intensive inpatient treatment, followed by outpatient aftercare and a start in a Twelve Step fellowship, is simply an optimum program to enable the wisdom of the body and the reeducation process to resurrect the real person from the ashes of the disease, and to prepare him or her to start life in sobriety. Effective alcoholism treatment is hard work, and it takes time.

Through the special treatment programs, millions of alcoholics and other addicts have escaped the revolving doors of the establishment into total abstinence from alcohol and other drugs. After successful addiction treatment, their social service and health costs drop to levels below those of the general population. Cumulative costs saved have been in the tens of billions of dollars. Of course, costs saved by the special programs have been revenues lost to the establishment, which, together with the threat to the psychogenic paradigm, explains the hostile rejection of this major breakthrough in public health. Because referral for effective addiction treatment has become a very real option, the traditional professions and agencies must now be seen as primary “enablers,” and the endless problems they subsidize as iatrogenic.

Unfortunately, the success and high profile of the special addiction treatment programs during the 1980s attracted investors and professionals who brought into the field the psychogenic paradigm. Their low rates of addiction recovery, their “discovery” of a high rate of dual diagnosis, and their extraordinarily high costs of vainly treating the iatrogenic disorders have created major public relations problems for the whole field of addiction treatment.

Not knowing that the dual diagnosis problems they find so prevalent and so frustrating are iatrogenic, mental health professionals imagine that special programs must also be confronting these same psychiatric problems. It is therefore inconceivable to them that “Twelve Step” programs could be having any more success with these stubborn patients than they are. They even imagine that the special programs need their expertise to better treat the difficult psychiatric problems. They don’t. They don’t create them.

Whatever their assumptions, some mental health professionals have diverted attention away from their own failure to get recoveries (e.g., the Rand report) with outrageous allegations that enlightened treatment programs also fail to get recoveries, calling them a “rip-off industry.” This loud minority has jeopardized the lives of untold millions of alcoholics and drug addicts and inflated health care costs by shifting public attention away from effective addiction treatment over to a preoccupation with redesigning the whole health care establishment to more broadly serve the endless iatrogenic problems. It has also helped to unbalance the drug war by justifying the neglect of intervention and treatment (of Jekyll) in favor of an almost exclusive reliance on interdiction and punishment (of Hyde).

Citing the failure of alcohol prohibition in the attempt to justify legalizing other drugs seems reasonable only from the psychogenic premise–the denial of physical addiction that created and still nurtures the drug epidemic. Again, the biogenic view is entirely different. The 10 percent alcoholism rate among drinkers in America always has been a marginally acceptable rate of addiction, barely tolerable by society. Witness the anguish of prohibition and its repeal. Using the disaster of alcoholism to justify legalizing brain-damaging drugs with addiction rates edging toward 100 percent is totally irrational.

THE END GAME

That there is no legitimate research evidence available to support the psychiatric premise is highlighted by the fact that bogus research reports are being cited in the media as part of the current political battle to regain control of the patient population. A couple of recent examples:

(1) The report of drinking by fathers and sons purporting to show that alcoholism is not a primary hereditary disorder. This was a ridiculous drink counting study, not an alcoholism study. Alcoholism was not diagnosed in either fathers or sons. It was found that amounts consumed by sons were not affected by whether their fathers drank 2 or more drinks per drinking occasion or customarily drank 1 drink or less. Abstaining genetic alcoholic fathers whose sons are drinking alcoholics are–of course–placed in the “one drink or less” group.

(2) Psychiatrist Frederick Goodwin, then director of the Alcohol Drug Abuse and Mental Health Administration, has co-authored a report alleging that about a third of alcoholics have a dual diagnosis, a psychiatric problem along with their alcoholism. Patients in an alcoholism treatment program were merely asked if “ever in their lifetime” they had been given a psychiatric diagnosis. Thus the rate of historic and continuing misdiagnosis of alcoholics in the revolving doors became, for these authors, a measure of the rate of dual diagnosis.

In recent congressional testimony, psychologist Michael Hogan has inflated this contrived statistic. Arguing that alcoholism funds should be put back under mental health jurisdiction, he stated that “…in over 60 percent of all people with a substance abuse disorder, there is a concomitant mental illness.” It is a frightening prospect for the still sick alcoholic and drug addict that these agents of iatrogenic disease aim to control and “improve” the special addiction treatment programs.

