Download Why AA by Mike Miller

“Why AA?”
For Patients in Residential Treatment
at Herrington Recovery Center
…and how it fits into overall
Goals of Treatment and Recovery
Michael M. Miller, MD
Medical Director, HRC
Rogers Memorial Hospital
Persons in treatment at HRC
have Addiction
• HRC provides professional treatment to persons
who have not achieved their goals via self-help or
via professional treatment at a less intensive level
of care.
• Persons with addiction may try to quit on their
own, or reduce their use so they don’t experience
problems, or they may seek professional
treatment: 1:1 visits with a counselor, doctor, or
mental health professional; or enrollment in an
IOP or PHP or in another residential program
ASAM Public Policy Statement on
Alcoholism as a Primary Disease
“Based on many years of clinical experience,
reinforced by recent and continuing research into
the genetic, biochemical and physiological
aspects of the effects of alcohol on living systems
and of alcoholics and their families, the American
Society of Addiction Medicine finds that
alcoholism is a complex primary physiological
disease, and neither a primary behavior disorder
nor a symptomatic manifestation of any other
disease process.”
Adoption Date: October 1, 1983; revised October 1, 1996
When the disease is still active…
• When substance use is still happening and the
person doesn’t exhibit control over their use
• When problems due to use keep accumulating
• When “addressing the problem yourself”
hasn’t worked
• When other professional help hasn’t worked
…then, people come to the HRC at RMH.
So, why so much emphasis on AA?
• Residents at HRC attend AA or NA almost nightly
• Residents attend meetings on campus—these are
‘open meetings’ including persons from the
community, but are almost like ‘institutional
meetings’ established for persons in
inpatient/residential treatment
• Other RMH patients attend as well: from other
residential and IOP programs, or from inpatient
psychiatry unit or inpatient eating disorders unit
Why not just ‘do professional
treatment’ without all the involvement
in 12-Step groups (which are NOT
professional treatment)
• AA is a supplement to treatment
• It is for recovering people, and offered by
recovering people, without a trained
professional to ‘lead’ the group, without any
charges or documentation
• It is NOT treatment.
• It promotes recovery.
Who is AA for?
• Not just for persons with addiction
• Not just for persons who identify themselves
(admit it) that they have addiction
• Only criterion for attendance: “A person with a
desire to stop drinking.” (or, for N.A., “…using.”)
• It’s for persons not pursing professional tx.
• It’s for persons pursing professional tx. (it can
help treatment work better!)
What are we trying to accomplish
through “Professional Treatment?”
ASAM Public Policy Statement on Treatment for Alcohol and
Other Drug Addiction
• Addiction Treatment is the use of any planned, intentional intervention
in the health, behavior, personal and/or family life of an individual suffering
from alcoholism or from another drug addiction, and which is designed to
enable the affected individual to achieve and maintain sobriety, physical,
spiritual and mental health, and a maximum functional ability.
• Addiction Treatment services are professional healthcare services,
offered to a person diagnosed with addiction, or to that person’s family,
by an addiction professional. Addiction professionals providing addiction
treatment services are licensed or certified to practice in their local
jurisdiction and may be nationally certified by a professional certification
body for their professional discipline.
Adopted by ASAM Board of Directors May 1980; revised September
1986, October 1997, July 2001, October 2009, and January 2010.
Targeted Therapeutic Changes in
Addiction Treatment
BEHAVIORAL CHANGES
BIOLOGICAL CHANGES
• Eliminate alcohol and other
drug use behaviors
• Eliminate other problematic
behaviors
• Expand repertoire of healthy
behaviors
• Develop alternative
behaviors
• Identify triggers for using
behaviors/relapses
• Resolve acute alcohol and other
drug withdrawal symptoms
• Physically stabilize the organism
• Develop sense of personal
responsibility for wellness
• Initiate health promotion
activities (e.g., diet, exercise,
safe sex, sober sex)
• Address cravings through
medical interventions
(treatment medications)
Targeted Therapeutic Changes in
Addiction Treatment
COGNITIVE CHANGES
AFFECTIVE CHANGES
• Increase awareness of illness
• Increase awareness of
negative consequences of
use
• Increase awareness of
addictive disease in self
• Decrease denial
• Increase emotional
awareness of negative
consequences of use
• Increase ability to tolerate
feelings without defenses
• Manage anxiety and
depression
• Manage shame and guilt
Targeted Therapeutic Changes in
Addiction Treatment
SOCIAL CHANGES
SPIRITUAL CHANGES
• Increase personal responsibility
in all areas of life
• Increase reliability and
trustworthiness
• Become resocialized:
reestablished sober social
network
• Increase social coping skills:
with spouse/partner, with
colleagues, with neighbors,
with strangers
• Increase self-love/esteem;
decrease self-loathing
• Reestablish personal values
• Enhance connectedness
• Increase appreciation of
transcendence
Taken from: Miller, Michael M. Principles
of Addiction Medicine, 1994; published by
American Society of Addiction Medicine,
Chevy Chase, MD
What can AA do for you?
