Title: Ecological Relevant Cognitive Behavior Therapy: The slogans and sayings of Twelve Step Programs and Their Use in Chemical Dependency Treatment.

Author: John D. McPeake, Ph.D., C.A.S., M.A.C.T.A.

Abstract: Twelve Step oriented therapies and Cognitive Behavior Therapy (CBT) both show positive outcomes in treating chemical dependency. Twelve Step oriented therapies include an "ecologically relevant" CBT component in the many slogans and sayings that identify dysfunctional patterns of behavior and thought and encapsulate constructive chemical dependency treatment strategies. These slogans and sayings also help bridge the cultural gap between professional treatment and Twelve Step Programs. In addition they provide insight into important cognitive and behavioral issues in recovery, have mnemonic benefits and sometimes appear to be able to produce rapid and constructive cognitive changes. This paper reviews a sample of slogans and sayings and offers suggestions for their utilization in clinical work.

Key words: Twelve Step, Cognitive Behavior Therapy, slogans and sayings, clinical tools, mnemonic devices, rapid cognitive change

Introductory footnote: John D. McPeake, Ph.D., C.A.S., M.A.C.A.T.A., President, The Dublin Group, Inc.: Behavioral Health Consultants, P.O. 129, Upper Jaffrey Road, Dublin, NH, 03444, jmcpeakeC monad.net

Title page                                                                                  Eco.Rel.CBT CRT

Ecological Relevant Cognitive Behavior Therapy: The slogans and sayings of Twelve Step Programs and Their Use in Chemical Dependency Treatment.

Introduction

Among contemporary schools of therapy for chemical dependence Cognitive Behavior Therapy (CBT) is one of the most widely research and demonstrably successful (Monti, P.M., Abrams, D.B., Kadden, R.M.& Cooney, N.L., 1989; Project Match 1997). CBT explores and exposes patterns of thinking and behavior that are dysfunctional, attempting to replace both with more adaptive strategies. Twelve Step based therapies also produce successful treatment outcomes (Project Match 1997; McCrady, 1998) and have the advantage of dovetailing with a unique, freely available, international network. In part, Twelve Step approaches produce their effects through an "ecological relevant" informal CBT approach implicit in the extensive repertoire of slogans and sayings which recovering members of Twelve Step Programs learn and practice. These slogans and sayings also expose dysfunctional patterns of thought and behavior and offer pragmatic, real world responses.

This paper examines the use of slogans and sayings as CBT tools to treat clients. These slogans and sayings provide an ecologically relevant mechanism and a contextual bridge allowing the therapist to understand and use the language the patient experiences. The therapist may then present clinical interventions that begin with this language and support, re-interpret and discuss the underlying cognition and behavior. The slogans and sayings also provide the therapist with rapid insight into the cognitive world of the recovering person. In addition, slogans and sayings have mnemonic characteristics, which allow them to be easily retained and also provide when divorced from their Twelve Step context pure CBT strategies, e.g., "Think the drink (drug) through." Slogans and sayings facilitate an affective connection with the process of recovery. Finally, slogans and sayings appear to have the potential to produce sudden and constructive rearrangements of cognitive life.

After offering a clinical illustration this paper continues with a summary of themes derived from hundreds of slogans and sayings with suggestions for their utilization in clinical work.

Case Illustration #1

William was a 22 year old, unmarried, white, male, college student with a history of substance use disorder, epilepsy and a mild stutter. William was referred to our outpatient program by a family friend. William came from an intact, upper SES family that included a sister several years older. William's father, owner of a business, drank regularly in a controlled fashion and his mother, who was the prime mover in seeking treatment for her son drank socially. On initial evaluation William was smoking marihuana daily, ordering anxiolytic medication via the internet and drinking regularly. His epilepsy was not well controlled because of non-compliance with his medication regimen and his alcohol and other drug use. As a result of his chemical dependence he had just barely completed his junior year at college. William and his parents agreed to a rehabilitation hospitalization and he was referred to a program in the Southwest. During