It is impossible to counter the outrageous “research” reports one at a time as they flow into the national communications media from the professional and political high ground. No single research study can refute a nonstudy, and the network of research knowledge that shows it to be absurd is too complicated for a brief rebuttal. Only the familiar standoff can be achieved: “Apparently nobody understands alcoholism.” Once and for all, it is the whole biogenic paradigm that must be communicated.

Some steps have been taken in the right direction. During the early 1980s, the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse shifted their funding emphasis to support research in the biology of addiction. It is hoped they will finally recognize the effectiveness of nutritional therapy and the wisdom of the body in healing the brain syndrome and craving, and not just narrowly search for yet another toxic drug for psychiatrists to prescribe. The destructive methadone program for heroin addicts was never a legitimate model. It seemed promising only in relation to the zero recovery alternatives known to its instigators.

For the longer term, it is encouraging that in 1986 Harvard, Dartmouth and Johns Hopkins broke with academic tradition and announced they were going to inaugurate courses in alcoholism in their medical schools. In the same news release they frankly acknowledged that none of their faculty, including their many psychiatrists, were qualified to teach such courses. The word “inaugurate” underscores the fact that the many thousands of psychiatrists already on university faculties and out in society as authorities are not qualified in alcoholism either by academic courses or clinical training where they could witness recoveries. They are only authorities in the psychogenic paradigm in which alcoholism does not exist. Deeply understood, this paper is an attack not on these untutored professionals, but on the destructive cultural paradigm that has held them in thrall.

Facing up to their deficiency, a significant number of physicians, psychiatrists and psychologists have already defected to the enlightened treatment programs and organizations, first to learn and then to provide professional leadership. They have been generally ignored by mainstream professionals but will form an important nucleus for education and training as larger numbers come over to join them. Until the countless revolving doors are cleared of alcoholics, there will be plenty of productive and highly rewarding work for all who are willing to learn. As their numbers swell, they will finally provide the legitimate clinical window that has been so urgently needed both to guide and to integrate scientific research.

The biogenic paradigm has not yet been systematically articulated by any major organization or presented to the public through any of the national communications media, but having reeducated themselves to the realities of addictive disease, these professionals are now leading the inevitable movement toward the biogenic paradigm.

Two enlightened organizations, the American Society of Addiction Medicine and the National Council on Alcoholism and Drug Dependence, have jointly formulated a new definition of alcoholism that is consistent with the biogenic paradigm, as follows:

“Alcoholism is a primary, chronic disease with genetic, psycho-social and environmental factors influencing its development and manifestations.” The definition is further elaborated, but note especially that psychosocial and environmental factors are no longer primary, contributing causes of alcoholism.

Meanwhile, the ugly battle for control will continue in the political arena. The public has recently heard the hostile allegations that nobody understands alcoholism, that alcoholism does not exist, that it is merely willful misbehavior, that since treatment doesn’t work anyway, only the briefest and least expensive should be funded. “…every word they say chagrins us…” because all of these criticisms are true of the bankrupt psychogenic approach to alcoholism; none, however, is true of the biogenic.

These attacks on the “treatment industry” are merely a reactionary attempt to regain in the social and political arenas the control over alcoholism that has been irretrievably lost in scientific research and clinical practice. Their effectiveness depends entirely on public ignorance of the fact that the paradigm shift has already occurred.

With many millions of lives and hundreds of billions of dollars in the balance, surely it is time to embrace and to reveal the whole truth about addictive disease to decision makers and the public, to present the biogenic paradigm as the comprehensive successor to the disastrous psychogenic model. It will be quickly validated and ratified by an enormous latent fund of public experience and knowledge. Virtually everyone has witnessed the reality of addictive disease and the effectiveness of treatment, both first-hand and in media reports of the lives of a multitude of recovering celebrities.

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James R. Milam, Ph.D., is a clinical psychologist specializing full time since 1966 in addiction research and treatment. For over 25 years, he was the leading national proponent of the view that alcoholism is a primary neuropsychological disorder, not a symptom or consequence of psychosocial “risk factors,” as commonly believed. It was his Position Paper, written for the Washington State Council on Alcoholism in 1972, that provided the rationale for moving alcoholism out of mental health jurisdiction in Washington State and elsewhere. He is best known as the author, with Katherine Ketcham, of the best seller “UNDER THE INFLUENCE,” Bantam Books, New York, 1983.

Cofounder of several demonstration treatment programs, his efforts were focused on the rehabilitation of scientific, professional and public understanding and attitudes about alcoholism and other drug addiction.   For more background on Dr. Milam’s work, see his essay More on the Alcoholism Revolution.

