Integrating therapy with 12-Step Programs - Why the steps alone won't do it!

By Joseph Sacks LCSW

Have you participated in 12-Step meetings for years, and found them helpful, but still feel that something is missing? Do you know people who work those programs diligently, but still suffer from major emotional health problems and unhealthy lifestyles? Would you like to finally find true and lasting recovery?

Have you realized the importance of integrating therapy with 12-Step Programs?

In order to truly accomplish recovery we need to understand 2 points. One, that although 12-Step programs have some redeeming qualities, namely step number 12 which prescribes coming together in meetings, steps 1-10 are deeply flawed and can actually prevent recovery! This will be explained at length shortly. The second point that we need to understand is that in order to truly recover from alcoholism/addiction, it is almost always necessary to undergo a serious regimen of good psychodynamic psychotherapy. This means specifically addressing issues arising from unresolved trauma originating in childhood. Almost all addicts, if not all, had difficult childhoods. Some when first coming to therapy report, “I had a happy-go-lucky childhood,” but after a few sessions realize that it was actually troubled and their relationship with their parents was actually conflicted. Therefore since going to meetings is extremely helpful, I definitely recommend you continue, but that you simultaneously seek good psychodynamic psychotherapy with a warm empathetic therapist.

So what is it about steps 1-10 that is so unhelpful?

Steps 1-3 are as follows:

  1. We admitted we were powerless over alcohol - that our lives had become unmanageable.
  2. Came to believe that a Power greater that ourselves could restore ourselves to sanity.
  3. Made a decision to turn our will and our lives over to the care of God as we understood him.

It sounds very true, good and spiritual. But these 3 steps make a fundamental error in understanding God’s ways and His will for us in the world. The truth is, God wants us to make great efforts to heal ourselves. He wants us to be the authors of our own salvation, from addiction, or otherwise. These 3 steps advise us too much to just lay back and let God do all the work! But that doesn’t work because God wants us to have to our credit the amazing accomplishment of healing ourselves!

Let’s say someone had an infection. Would you advise him to admit that he is powerless over bacteria, and only God can save him through miraculous intervention, and he must leave it up to his higher power for a cure? No, we would say that it is God’s will that he make his own serious efforts to seek out doctors and take antibiotics! He does need a higher power to save him, but the mechanism through which God does so is through the person’s own diligent efforts.

Alcoholism/Addiction is an illness just like infection! Therefore God wants us to leave no stone unturned in seeking our own cure through going to meetings and also through medical science. What treatment? Good psychodynamic psychotherapy! Somewhat who lays back and only engages in spiritual efforts such as prayer and charity is actually not very spiritual at all, because he is ignoring God’s will that he seek medical treatment!

The problem with steps 1-3 is that they ask you to put too much into God’s hands!

The truth is He wants you to work with him in a partnership. God helps those who help themselves. Even the worst alcoholic is not completely powerless over alcohol. There are steps he can take to ameliorate his situation. He can seek treatment. God wants you to be the author of your own recovery. He wants you to heal yourself. He doesn't want you to lie back and let him do all the work. If you took a train to a 12 step meeting, that is God sending you help through that meeting. Why can't God help you at home? He wants you to make the effort of going to the meeting. The way the higher power restores alcoholics to sanity is by giving them good psychotherapy! That is your miraculous divine intervention. But he wants you to go out and get your therapy, and to work hard on it gradually overtime, and not to rely on instantaneous, dramatic, miraculous transformational cures.

See my post, “How does psychotherapy work?” for a description of the steps an addict needs to go through in psychotherapy in order to heal.

But here we need to understand that almost all addicts suffered serious childhood mistreatment. Some may at first report a happy childhood but under examination reveal that it was difficult and conflicted. Usually the addict is suffering from so much unresolved childhood trauma that he has a very low baseline pleasure level, and his unhealthy thought patterns prevent him from enjoying the normal pleasures of life. Only the intense addictive high can overcome the bad feelings left over from his childhood, and so he is so desperate for pleasure that he simply cannot resist acting out in addictive behavior in his desperate quest for much-needed happiness. 