Follow the Steps
1. We admitted we were
powerless over alcohol—that
our lives had become
unmanageable.
2. Came to believe that a Power
greater than ourselves could
restore us to sanity.
3. Made a decision to turn our
will and our lives over…
4 .Made a searching and fearless
moral inventory of ourselves.
• 5. Admitted the exact nature of
our wrongs (and stated this
openly to another human begin)
• 6. Were entirely ready to
have…all these defects of
character [removed].
• 7. [Humbly asked to have these
shortcomings removed ].
• 8. Made a list of all persons we
had harmed, and became willing
to make amends to them all.
• 9. Made direct amends to such
people wherever possible, except
when to do so would injure them
or others.
Readiness for Change
Stages of Change
• Precontemplative
• Contemplative
• Preparation
• Action
• Maintenance
[Motivational Enhancement Therapy]
Downward Spiral / Progression
Addiction
(constriction –of
affects, behaviors,
social network)
Atrophy
• Of social network
– People…
• Of activities / interests
– Places, Things
• Of emotions
– Flatness, less expressive, dysthymic / alexithymic
– Everything is anger/resentment
• Of rewards
– Salience
Downward Spiral of Addiction and
Upward Spiral of Recovery
Addiction
(constriction –of
affects, behaviors,
social network)
Copyright (c)2011, Covington, Griffin, & Dauer
Recovery
(expansion—
of feelings, rewards,
activities, social
connections)
How to come out of the depths?
How to RECOVER?
• “Re-people-ization”
–
–
–
–
–
–
AA
Sponsor
Church
Social clubs
Activities with others
Family
• Professional Treatment (group therapy, meet others)
• Re-Connectedness
So What Can AA Give Us?
• A place to go (structured daily activity)
– Something on your daily schedule
– Accountability to ‘be somewhere’
– Be reliable: keep your promises
• A place to be
– A supportive physical environment
– A place that is alcohol/drug free
– Separation from people/places/things that are
unhealthy
• People to be with
– A group of folks you can identify with
– Identify similarities to others, not focus on differences
– Find real-life examples of persons who are succeeding
So What Can AA Give Us?
• People to be with
– “Whenever two or more are gathered…”
– Overcome isolation
– Supportive recovery environment (people support
your abstinence vs. oppose/sabotage it)
• People to listen
– “be there with you” on your journey
– Accept, not criticize, not debate, not berate
– No “cross talk”: people talk, people listen
So What Can AA Give Us?
• A Group
– even if it’s not a professionally-led psychotherapy
group
– it’s different from professionally-directed group
therapy, where a therapist might provide active
“advice” (vs. the “feedback” that comes in the
hallways at an AA clubhouse after a meeting)
– but the “curative factors” seen in professionallyled groups, can happen in AA groups
Irvin Yalom's Curative Factors
of Group Treatment
The Theory and Practice of Group Psychotherapy, 4th Ed., 1995.
• Instillation of Hope - faith that the treatment mode can and will be
effective.
• Universality - demonstration that we are not alone in our misery or
our "problems".
• Imparting of information - didactic instruction about mental health,
mental illness, psychodynamics or whatever else might be the focal
problem of the group (Ex. ACOA, Alanon; learning about the disease
process itself).
• Altruism - opportunity to rise out of oneself and help somebody
else; the feeling of usefulness; get out of yourself; give back
• Corrective recapitulation of primary family group - experiencing
transference relationships growing out of primary family
experiences, providing the opportunity to relearn and clarify
distortions.