Alcoholics Anonymous and the Counseling Profession: Philosophies in Conflict

By Christine Le, Erik P. Ingvarson, and Richard C. Page

From Journal of Counseling & Development, 07-01-1995, p. 603.

This article describes the contribution of Alcoholics Anonymous (AA) to drug and alcohol treatment. The potential for AA ‘s steps to encourage growth is discussed, and their consistency with counseling philosophy examined. To stimulate constructive discussion, 12 new steps based on counseling theory are proposed and contrasted with AA ‘s steps. The need for counselors to be aware of these differences is emphasized and the move toward more solid boundaries between AA and the counseling profession is advocated.

Since its conception in 1935, Alcoholics Anonymous (AA) has grown to be the most widely used organization for the treatment of alcoholism and substance abuse. Currently consisting of an estimated 1,800,000 members in 134 countries and more than 87,000 local groups (Alcoholics Anonymous World Services [AAWS], 1990), AA has become a major force in shaping society’s view of addiction.

AA’s treatment philosophy has changed how many people view themselves, their substance use and abuse, and the roles played by the people around them. The influence of AA is seen not only in the treatment of alcoholism, but also in the range of support groups for varying concerns of eating disorders, drug addiction, and gambling (Browne, 1991; Gifford 1989; Yeary, 1987). AA can provide the individual with an environment in which experiences can be shared and trust can be established. Members can exchange stories and encourage and support each other (Flores, 1988). Feelings of isolation that may be felt by many alcoholics can be reduced through the AA group process (Talbott, 1990). AA meetings are accessible; there is no screening of members, and the free help can be as long term as the member desires. A particular strength of AA is its ability to help members in times of crisis. This idea of assistance originated with AA’s founding members Bill Wilson and Bob Smith. Out of their friendship and support for each other came the AA philosophy that one member can be of aid to another during periods of stress (Kurtz, 1988). Organizations such as AA can be critical in determining whether a crisis will lead to growth and development rather than to increased difficulties such as heightened anxiety and feelings of hopelessness (Slaikeu, 1990). AA is especially well prepared to aid individuals in distress by providing direct support through sponsors. Sponsorship gives AA members the opportunity to have continuous, personal help from individuals who have made some progress in the program (AAWS, 1976b). The use of sponsors has been found to be a significant factor in the recovery process, especially in the initial stages when greater assistance is usually needed (Fagan, 1986).

AA has also been instrumental in bringing about the acceptance of the disease model of alcoholism (Kurtz, 1988). It supports the idea that some people may be “allergic” to alcohol and unable to use it in any form (AAWS, 1976a), and presents alcoholism as a progressive illness that can be arrested but not cured (AAWS, 1984). Although AA’s explanation of alcoholism as a disease is supported by the American Medical Association, its validity continues to be debated in the literature (Erickson, 1992; Miller, 1991; Peele, 1990, 1992). Some of the controversy concerning the disease model has arisen due to a lack of scientific evidence, and from differing definitions of disease (Fingarette, 1988). It is beyond the scope of this article to discuss this debate in detail; however, it should be noted that for many individuals AA’s view has reduced feelings of guilt and shame, clarified the cause of their desire to drink, and removed much of the stigma associated with treatment.

Although AA believes in a medical cause for alcoholism, their treatment program is a nonmedical one that includes both social and emotional elements. At the core of AA’s treatment program lie the 12 steps. These steps were originally adapted from a Christian organization, the Oxford Group. The group emphasized changing one’s life and removing sin by passing through five stages known as the five procedures. These stages involved giving in to God, listening to God’s direction, checking for guidance, achieving restitution, and sharing (Kurtz, 1988).

The majority of professional substance abuse programs in the United States use the 12 steps, either by making them the foundation of their treatment plan or by introducing them to clients as a means of recovery (Bradley, 1988). The use of AA philosophy by professional substance abuse programs is usually perceived as being beneficial to clients (Hulbert, 1992; Irwin & Stoner, 1991; Miller & Mahler, 1991). The benefits of AA are especially emphasized to AA newcomers who are told that sobriety can be achieved if they will “just work the program” and are assured that “there is no reason in the world why it should not work for you” (AAWS, 1984, p. 19).