While integrating therapy with 12-Step programs, we must remember that Parents make mistakes!

In Psychodynamic Psychotherapy, the patient will come to understand that although his parents loved him very much and did the best they could for him considering the circumstances, they unfortunately made some serious mistakes in the way they raised him and those mistakes led to addiction. Therefore we do not blame your parents, we simply attribute cause. You must first recognize and understand the monstrosity of those mistakes and how they affected you. You must gain a keen awareness of the truth of the childhood errors committed against you. Examples of a troubled childhood include coming from a divorce or separated home, or being partially abandoned by one parent. Maybe his parents were together but they verbally, emotionally or physically mistreated him, being over critical, controlling, yelling, giving out harsh reprimands or putting him down. Such a person will have been emotionally harmed by such parenting and that harm will create in his mind and self a very low baseline pleasure level. For example he will have many unpleasant emotions such as anger, fear, frustration, hurt and shame which were generated by the mistreatment but had been repressed in childhood. These repressed emotions simmer in the person is unconscious and simply make him feel terrible, resulting in a low sense of well-being. In addition childhood mistreatment causes faulty false thought patterns such as low self-esteem and low self-worth.

Low self-esteem is a complete lie, an illusion and illogical.

Aren't you a decent person like everyone else? Weren’t you born innocent? Haven’t your good deeds outweighed your mistakes? However, chronic emotional mistreatment in childhood creates deep lifelong thoughts and feelings of low self-worth. This drives the baseline pleasure level even down further to the point where you feel so bad and guilty about yourself that you cannot enjoy everyday, mundane pleasures such as reading the newspaper, walking down the street or enjoying the weather. That’s the key to addiction. Only the super-intense pleasure of the addictive substance/behavior is strong enough to overcome their bad feelings about themselves and provide the desperately needed pleasure and satisfaction. Everyone needs a certain amount of pleasure and happiness every day in order to function just like he needs food, but because of his childhood repressed emotions and low self-esteem, the addict is suffering such a loss of pleasure that he is desperate for joy and happiness and only addictive pleasures can provide that for him. The high is the only thing that can drown out the voice of the negative self-talk in his head, and cover over the unpleasant effects of all those repressed emotions.

Therefore an important part of integrating therapy with 12-step programs, is deeply mourning and grieving those parenting errors,

similar to the way you mourn the loss of a loved one, only more intensely because the loss of a healthy childhood is a much greater tragedy! Then you must understand that children who are mistreated usually have a tremendous amount of repressed emotions, which simmer in your unconscious and cause misery and addiction. Therefore you must in therapy gain conscious awareness of all your emotions that were repressed in childhood and afterwards. This will bring significant relief and reduction in addictive tendencies. Then you must understand that whenever someone hurts you, even your parents, you are automatically angry. Addicts have huge amounts of repressed anger which they unfortunately direct towards others and especially themselves, and it drives them to addiction. Therefore you need to recognize, validate, release, understand and express your anger towards your parents and early caretakers, or those that hurt you. You must first recognize it yourself in therapy and then find a way to respectfully communicate it to them. This will bring great healing.

The above work together with attendance to meetings is God’s will and is the most spiritual thing you will ever do!

There are some alcoholics/addicts who manage to stay sober with the 12 steps only without psychotherapy. But who says drinking is the only problem? That's only a symptom of the problem. Poor emotional health and unhealthy thought habits is in itself a terrible burden and a suffering to live with. Only psychotherapy can cure that.

face-1985673_1920.jpg

It could be that the alcoholic/addict does need a higher power to recover but why? He needs a higher power to guide him through the course of treatment in psychotherapy!

In the bible of 12-Step programs, Alcoholics Anonymous, or the Big Book, on page 39 it claims that an alcoholic is absolutely unable to stop drinking on the basis of self-knowledge. It is assumed that they pursued self-knowledge assiduously, and found it, yet it was to no avail. However, curiously, knowledge of their own childhood, which is among the most important knowledge that any man must possess, are completely absent from the Big Book! It is astounding that with such an omission they claim self-knowledge. The truth is, self-knowledge does cure addiction. You may need divine help in acquiring that self-knowledge but the knowledge is the conduit through which the divine grants you his salvation.