1-12.                                                                                                                Eco.Rel. CBT

his senior year in school he saw a therapist occasionally and attended A.A. irregularly. Prior to graduation William and two college friends were arrested for attempting to import MDMA into the U.S. and although he graduated, William was placed on federal probation. Subsequent to graduation William moved to Metro Boston and sought employment. During outpatient therapy William was compliant and polite but only moderately involved in his treatment plan.. During a particular therapy session as the consequences of William's alcohol and other drug use were under review the therapist said: "William you weren't always in trouble when you used, but every time you were in trouble you had been using." The turn of phrase had a noticeable effect on William who repeated the expression but personalized it, "I wasn't always in trouble when I used, but every time I was in trouble I had been using. Yeah, That's me." By his own report the idea embedded in the slogan was a new insight. During subsequent sessions this slogan became a mantra for William and appeared to be associated with an improvement in his motivation and commitment to recovery. As he was also attending A.A. he reported that he heard the same expression used and illustrated on several occasions by people, speaking in A.A., enhancing his identification with the speaker and the program. He also reported the not uncommon scenario that the slogan often "popped into his head" unbidden and occasioned meditation on its meaning. William had implicitly believed that his alcohol and other drug use were not related to the problems and difficulties in his life. Fortuitously perhaps, this slogan reorganized William's cognitions.

Major Themes of Slogans and Sayings and Their Clinical Application

An informal analysis of the author's collection of 141 slogans and sayings suggests (Anonymous 1983) over a dozen thematic categories. Twelve of these categories are listed below with a representative slogan or saying and suggestions for how it has been utilized in a therapeutic context.

l. Obsession and the First Drink or Drug

Individuals who suffer from chemical dependence are often marked by their inability to predict when they will over use a substance and the outcome of such over use. In consequence the first drink or drug, which often triggers craving and compulsive use, is immortalized in a number of slogans and sayings, i.e., "It's the first drink (drug) that gets you drunk." Most recovering people are aware that this is not literally true. They realize that first use often re-establishes craving and usually results in a pattern of return to use with adverse consequences. The slogan and others like it, however, suggest extraordinary vigilance to initial use and its unpredictable consequences. This slogan leads to a discussion about the assumption that, "I can drink or drug safely and without consequences."

One client was amazed at the notion that first use, itself triggered by cues worth exploring, was the beginning of an obsessive compulsive chain. Until this point in her therapy she had continued to believe that she could have a "few" and it would be OK. She said that oddly this was both dramatized and made humorous for her by an old man,

2-12                                                                                                                 Eco.Rel. CBT CRT

with whom she would not ordinarily identify, who at an A.A. meeting described his unsuccessful strategy for staying sober. She said that he related he had heard all about the danger of the first drink and so whenever he went into a bar he would order that first drink and set it aside on the bar. Then he would drink the second drink, the third and so on. He said with infectious good humor that he had proved conclusively that it wasn't the first drink that was the problem. She noted that listening to the humorous and self­effacing old man was one of several early turning points in her recovery.

This vignette is illustrative of the fact that slogans and sayings are the beginning of a dialogue that can occur within the individual, in individual counseling, or in a group setting. The dialogue productively raises questions about the implications of "first use" in a person suffering from chemical dependence. The slogan or saying then may become a mnemonic device that can store in memory all of the ideas associated with the discussion. And, as this slogan demonstrates, the added humor associated with hearing such a wry tale from another recovering person reduces defensiveness and accelerates identification.

2. The Specific Suggestion "Don't drink (Don't Use!)!"

Despite the fact that objective observers see the painfully obvious nature of this issue, that drinking or using other psychoactive substances is the central issue, it is remarkable how often the discovery that this is the case is a little "sartori" for the recovering person. In addition, it is remarkable how often recovering people enjoin each other not to use by employing "Don't use!" both as a greeting, salutation and unendingly repeated piece of self-talk. While such an injunction from a non-recovering person may be angrily rejected, with identification with recovery and recovering people, it becomes accepted and playful. Within recovery circles a day of not using is regarded as a "miracle" because recovering people believe that the natural tendency of the recovering person is to use and something quite unusual must be actively happening to interfere with this powerfully tendency. This slogan challenges the suggestion that "use" is not the problem and that direct suggestion not to use is somehow taboo.