Research is less clear as to whether working the AA program is helpful in achieving sobriety. Outcome studies have attempted to assess AA’s effectiveness by investigating the relationship between AA attendance and length of abstinence. Several studies have found that AA members report greater abstinence than nonmembers (Cross, Morgan, Mooney, Martin, & Rafter, 1990; Hoffman, Harrison, & Belille, 1983; Thurstin, Alfano, & Nerviano, 1987), and that the longer the membership in AA the greater the length of sobriety (McBride, 1991). Unfortunately, these studies are methodologically flawed due to the voluntary nature of AA membership. With the only criterion for membership being “a desire to stop drinking” (AAWS, 1984, p. 2), it is likely that those attending AA recognize their drinking problem and are motivated to change. Because of this self- selection it becomes impossible to know whether it is AA efficacy or member motivation that is being measured (Bebbington, 1976). Additional problems involved in the scientific research of AA include member anonymity, lack of control groups, and the confounding effects of other treatment programs. These difficulties have led researchers to conclude that the effectiveness of AA has yet to be proven (Bebbington, 1976; Bufe, 1991; Glaser & Ogbome, 1982; Vaillant, 1983) and that the study of AA may need “unprecedented standards of measurement not appropriate to other treatment programs” (Leach, 1973, p. 277).

As research has failed to assess the effectiveness of AA, counseling theory may be a more appropriate standard of measurement. Through a comparison of AA and counseling philosophy, counselors can have the opportunity to decide for themselves if the AA program is consistent with their counseling values and potentially helpful for their clients. This decision is similar to the numerous choices that counselors must make concerning the use of different treatment methods, models, techniques, and schools of thought. Becoming well acquainted with the AA program will help to make this choice easier and will allow counselors to be clearer on the extent to which they wish to integrate AA into their work.

AA’s 12 steps are especially relevant as they represent the AA program and are the member’s main guide to sobriety. Because the counseling profession advocates the use of these steps with a wide variety of clients (Chappel, 1992; Polcin, 1992; Ratner, 1988), it is desirable that counselors be knowledgeable about the steps and aware of any differences between them and their own counseling philosophy. AA’s 12 steps are therefore examined and their consistency with counseling philosophy discussed.

Because of the diversity of philosophies that exist within the counseling field, the AA steps will be looked at in relation to the theories of selected writers including Rogers (1961, 1980); Maslow (1968); Jung (1933); Homey (1950); Frankl (1959); Perls, Hefferline, and Goodman (1951); Ellis (1989); and Bandura (1982). This selection represents a variety of counseling theories and includes the person-centered, humanistic, analytical, neo-Freudian, existential, Gestalt, rational-emotive, and cognitive approaches to counseling. As there is no single inclusive theory of counseling, our choice will necessarily be both subjective and limited. Nevertheless, as the theories chosen place emphasis on change, growth, and the development of the individual, they are representative of the values held by many professionals in the field, and are consistent with what is taught in most graduate programs in counseling.

To help stimulate constructive thought and discussion, 12 new steps will be proposed. AA’s steps have been rewritten by several professionals, including B. F. Skinner (1987), who wished to provide an alternative program for the nonreligious. The goal of this article is not to provide an alternative program, but to offer the reader the chance to compare AA’s steps with steps containing principles drawn from counseling theory. Inconsistencies between AA philosophies and counseling values will be clarified and the possible consequences for the client examined.

THE 12 STEPS

Step 1

AA Step 1: We admitted that we were powerless over alcohol, that our lives had become unmanageable.

Proposed Step 1: I realize that I am not in control of my use of alcohol.

AA views the admission of powerlessness as the first step toward sobriety. Here, individuals learn that they are passive victims, resting at the mercy of the greater power of alcohol. Admitting powerlessness has the potential of guiding the individual in one of two directions. The first leads toward the AA program and Step 2. The second, and more dangerous, encourages the individual to view himself or herself as a helpless alcoholic who accepts the futility of trying to stop drinking.

In a profession where empowerment is a widely accepted goal, it seems strange that powerlessness should be the primary focus of the most referred-to substance abuse treatment program. Stensrud and Stensrud (1981) wrote that the helping process can even be dangerous if feelings of powerlessness are increased. It is therefore advisable that, although the first step recognizes that the individual is not in control of his or her use of alcohol, it also has as an underlying rationale the belief that people are capable of self-direction and self-responsibility regardless of their level of alcohol dependence. Egan (1990) pointed out that “if clients are not urged to explore and assume self-responsibility, they may not do the things needed to manage their lives better, or they may do things that aggravate the problem they have” (p. 73). This belief in self-direction and self, responsibility is echoed in the writings of Rogers (1961), Maslow (1968), and Peris et al. (1951).