What are the problems with steps 4-10?

Steps 4-10 are as follows.

4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
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.
10. Continued to take personal inventory and when we were wrong promptly admitted it.

What do you notice is peculiarly characteristic of these steps? They place the blame for the problem squarely on the ill person himself, and prescribe a cure involving righting all the terrible wrongs that he has supposedly done to others! But nothing could be further from the truth! The alcoholic/addict is a completely innocent victim of childhood mistreatment! Most of them were treated so badly, that the fact that they didn’t turn into ax-murderers attests to their great righteousness! It is critical that you get this point.

You are not a bad person, you are not at fault!

You are the victim of childhood mistreatment and are a fantastic person considering the way you were raised. Blaming and guilting yourself, as steps 4-10 prescribe, only makes you more miserable and fuels more addiction! You must do the opposite, realize that your problems are not your fault, that you are a wonderful person! You much develop an attitude of understanding, kindness, compassion, pity and generosity towards your very self, and that is what will heal you. Most alcoholic/addicts are terribly self-critical and self-blaming. You need to do the opposite for healing. You need to adopt a totally non-critical attitude toward yourself, because self-criticism pushes your pleasure level down lower, driving you to need that high again.

However compassion and kindness to yourself brings your pleasure level up so you won't crave those addictive highs so much.

Making amends to others should only be done after you have taken care of yourself! It is your parents who need to make amends to you! It is recommended that after some time in therapy you respectfully approach them and explain to them that you recognize that they loved you and did the best they could, but unfortunately they made errors that affected you, and it will be tremendously beneficial for your relationship if they could recognize their mistakes and yes, apologize. When approached in a calm, respectful way, most parents will be willing to help. An admission from your parents will help your recovery tremendously and bring great healing.

It is true that you may have harmed others, even significantly, in the course of your life, but your traumatic upbringing seriously reduces your blame and guilt! Considering the way you are raised, you are truly saintly that you didn’t hurt people much worse! Realizing this fact will propel you towards recovery.

On page 36 the Big Book describes how a particular alcoholic was feeling ashamed and like a failure at being a salesman for a concern he once owned, and this led him to drown out his feelings of shame in drinking. The solution would have been to understand that his behavior was not at all worthy of shame. Considering the way he was raised, the fact that he's not a criminal is a tremendous accomplishment of self-control and righteousness. His addiction and professional failures is a totally normal and understandable reaction to the way he was raised. It is indeed commendable that he has maintained himself up until this point as well as he has. This kind of cognitive reframing of a situation will reduce the shame and the accompanying drive to drink.

Unfortunately the Big Book preaches a revulsion for the self of the alcoholic/addict, of his guilt and his blame.

This attitude only causes more drinking. The problem with AA is that it assumes the alcoholic/addict is essentially defective and he must admit it and this is his only path to healing, however the truth is his symptoms are actually a normal and healthy reaction from unresolved childhood trauma. He is in no way defective. Once an alcoholic always an alcoholic is simply not true. Healing is possible. In order to heal you need to take the opposite attitude, compassion, understanding and kindness towards yourself.

For example of page 13, it says, “Never was I to pray for myself except as my requests bore on my usefulness to others, then only might I expect to receive.”  This is surely a ridiculous understanding of prayer! Although praying for others is fine, God wants you to pray for yourself more than anything! If you don't take care of yourself who will? Is it not God's will that you feed and care for yourself commensurate with the decent human being that you are? Why should only others be deserving of prayer? Contrary to popular belief, the rule in spirituality is that you must always take care of your own needs first, and only when your needs are amply fulfilled can you be freed up to turn your attention to the needs of others. If you are starving, you must first seek food for yourself before you seek to do charity. The same attitude is necessary for recovery. God wants you to care deeply for yourself! You are a child of God and are deserving of kindness and consideration as much as anyone else! Taking care of yourself first puts you into an immensely strong position from which you will be able to perform tremendous acts of kindness to others in the future, but you must re-parent yourself and heal from your childhood trauma first.