The following anecdote, related by a man in early recovery, demonstrates the change in attitude toward this injunction that is symptomatic of clinical progress. "This will sound pretty strange from a person who believed that alcohol and other drugs were not the problem but here's the way it is now. When I see people who are involved in A.A. or who are trying to stay away from alcohol and other drugs, I usually say "Don't drink!" in place of "Hello" or "Goodbye." Sometimes people are surprised or even offended, even people who have been in recovery a long time. "What do you mean," they sometimes say "I've been sober three years." I say "Don't drink!" or alternatively "Don't use!" for me, not for anyone else. Oh, I guess that I'll admit when someone else hears "Don't drink!" it might focus his or her attention on sobriety and not drinking or drugging. If it does that I'm glad but basically I say it for me. I want to remind myself every chance I get of what alcohol and other drugs did to me and what a life of sobriety in A.A. is doing for me."

3. Other Specific Suggestions for Behavior Change

3-12                                                                                                             Eco.Rel. CBT CRT

Twelve Step Programs are full of additional direct suggestions that frequently include imagery and goal directed cognitive behavioral strategies. In fact, Twelve Step Programs seem to have an implicit or covert theory that resembles clinical hypnosis and other forms of suggestive therapeutics. From a theoretical viewpoint: certain antecedent conditions enable a person to enter a particular state of consciousness or awareness that allows them to do things that they previously had difficulty doing. Members A.A. and N.A. believe that pain, suffering and humiliation will eventually create in the chemically dependent person a subjective state that is called "willingness (Twelve Steps and Twelve Traditions, p.34 ff., 1981)." When this state has been achieved the chemically dependent person will be able to follow suggestions that they had previously been unable to follow. Often the chemically dependent person may report that they "heard" or "understood" the suggestion for the first time, in what appears to be a spontaneous or dramatic insight.

Corey had grown up in a family full of chemical dependence. He was fond of saying that alcoholism didn't run in his family, it "galloped." He had been to many A.A. and ALANON meetings with family members. Now the court had mandated that Corey go to A.A. for himself or go to jail, but he was having trouble with A.A. He felt that he knew a lot about A.A. from his earlier experiences. He could sometimes predict the questions people would ask and be ready with the answers. He felt he knew who was sincere and who was just "using" A.A. to get out of trouble. He knew many of the old timers in his area of the city because he had been to so many meetings with his dad, who Corey said, "Never really got it." At a particular meeting one of the old timers listening to Corey's complaints about his difficulty in "getting" the program suggested to him that he should, "Look for a way in, not a way out." The suggestion "stuck" with Corey. He couldn't get it out of his head nor could he find the strategy that would make the program work for him. Another A.A. member, noting Corey's frequent comments at meetings about knowing all about it, but still not getting it, suggested that Corey, "Take the cotton out of his ears and stuff it in his mouth." So Corey adopted a policy of not speaking at meetings and just listening, listening hard for the thing that would open up the program to him as he knew it had to others. While listening he found that many of the people whose presentation and recovery he respected had participated in a particular, intensive, Twelve Step Study in another part of the city. Corey enrolled in this program despite the fact that it was a 22 night commitment over 22 weeks. For Corey that intensive Step study seemed to hold the key to a happy and productive recovery. He realized that most of the people he had been associating with were not really advocates of the Steps but were really "Two Steppers" people who didn't drink and went to meetings but avoided Step work. He said he should have known all along that the Steps were the A.A. program. It was what had been missing for Corey, he had found a way into recovery by listening. Corey subsequently became one of those A.A. members who didn't say much, but when he spoke people listened.