The AA steps all begin with the plural “we,” which may cause individuals to simply identify with the group as a whole without internalizing the steps for themselves, thus further reducing the need for self- responsibility. Having the steps in the first person (using “I” as opposed to “we”) helps to emphasize the need for individual decision making and responsibility within the group atmosphere. According to Jung, the need to separate oneself from the collective and find one’ s own way is essential for self-realization (Kaufmann, 1989). Because the AA steps are written in the past tense, they tend to imply that once a step has been achieved work in that area has been completed. The use of the present tense in the proposed steps may encourage continuous work on the steps and self in the here and now.

Step 2

AA Step 2: We came to believe that a Power greater than ourselves could restore us to sanity.

Proposed Step 2: I acknowledge that a spiritual awakening can help me to find a new direction.

Having accepted powerlessness, AA’s Step 2 reinforces the idea that change is only possible if a power outside of oneself can come to the rescue. The theme of greater forces saving powerless individuals reminds one more of ancient myths than modern day realities, and for many the promised happy ending never arrives. The goal of being restored to sanity also raises concerns. Even though some individuals in the AA community might have unique interpretations for certain words, for many clients and counselors it is unacceptable to label all problem drinkers as insane. Bufe (1991) pointed out that this step promotes the idea of individual helplessness and encourages dependency, which is directly contrary to the usual therapeutic goals of self-direction and independence. Although individuals in crisis may need direction from outside forces to help restore equilibrium, too much reliance on external powers may prevent the development of internal resources (Gorton & Partridge, 1982). Theorists like Rogers (1961, 1980), along with many professional counselors, place faith in the individual’s ability to grow.

For some counselors, the emphasis on outside forces and greater powers may be attributed to the recognition that a sense of spirituality is one of the factors that correlates with positive treatment outcomes (Ludwig, 1985; Rogers, 1980). Carl Jung expressed his belief in spirituality as an aid to recovery from alcoholism when writing to Bill Wilson (Adler & Jaffe, 1963). Wilson placed less emphasis, however, on recognizing the spirituality that lies within the individual and on helping people to awaken their own spiritual strength.

Although some clients are comfortable with the idea of a “power greater than ourselves” coming to rescue them, others might feel this aspect of spirituality is foreign and alienating. Thus, rather than prescribing the type of spiritual assistance needed for the client, the focus could be changed to developing an individual spiritual awakening. This awakening could lead the client in a new, personal direction developed from within.

Step 3

AA Step 3: We made a decision to turn our will and our lives over to the care of God as we understood Him.

Proposed Step 3: I am ready to follow and stay true to the new path I have chosen.

AA’s third step encourages individuals to turn their “will and lives over to the care of God as we understood Him.” Having completed Steps 1 and 2 it is understandable that this is the main option left for individuals who have accepted their powerlessness and are waiting for a powerful sane force to take control of their lives. Although AA literature states that the interpretation of the nature of God is a personal matter, it makes it clear that any sense of spirituality must come from outside oneself. The main objective of the book Alcoholics Anonymous is stated as being “to find a Power greater than yourself which will solve your problem” (AAWS, 1976a, p. 45). It also states that “any life run on self-will can hardly be a success” (p. 60).

This is directly contrary to the underlying principles of most theories of counseling. As counselors we must ask ourselves if the messages in AA’s steps are ones we wish to send to our clients. A more suitable approach might be to help the client to follow and stay true to his or her individually chosen path. This can allow independence of thought and remains consistent with the belief that individuals are capable of self-direction. Jung, in particular, felt that individuals are not only capable of self-direction, but that movement toward individuation is a vital instinct for achieving wholeness and growth (Kaufmann, 1989).

Although the group may provide support and encouragement, it is important to remember that it is the individual who maintains the ultimate responsibility. The idea that people are responsible for their own individual moral choices, as advocated by Yontef and Simkin (1989), among others, is central to this belief.

Step 4

AA Step 4: We made a searching and fearless moral inventory of ourselves.

Proposed Step 4: I have the strength and courage to look within and to face whatever obstacles hinder my continued personal and spiritual development.

AA’s fourth step demands a “searching and fearless moral inventory of ourselves.” The object of such a search is to “disclose damaged or unsalable goods, to get rid of them promptly without regret” (AAWS, 1976a, p. 64). The idea of being expected to remove immoral or unwanted aspects of the self can set the individual up for exaggerated shame and guilt. The individual may learn that “parts of myself are no good. I must get rid of them, right now. If I cannot, then I am a failure. ”

AA’s idea of looking within the self is excellent, especially if it can be achieved in a nonaccusatory, growth promoting way. Emphasis could be placed on accepting what one is first; not rejecting parts of oneself as if these parts were foreign to the person. Rogers (1961) found that acceptance of the self is crucial to change and growth. The process of change will also be continuous and will not always be prompt and without regrets.