Irvin Yalom's Curative Factors
of Group Treatment
The Theory and Practice of Group Psychotherapy, 4th Ed., 1995.
• Direct Advice - receiving and giving suggestions for strategies
for handling problems.
• Interpersonal learning - receiving feedback from others and
experimenting with new ways of relating.
• Development of socializing techniques - social learning or
development of interpersonal skills
• Imitative behavior - taking on the manner of group members
who function at a higher level (model the experienced ones)
• Catharsis - opportunity for expression of strong emotions
• Existential factors - recognition of the basic features of
existence through sharing with others (e.g. ultimate
aloneness, ultimate death, ultimate responsibility for our own
actions).
Treatment can make AA work better!
Twelve Step Facilitation treatment
http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=55
• The principles include acknowledging that willpower alone
cannot achieve sustained sobriety, that surrender to the
group conscience must replace self-centeredness, and that
long-term recovery consists of a process of spiritual
renewal.
• Therapy focuses on two general goals: (1) acceptance of
the need for abstinence from alcohol and other drug use
and (2) surrender, or the willingness to participate actively
in 12-step fellowships as a means of sustaining sobriety.
Treatment can make AA work better!
• The TSF counselor assesses the client's alcohol or drug use,
advocates abstinence, explains the basic 12-step concepts, and
actively supports and facilitates initial involvement and ongoing
participation in AA. The counselor also discusses specific readings
from the AA/NA literature with the client, aids the client in using
AA/NA resources in crisis times, and presents more advanced
concepts such as moral inventories.
• A key is for the therapist to ask follow-up questions to the patient
about their experiences when they attend AA meetings, what’s
working for them, what barriers they are experiencing.
• Setting goals is important: Are you attending the number of
meetings you said you would? Are you talking with a sponsor?
Are you talking with people you got phone numbers from? Are
you talking when you attend, or just saying “I pass”?
So What Can AA Give Us?
• A place for “re-people-ization” and to
establish a new “Social Network”—of
sober/recovering people!
• A place to “try out new things”—SAY
SOMETHING, get out of your shell, break the
“No Talk” rule of your family of origin
• A place to “ASK for HELP” from someone else
– It’s not ‘all me’
– Help comes from outside, to ‘turn it over’
How Does it Work?
• Fake it till you make it—Just Do It! (Nike)
• Show Up! (attend; establish the habit/regimen)
• Talk!
– Be a participant in A.A.
– Don’t just be a spectator at A.A.
– Don’t just “pass” each time
• Do SOMETHING different. Take a (healthy) risk.
How Does it Work?
• Listen!
–
–
–
–
To the stories
To those who have ‘made it’
“vicarious learning”
“modeling”
• Do more than ‘just listen’—be a part of it!
– take a risk and share your experiences, what’s going on for you
– this can decrease your shame and guilt as you experience
acceptance
– when you do this, you’ll end up being able to identify with
others at the level of shared experience.
• The ‘bottom line’—like they say ‘around the tables’ at AA:
“It works only if you work it.”
How It Works
(paraphrased from Chap. 5 of The Big Book)
• Remember that we deal with alcohol - cunning,
baffling, powerful! Without help it is too much
for us. It’s bigger than us.
• But there is help: outside of yourself, beyond
yourself. May you find it now.
• Half measures availed us nothing. We stood at
the turning point. We asked our Higher Power
for protection and care, with complete
abandon.
“AA is a Spiritual Program of Recovery”
• What does this mean?????????
• Does this mean being religious?
• Does this mean I have to believe in God?
– Have a ‘religious faith’
– Not be agnostic or atheistic
ASAM Definition of Addiction
Addiction is a primary, chronic disease of brain
reward, motivation, memory and related
circuitry. Dysfunction in these circuits leads to
characteristic biological, psychological, social
and spiritual manifestations.
Addiction is a Bio-Psycho-Social-Spiritual Disease
ASAM Definition
• The orientation of the ASAM work group was
that the spiritual dimension could be looked
at as describing the basic values which give
meaning to a person’s life and which provide a
framework for a human being’s relationship
beyond oneself and with the transcendent.