It is not a lack of kindness to others that alcoholics/addicts suffer from have. It is a lack of kindness towards themselves. Charity starts at home.

Why is prayer for yourself so desired by God? Because begging God for your needs gives you tremendous conscious awareness of them, so you can go about taking care of yourself properly and thereafter care for others, and that is what God wants!

What about resentment?

On page 64-66, the Big Book says that resentment and anger towards others is the number one offender and cause of alcoholism/addiction. This is true except those feelings are placed on the wrong recipient. 90 percent of the time, the addict is not truly angry and resentful at his wife, boss, business associates and friends. He is truly angry at his parents and resentful for the way they treated him as a child. It is that anger and resentment unredressed that is causing him to misplace it onto innocent others and is causing his alcoholism. So again although avoiding anger and resentment towards wife, boss and friends is admirable and helpful, this can only be done if he first recognizes, validates, processes and resolves the anger and resentment towards his parents! Yes, his parents need to do steps 4 to 10 to him! In order to heal his resentment and anger his parents have to make amends to him. If they're unwilling or it is otherwise impossible you must at least get a firm conviction of how wrong they were and how you were a completely innocent victim, as you were just a child. I recommend in therapy spending a certain time each day expressing your anger towards your parents, raging into your pillow as described in "How does psychotherapy work?" Paradoxically an amazingly, expressing, validating feeling, understanding and giving a voice to our angry and resentful feelings is what allows them to be processed and resolved so they can then fade into the past and only become a memory, never to be displaced again onto innocent others.

You cannot tolerate any more mistreatment!

On page 67 the big book talks about being patient and kind towards those who indeed do hurt us, however that is the path for someone who is very strong emotionally and spiritually and can tolerate being harmed to certain extent without upsetting the health of his equilibrium. But for the alcoholic/addict who had a troubled childhood and is emotionally damaged, this is bad advice. He has suffered too much in his childhood to be able to tolerate even one more bit of abuse. Therefore as a means to preserving his mental health and achieving recovery, he needs to be very careful to not let anyone abuse him anymore, especially his parents or early caretakers who had mistreated him so much in the past. See my post on anger where I explain in depth how it is very unhealthy to either repress anger or express it towards the wrong people, but expressing it towards those who truly hurt you is immensely healing.

Not miracle cures, gradual, natural healing!

On page 50, the Big Book talks about the higher power accomplishing the miraculous, the humanly impossible. Indeed recovery is miraculous in so far that everything in the world is actually miraculous, but it's no more miraculous than anything else. People are tempted to hope for tremendous life-changing spiritual revelations as a solution to their problems. However these so-called solutions are usually manic in nature, that is they are vainglorious, unrealistic and not genuine. True growth, be it spiritual or emotional, must happen very gradually and through natural, non-miraculous means such as psychotherapy and social contact, where little by little you become less dependent on your addictive substance and more and more emotionally healthy. Miraculous, sudden recoveries like described on page 56 to 57 are rare and not to be expected.

Healthy intimate relations.

If a spiritual experience alone is powerful enough to save an alcoholic why can't they thereafter drink in moderation? Why does it have to be all or nothing? I know a "Recovered" sex addict who has been in meetings for 20 years and the whole time has not acted out once sexually, not even with masturbation. He was unmarried the whole time. You call that recovered? Celibacy is one of the most bizarre and cruel forms of living that a human being can take! It is akin to forcing oneself to starve for 20 years but miraculously not dying. God wants you to have a normal, healthy sex life! This so-called recovered addict has simply repressed his feelings. He is no one to be admired and he has found no cure.

On page 68-70 the Big Book talks about sexual relations. Here I agree that "Our sex powers were God-given and therefore good." Sex is like food, it is a basic need. In order to recover properly it is very helpful for the alcoholic/addict's to have the pleasure and satisfaction of a healthy, sane sex life to bring his pleasure level up to where it should be so he won't need to act out in self-destructive addictive behaviors. Celibacy is no virtue. Long term, monogamous relationships seem to be much healthier and helpful than short-term affairs. However one has to use his head in setting up such a marriage or relation. It may be that in some cases the alcoholic/addict needs to progress for six months or a year further in therapy before seeking an intimate relationship, as emotional health is a necessary prerequisite to healthy intimate relations. I realize that for some people such a relationship is unrealistic or impossible, so please be advised that you can still recover without it. My only point is that a normal sexual life as well as an emotional relationship with a significant other would be helpful.