Step 5

AA Step 5: We admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

Proposed Step 5: I commit to become fully aware of how my use of alcohol hurt those around me.

In AA’s Step 5 members must admit to God, to themselves, and to another human being the exact nature of their wrongs. Through repentance, this step attempts to remove some of the guilt that may have been exaggerated by the fourth step. AA suggests that “though we have no religious connection, we may still do well to talk to someone ordained by an established religion” (AAWS, 1976a, p. 74).

Repentance has long been used in religion to remove guilt and to provide a sense of a new beginning. In using the AA steps as part of a treatment program, the counselor needs to be clear that this is in the client’s best interest. One of the difficulties with asking our clients to repent is that we are endorsing the concept of sinful behavior and placing ourselves in a righteous position. AA seems to be demanding that the individual asks for God’s forgiveness, rather than finding internal peace.

For some members, asking for and receiving this forgiveness may lead to internal peace, but for many others it can be alienating and may not produce the desired serenity. Developing awareness of the consequences of behavior might be more useful than insisting on repentance. Awareness involves an internal search that keeps the responsibility with the individual, rather than relying on outside forces. The person is not being judged or forgiven, but can develop insight into how the use of alcohol has harmed those around him or her. With awareness there is often a greater understanding and acceptance of self, which can allow growth to occur.

Step 6

AA Step 6: We were entirely ready to have God remove all these defects of character.

Proposed Step: I am changing my life and developing my human potential.

Having admitted to God the nature of the wrongs, this next AA step prepares the individual to have God “remove all these defects of character. ” It is interesting that what was an action or “wrong” in Step 5 is being described as an integral albeit defective part of a person’s character in Step 6. Labeling parts of the self as defective may increase feelings of shame. Defect can imply failure, and may also establish guilt.

The AA member is advised to prepare to have God take away these broken parts. It is doubtful if there is any therapeutic value in installing shame in clients, yet this is exactly what this step risks doing. The person is discredited, and then left dependent on outside forces to make changes in the self. An alternative step could encourage individuals to develop their human potential. Bandura has pointed out that effective functioning requires not only the development of competence and skills, but also the formation of a strong belief in one’s own efficacy (Evans, 1989).

Step 7

AA Step 7: We humbly asked Him to remove our shortcomings.

Proposed Step 7: I am proud of my strength and ability to grow.

In Step 7 AA members ask “Him” to remove their shortcomings. The message seems to be “parts of myself are defective. I cannot accept or change these parts. Only God can save me by removing them.” Is this a message we want clients to learn? Instead of teaching people dependency and humility, the 12-step program could be aimed toward helping the individual become an active agent in the recovery process, rather than a passive patient who is hoping to be rescued. Emphasis can be changed from removing shortcomings to developing strengths.

Whereas AA seems to believe that personal growth is best achieved by the removal of defects of character, the counseling field usually appreciates the value of working with a client’s strengths (Egan, 1990). Maslow, Rogers, and Ellis strongly advocated waking the client’ s untapped growth forces, no matter what the client’s difficulty (Ellis, 1989). For clients in crisis, emphasis on strengths can help to increase self-esteem and participation in treatment (Gorton & Partridge, 1982). Empowerment often leads to self-respect and faith in one’s ability to follow a new direction.

Step 8

AA Step 8: We made a list of all persons we had harmed, and became willing to make amends to them all.

Proposed Step 8: I will do all I can to make up for the ways I have hurt myself and others.

AA’s Step 8 attempts to remove guilt by repairing past damage. Members are asked to become willing to make amends to all those that they have harmed, and to go to them “in a helpful and forgiving spirit, confessing our former ill feeling and expressing our regret” (AAWS, 1976a, p. 77). Here, the individual is being asked to take on AA’ s accepted feelings of sorrow and regret, regardless of what their true feelings may be. This task may serve to increase guilt as true feelings surface and the individual feels that he or she has failed, or is experiencing the wrong feelings. Not only is this task impossible, but it may also be therapeutically unsound in denying clients the right to their true feelings (Benjamin, 1987; Carkhuff, 1983; Maslow, 1968; Rogers, 1980). As Homey (1950) pointed out: “His not feeling his own feelings makes him unalive, no matter how great his surface vivacity. His not assuming responsibility for himself robs him of true inner independence” (pp. 172-173).