Mayo Foundation for Medical
Education and Research
“Spirituality has many definitions, but at its
core spirituality helps give our lives context. It’s
not necessarily connected to a specific belief
system or even religious worship. Instead, it
arises from your connection with yourself and
with others, the development of your personal
value system and your search for meaning in life.
For many, this takes the form of religious
observance, prayer, meditation or a belief in a
higher power. For others, it can be found in
nature, music…art or a secular community.
Spirituality is different for everyone.”
Recovery and Connectedness
• Connectedness to self
• Connectedness to others
• Connectedness to a greater whole
Get out of your emptiness/your hole
Get out of your “self”
Recovery is HOPE
• It’s been Hell on earth, but it doesn’t have to
stay that way.
• Unmanageability can be replaced by sanity.
• Yes, it can happen to you.
• Yes, it’s a gift. An attitude of gratitude helps.
AA Works!
• Persons who have long-term recovery
– Regular/long-term attendees of AA are overrepresented among those in long-term recovery
• Some persons can ‘do it on their own’
– Strong-willed; will-power
– This actually isn’t that common
• Fellowship is the key – plus some
accountability to others as well as yourself
What do we expect at HRC?
• That you’ll TRY IT
• That you won’t say ‘AA sucks, it’s not for me’ without
having had your own personal experience with it
• That you’ll experience different groups
• That you’ll take risks and go on your own to new
groups
• That you’ll have some experience with the sponsorsponsee relationship before you leave
• That you’ll attend AA in your home area and, ideally,
secure a local sponsor, before you leave the
structured/protected environment of residential tx.
Is it just AA?
• No, but we think you need to engage and
participate in something that can do for you
what AA can do
• Other 12-step programs
– Narcotics Anon, Cocaine Anon, Nicotine Anon,
Gambling Anon, Sex Addicts Anon, Overeaters Anon
– Alanon
– Adult Children of Alcoholics (ACOA) groups
• Rational Recovery (RR) / SMART Recovery
Summary
• Do something every day to affirm your recovery
(admit your disease, commit to change)
• Establish a routine, a set of healthy behaviors
• Get outside of yourself; don’t ‘go it alone’
• It’s available everywhere
– Phone number lists for people in your ‘home group’
– When out of town, you can go (plan ahead)
– When in crisis: if it’s not unfamiliar to you, you’re
more likely to use it
What can AA do for you?
How to live the Steps
1.
2.
3.
4.
ADMIT IT – your life wasn’t as rosy
as you were making it out to be,
you and others were being hurt;
you were NOT ‘handling it’
The source of your life’s unmanageability is no mystery: it’s your
pathological pursuit or reward or
relief, your ‘drug’
Trying to overcome it by the sheer
force of your will, generally won’t
work--and it’ll leave you
disappointed/frustrated and your
loved ones not trusting your
declarations and platitudes
There is hope—and getting outside
of yourself is a path, and ‘doing it
different’
• Acceptance. Willingness. Readiness
to change. Actually changing.
• Admitting what you have done that
you could have done differently/
better.
• Being fully prepared to behave
differently
• Actually changing what you do.
• Have regrets, say you’re sorry, make
amends.
• Changing how you deal with your
“feeling” life—be aware of your
feelings, let yourself experience
them, let yourself show them
• Changing how you relate to others.
• Getting connected with yourself,
with others, and with the larger
whole (H.P.)
A bit of history…
• From “Alcoholics Anonymous”,
the “Big Book” of A.A.
Foreword to First Edition
• PRECISELY HOW WE HAVE RECOVERED
• Better understand the alcoholic
– The alcoholic is a very sick person
• Anonymity
• Non alliance
Foreword to the Second Edition
• By 1955 a miracle has happened
– 6000 groups, 150,000 members
• The two elements of recovery
– Carry the message – alcoholic to alcoholic
– Spiritual principles
• A brief history of the early days
Foreword to the Third Edition
• By 1976 over 1,000,000 members and 28,000
groups
• “…At its core it remains simple and personal.
…One alcoholic talks to another alcoholic
sharing experience strength and hope.”
Thank you!
Michael M. Miller, MD, FASAM, FAPA
Medical Director
Herrington Recovery Center
262-646-1056
[email protected]