Step number 12: The saving grace of 12-Step Programs

Now you may ask: if there are so many problems with the steps, why are 12-step programs so popular and successful? The answer is step number 12: “We tried to carry this message to alcoholics,” the source for the custom of the togetherness and fellowship of 12-step meetings. That step is in itself so powerful that it redeems and heals, in spite of the errors of the first 10. How does it work? As I said before, in order to heal you need to do kindness towards yourself. Going to meetings and coming together with other alcoholics is a great kindness to yourself! Socialization, togetherness and unity between people is one of the greatest pleasures on earth. God wants you to be together with others, helping them and being helped in a constant give-and-take. By coming together with others you are demonstrating that you do have power over alcoholism and addiction you are helping yourself and that is what God wants you to do. So keep going to meetings however at the same time in order to have a true recovery you must get good psychodynamic psychotherapy as well, to heal from the cause of your addiction, childhood trauma.

Kindness to others is very important and helpful, I'm not taking away from that fact, however it must be preceded by kindness to the self.

God created the world for kindness. He constantly showers goodness down onto us. What is the vehicle by which that kindness gets to a person? Through his parents. Healthy parents take the goodness that God gave them and shower it endlessly upon their children. In this way the child learns by example that he is deserving of kindness and he is in turn inspired to be kind to others. But if the parents err in their task and do not shower the child with kindness and maybe worse actually harm him, the child does not learn about the kindness of God. He does not learn to be kind to himself nor to others. In therapy the alcoholic/addict and needs to re-parent himself and make up for all that kindness to the self that he missed as a child.

Remember Alfie Kohn, renowned parenting expert, said a person whose emotional and physical needs were met as a child is then freed up to be able to think about the needs of others and be kind to his fellow. But someone whose needs were not met as a child becomes preoccupied with those needs and is unable to show consideration and kindness to his fellow. So the alcoholic/addict's is selfish, as the big book says, but not because he chooses to be so and not through any fault of his own. He was set up to be so through the errors of his parents. The only way to cure his selfishness and be generous to others is to first re-parent and be generous and kind to himself. He must take care of his own emotional and physical needs through good psychotherapy, and then he will be able to be kind to others. However skipping that step of kindness to the self and just forcing yourself to be kind to others is grandiose, self-righteous and doomed to failure, as he will perceive an inherent contradiction. He will think, what about me? Don't I deserve kindness too? Why are my needs ignored? indeed acts of kindness to others do help because it feels good to be kind, and in that regard being kind to others you're really being kind to yourself, but it must be proceeded with true kindness directly to the self.

On page 74 it says, “The rule is we must be hard on ourselves but always considerate of others.” That is surely preposterous! You are a person too and God want you to treat yourself with utmost kindness and consideration!

I do not believe God wants us to “Utterly abandon ourselves to him” as it says on page 63. He wants us to do his will, but he wants us to take care of ourselves first so we are in a position to be able to do his will.

On page 68 the Big Book talks about our fears and asking our Creator to remove them. This is done by first understanding where they come from! A person who was mistreated in childhood get the idea into his head that "Bad things happen to me." Therefore it seems logical to him that more bad things are likely to happen in the future and this generates fear. But understanding that those thoughts were only created by the errors of his parents and it is not an essential aspect of the world, that no one has power over him to harm him now, his fears will subside.

Knowledge is power! We must recognize the value of integrating therapy with 12-Step Programs. Keep consistently searching for the truth of your childhood and you will find great healing!

Feel free to peruse my interesting blog, and the specialties on this website. If you are interested in integrating therapy with 12-step programs, and would like the guidance of a wise, kind-hearted therapist in NYC, you may call me at 646-681-1707 for a complementary 15-minute consultation. I look forward to speaking with you!