The concept of making amends can be therapeutic, but before one can achieve harmony with others, it is important to be at peace with oneself. Individuals could be encouraged to make up for the ways they have hurt themselves first, and then how they have hurt others. True feelings may be acknowledged, and emphasis could be taken away from making amends with everyone to doing what one can to repair past damage. This more realistic approach may help the individual achieve a harmony undisturbed by feelings of culpability.

Step 9

AA Step 9: We made direct amends to such people wherever possible, except when to do so would injure them or others.

Proposed Step 9: I will take direct action to help others in any way that I can.

Step 9 extends Step 8 by taking the willingness to make amends and converting it into the act of actually doing so. Now the AA member must not only convince himself or herself of benevolent feelings, but must also act on them. The result is likely to involve a mixture of guilt and dissonance. Emphasis on helping all people, regardless of whether they have been the victims of our past wrongs, might help to move a person out of the past and into the present. Clients can focus on helping others in any way that they can, rather than agonizing over those on their list of wronged persons that they have not yet been able to reach. Growth through helping others is reflected by Mosak (1989) in describing the Adlerian goal of therapy as “to release people’s social interest so they may become fellow human beings, cooperators, contributors to the creation of a better society, people who feel they belong to and are at home in the universe” (p. 107).

Step 10

AA Step 10: We continued to take personal inventory and when we were wrong, promptly admitted it.

Proposed Step 10: I will strive to be self-aware and follow the new path I have chosen.

This step repeats the fourth, only now it is stated that personal inventories must be made continuously and wrongs must be promptly admitted. The AA member is advised that this “should continue for our lifetime” and that when wrongs occur “we ask God to remove them at once” (AAWS, 1976a, p. 84). Here it is made clear that continual dependence on higher powers is considered necessary for sobriety. Whether counselors wish to include continual repentance as a part of their treatment programs is doubtful, yet this is exactly what this step encourages.

Yet, striving to be self-aware and working toward following an individually chosen path does not necessarily leave the person dependent on any program or higher power. Parts are not labeled immoral, and the individual is not expected to have them removed. This development of self-awareness, rather than dependence on higher powers, can help to guide the person along his or her chosen path. As Perls (1973) noted: “If we produce our own awareness, if we do it ourselves and do not rely on artifacts, we have all the basis for growth that we need” (p. 133).

Step 11

AA Step 11: We sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of his will for us and the power to carry that out.

Proposed Step 11: I will continue to develop my potential through helping others and strive to become fully conscious of myself and life around me.

Now that the AA program has instructed individuals on how they should feel and act, Step 11 provides directions on what they should pray for. Suggestions include “How can I best serve Thee-Thy will (not mine) be done” (AAWS, 1976a, p. 85). Some clients may find these prayers valuable, but others may not. It is important that there are programs flexible enough to accommodate both. Greater emphasis on encouraging individuals to continue to develop their own potential through helping others can increase growth and still allow freedom of choice. Particular talents, skills, and interests may be discovered and put to excellent use. The strengthening of cooperation between individuals was particularly valued by Adler, who noted that the development of social interest can lead to increased feelings of confidence, worth, and accomplishment (Ansbacher & Ansbacher, 1979). Clients can also strive toward being fully conscious of themselves and life around them. Rogers realized the importance of developing consciousness, and felt that he would be satisfied with his work as a therapist “if the individual is becoming more able to listen to what’s going on within himself, more sensitive to the reactions he’ s having to a given situation, if he’s more accurately perceptive of the world around him” (Kirschenbaum & Henderson, 1989, p. 75).

Step 12

AA Step 12: Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

Proposed Step 12: I will continue to develop my own human potential and spirituality and will actively help others who cannot control their use of alcohol.

In this last part of the program, AA members state that they have had a spiritual awakening as a result of these steps, that they will carry the message to all addicts, and will practice the principles in all their affairs. It is interesting that in this last step AA chooses the term spiritual awakening. With AA’s emphasis on greater powers, immorality, and the carrying out of God’s will, it would seem that the steps are more inclined to lead a person to a religious conversion than to a spiritual awakening.

Either way, gains that have been made through working the program are not attributed to the individual, but to the steps. Any pride that the person might have developed is removed and credit is given to AA and to God. Instructing members to carry the message and practice the principles reminds one more of missionary work than sound counseling or guidance. Members are not encouraged to help others control their drinking, but to present the AA message as the solution for all.