4. Blaming People, Places and Things

4-12     Eco.Rel. CBT CRT

One of the most common and accepted assumptions about chemical dependence is that recovery is strongly causally related to "circumstances" or, worse, "underlying causes." Chemically dependent people themselves are very good at blaming "people, places and things" for their use. They resist the need to first change their alcohol and other drug use behaviors, often leaving this strategy until all else has failed. In fact, we have good evidence that dependence is caused by use, and resulting genetically programmed changes in midbrain neourophysiological systems, i.e., the ventral tegmental-medial forebrain-nucleus accumbens axis (McLellan, A.T., Lewis, O'Brien and Kleber, 2000), that subsequently do not respond well to executive cortical functions. All the insight in the world isn't worth much, nor is changing people, e.g. wives, friends and lovers, places, e.g., exchanging San Francisco for Boston, or things, e.g., the new house will solve the problem. The specific alcohol and drug use behaviors that are part of the chemically dependent person need to be changed. Consistent group pressure is frequently needed to accomplish this. The wisdom of Twelve Step programs has been that if you deal with the alcohol and other drug use you can move forward, if you don't you can't.

Alex had been going to A.A. for only a very short time when he heard "Wherever you go there you are." in reference to a geographic cure. Alex was a professional who had "started over" several times in several cities. He felt that the Myth of Sisyphus described his life. He'd move to a new city, he had very transferable computer skills, and begin life again. Gradually over several years his alcohol and other drug use would produce the same scenario he had experienced in his old location. His life, like Sisyphus' rock, would role back down the hill to the very bottom and he'd begin again rolling it uphill. He tried meditation, psychotherapy and various wellness fads. When he heard this expression something clicked for him. He saw that in every instance he had failed to significantly alter his relationship with alcohol and other drugs. Now that he was staying put and confronting his drug dependence something good seemed to be happening.

5. Change

The issue of change as suggested above looms large for the alcohol and drug dependent person. There is a specific temporal order to this change within Twelve Step oriented approaches, and it begins with changing the alcohol and drug related behaviors. Many slogans and sayings encapsulate this fact. These slogans challenge the assumption that if the chemically dependent person changes the circumstances that led to becoming drug dependent she will stop using.

George was dealing with the issues of cues and triggers and discussing the issue in group therapy but he didn't really accept the associated ideas as they were being presented. He was also attending A.A, meetings. Subsequent to a particular A.A. meeting he came to group anxious to share a new insight. He said that while he had thought he understood the cues and triggers "thing" he had heard two expressions at that single meeting that brought it a11 together for him. One speaker had noted that getting drunk was like getting mugged, "You can't get mugged in a dark alley if you don't walk in dark alleys." he added. The very next speaker had during his qualification noted that, "If you keep going into the barber shop you're going to get a haircut." George told the group that he'd been mugged (metaphorically) so many times and he hadn't seen it coming and he'd had so

5-12                                                                                         Eco.Rel. CBT CRT

many bad "haircuts." He said that after the meeting he had had a dream in which he entered a bar and there were signs on the wall that said, "We're going to take your money!" We're going to beat up on you!" We're going to throw you out the door!" "We're going to make you feel awful!" but the final sign said "And you'll be back for more!!" George said he now "felt," not just understood, what triggers and cues meant.

6. The Issue of Illness vs Morality

The issue of whether chemical dependence is an illness, a social problem, or a moral problem continues unabated despite sophisticated comparisons of drug dependence with other chronic medical illnesses (McLellan, Lewis, O'Brien and Kleber, 2000). Nevertheless Twelve Step approaches have long championed the view that drug dependent people are sick and need to admit that fact. With the admission of illness and the rejection of the underlying assumption of "badness" many of the otherwise incomprehensible aspects of recovery make more sense and it becomes easier to participate in treatment.