Step 12 could encourage individuals to continue developing their spirituality and human potential, and emphasis could be placed on actively helping others to control their drinking. Although there are many different ways in which individuals can help others, an important contribution could be made through modeling. Bandura (1986) pointed out that many behaviors can be learned by observation through modeling. Individuals can act as guides, helping others to expand their knowledge and skills, and acquire new patterns of behavior. Individuals can also help to increase the perceived self-efficacy of others by conveying effective coping strategies (Bandura, Adams, Hardy, & Howells, 1980). Bandura noted that “even the self-assured will raise their perceived self-efficacy if models teach them better ways of doing things” (Bandura, 1986, p. 400). This can be especially helpful, as an increased belief in one’s efficacy has been shown to play an important role in the prevention of relapse (Annis & Davis, 1991; Solomon & Annis, 1990). Aiding other individuals by helping them develop their strengths and self-confidence might be more useful than merely carrying a message.

DISCUSSION

Using counseling philosophies as a standard by which to measure AA’ s effectiveness has certain limitations that need to be discussed. The choice of theories included in the study is not without bias. Although care was taken to select a diversity of philosophies, a theory that is significant for one counselor might be less important for another. Theories are also limited by the uncertainties inherent in many of their assumptions, and by their occasional lack of empirical support or structure.

Despite these limitations, it is clear from the preceding review that the principles of the AA program contrast with our interpretation of counseling theory. AA’s steps revolve around themes of powerlessness, dependency, and humility. AA members are encouraged to relinquish self-direction and self-responsibility and to turn their lives over to the care of a power outside of themselves. The steps emphasize removing character defects and personal shortcomings, rather than developing strengths and abilities.

Unlike the AA program, most professionals in the counseling field value helping clients develop their responsibility for self and use their strengths. Individuals are usually encouraged to choose their own direction and personal differences are supported. These philosophical differences may be the reason why AA has been questioned, doubted, and encouraged to change by many working within the counseling field. Ellis and Schoenfeld (1990) questioned AA’s use of religion, Bufe (1991) raised concerns relating to AA’s self- absorption and irrationality, and Trimpey. (1989) was particularly concerned about those who had specific objections to AA philosophies.

The temptation to encourage AA to change its program to fit counseling values is great. But, urging an organization to change its beliefs because they are not similar to one’s own is dogmatic and undesirable. AA is a vital community resource that has particularly contributed to the growth of self-help groups. It has grown to offer several types of groups to help meet differing needs. These include open meetings for all members of the community, closed meetings for those who have a desire to stop drinking, 12-step meetings, and speaker meetings. AA membership is rapidly increasing, not only in the United States, but also throughout the world (Klingemann, Takala, & Hunt, 1992). The AA group atmosphere provides support, feedback, socialization, and encouragement, and in times of crisis AA help is available 24 hours a day through the sponsorship program. Even though AA’s philosophies may differ from those of counseling, AA can still continue to grow and be helpful to many.

Nevertheless, AA is not the right program for everyone. It is not with AA that changes need to occur, but with the relationship the counseling profession has formed with AA. Numerous treatment centers use the 12-step program without considering whether the principles of AA are consistent with their counseling values and acceptable for their clients.

A full 80% of AA members are directed to AA through professional treatment and counseling programs (AAWS, 1990). It is clear that counseling theory and AA principles have become enmeshed and roles have grown confused. If a healthy relationship between the two is to be achieved, then a clarification of boundaries is needed. These boundaries must be solid enough that both clients and counselors are aware of the important differences between AA philosophy and non- AA treatment programs, but flexible enough that clients can be referred to AA, if desirable.

For appropriate referrals, it is important that counselors are not only familiar with the differences between AA and general counseling philosophy, but also with the variations that can exist between AA groups. As AA members can adapt meetings to meet their needs, local groups can greatly differ. By attending open meetings, counselors can become acquainted with their community groups and be better prepared to match groups to client needs. For centers that wish to continue step programs based on counseling principles rather than AA philosophy, this will also mean adopting a new set of steps. It is hoped that through these changes a wider variety of programs will be able to grow alongside AA. Although for both clients and counselors the choice of treatment philosophy should be an individual one, the move towards differentiation needs to be made collectively.

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Christine Le is a doctoral student in the Counseling Psychology Program at New York University, New York. Erik P. Ingvarson is a mental health therapist in Crestview, Florida. Richard C. Page is a professor in the Department of Counseling and Human Development Services at the University of Georgia, Athens. Correspondence regarding this article should be sent to Richard C. Page, Department of Counseling and Human Development Services, 402 Aderhold Hall, University of Georgia, Athens, GA 30602. Copyright 1995 by American Counseling Association. Text may not be copied without the express written permission of American Counseling Association.