John was a college educated, articulate professional who resented people telling him how to live. He felt he had a problem with alcohol and other drugs but had tremendous difficulty accepting the idea that he had a chronic illness and therefore accepting the idea that he needed regular treatment. While attending an alcohol and drug intervention program for operating a vehicle under the influence he was required to attend a twice­weekly group session and A.A. or N.A. At an A.A. meeting he heard the following which he related at group. A professional man at a meeting said something like this: "I think today of just how much subtle, and sometimes not so subtle, damage we have done to the beautiful, complex mechanism inside our skulls. Most of us do not have a wet brain when we arrive for treatment but it will take many months of physical and mental health before we can successfully think clearly and effectively. Particularly during this early period, taking suggestions that are given to us may well be a life saving proposition. Its not a normal state of affairs to subjugate one's behavior to the suggestions of others but it is important to remember that whether in a treatment center, under the care of a physician, but always with the help of A.A. or N.A., we are very sick people with a life threatening illness. Our fuzzy thinking, impulsive emotions, and labile moods cannot be allowed to kill us. Remind yourself of the fact that your alcohol use has hurt you badly. It has injured and abused the instrument that controls you, which in many senses is you. Get out of the driver's seat for a while and only get back in when others tell you they think you are ready. I try to remember, `I'm here because I'm not all there."'

John brought the expression "I'm here because I'm not all there." to group and wanted to discuss alcohol, drugs and brain damage. This produced several very stimulating groups. He was particularly interested in literature that suggested impairment of executive function and decision making in early recovery. The existence of neuropsychological deficits made the need for practical, down to earth treatment understandable to John and allowed him to more readily accept help and direction from others.

6-12                                                                          Eco.Rel. CBT CRT

7. Utilization versus Analysis

Many people find their initial experience with Twelve Step Programs difficult because of their simplicity and directness, prioritizing specific types of behavior above analysis of the "reasons for" or the "meaning" or "explanation" of the person's chemical dependence. In this sense Twelve Step Programs are like CBT training manuals which focus on learning and practicing specific behaviors. A.A. culture enjoins the newcomer do the following new behaviors: don't use for a day, go to meetings every day, join an A.A. group, get a sponsor, follow the sponsor's suggestions, get a job in the group, e.g., make coffee, set up the meeting, travel with the group to commitments, sit in the front row, "Listen to learn, learn to listen." etc. A.A. says to the newcomer "Learn these new behaviors!" The slogan is "Utilize don't analyze." Many people coming to Twelve Step Programs think they have to first figure out their chemical dependency, figure out the "why." These programs in their actual day to day enactment reject that idea and instead provide structured behavioral training. It is worth noting that after behavior has been stabilized there is a lot of opportunity for analysis, often called "Step work," but that comes at a later stage in the progression of recovery.

Like many highly credentialed professionals Martha, a psychiatrist, was offended by what in her view was the unbelievable and "stupid" simple mindedness of Twelve Step Programs. This was epitomized by the blue and gold banners decorating the room where her first N.A. meeting occurred. She was particularly offended by the "Keep it Simple" banner because she appropriately regarded herself as richly complex. Nevertheless she was forced to attend such meetings by her contract with the Board of Registration in Medicine in the state where she had been discovered self-prescribing and using opioids at work. She openly admitted to her therapy group, another requirement of her contract, that she never would have continued the participation at self-help meetings without the contract. She had been in psychotherapy with another psychiatrist for many years and felt it to be a much superior modality, although her therapeutic work had had no impact on her opioid dependence. After another instance of opioid use turned up on a urinalysis, her surveillance was intensified and Martha faced permanent revocation of her medical license. Martha decided to try and do exactly what her sponsor suggested to her. Six months later she related to the therapy group that she had joined an N.A. group, was making coffee, which she never drank, going on commitments, helping other addicted people, etc. She said her life had changed, she didn't understand it. She'd figure that out some time later. Her strategy at that time was "Fake it, `till you make it." "I'm just doing it the way its laid out by my sponsor," she said "its working and I don't care why."

8. Time: A Daily Program, A Present Time Orientation

Twelve Step Programs have something in common with Zen in their orientation to time. Zen says, "When doing the dishes do the dishes." Twelve Step Programs say look well to this day, "The past is history the future's a mystery." The emphasis in both is on now, this moment, being fully in the present. This does not obviate the need to plan for the future, but it does encourages awareness of the unpredictability of the outcomes of plans

7-12                                                                                                                 Eco.Rel. CBT CRT

and attempts to prevent unhappiness when things don't work out exactly as planned, i.e., "You can plan but don't plan the outcome." The people who come to Twelve Step Programs are often in a hurry, they're looking for a quick fix for a chronic problem. American health care is pretty good at things that can be fixed quickly. Rehabilitation medicine is a different story, slower, less glamorous, more painstaking, with the need for more patience. This different orientation to time can be a stumbling block.

April was a 29 y.o., alcohol, cocaine and marijuana dependent woman, divorced, a high school graduate, with a child in foster care, living in a women's recovery home. She was very anxious about the future, particularly what would happen to her young daughter. For her the idea of living a day at a time seemed unreasonable, and her main concern was getting out of the recovery home, getting a job and resuming life with her child. Since this was not her first attempt at recovery, she had been in one form or another of chemical dependency treatment on six occasions, she was at some level also aware that she lacked recovery and living skills. April entered into a contract with staff that first involved relaxation training. Progressive relaxation was selected as the method of relaxation because it gave April a significant measure of control and felt to her, "Sort of like a work out." She reported that progressive relaxation successfully reduced her anxiety level. In addition to daily attendance at meetings, both in the recovery home and in the community, April established daily written goals, e.g., daily review of the newspaper for jobs, a certain number of calls and interviews, completing her house responsibilities, as well as a written list of long term goals: job, apartment, living with her daughter. The strategy offered April was that by consistent work on her recovery and daily goals she would maximize her ability to achieve her long-term goals. In addition, to the reduction in anxiety, she reported that she frequently became productively immersed in her daily routine and could reduce anxiety by thinking about releasing muscle tension and her "strategy." She reported that for the first time she thought she was really living "a day at a time."

9. Loss of Control

Chemically dependent people, over the course of their illness, often experience progressively more dramatic instances of loss of control over their use, which invariably are correlated with more dramatic, adverse consequences. Despite this evidence they fight the notion that they cannot control their use. Chemically dependent people, who want to be like "normal" like other people, think they may discover a method which will allow them to "use in safety." In the Twelve Step Model recovery begins when the drug dependent person acknowledges the inability to control use. Many slogans and sayings address this issue and many of them are quite humorous.

Carlos was a Spanish speaker for whom English was a second language. His alcohol and marijuana dependence had produced numerous negative consequences, including a recent criminal charge of possession with intent to distribute, for which he was on probation and mandated to outpatient treatment. He came to group one evening perplexed by

something he had heard at the A.A. meeting he had attended that week. He said that the

R-12                                                                         Eco.Rel. CBT CRT

speaker said something like, "When I drink I break out in spots." and he wanted to know what that meant. Was there some kind of skin condition associated with drinking? The group laughingly explained to Carlos that the speaker must have meant that when he used alcohol he ended up in blackouts travelling to places he hadn't intended to travel to. This was particularly meaningful for Carlos because he had ended up living in the Northeast because his drinking and drug use had hooked him up with some itinerant kitchen laborers who finally stopped wandering when they got jobs in Boston. Carlos too was a victim of the unpredictability of a drinking life style and he began to see that. The slogan "When I drink I break out in spots." and his misunderstanding of it became part of his story.

10. The issue of Acceptance of Help

From a Twelve Step perspective the chemically dependent person needs to recognize the loss of control over alcohol and other drug use, as well as, their inability to deal with their use disorder themselves and therefore the need for help from outside the self. All of these issues involve the acknowledgement of loss of control and acceptance of help. Clients need to learn that accepting help from others can be viewed as a skill and we can evaluate the need for help based on how successful we are at the particular activity in question. And as they make progress they can get feedback from their own performance and from other's evaluation of their performance and then adjust their behavior. This involves a student teacher relationship, a coaching relationship or a mentoring relationship:           '

Steve was a surgeon who had been disciplined by the state board of medicine for incidents involving excessive use of alcohol. Steve was very self confident and intelligent and resented anyone telling him what to do. He was also very invested in his status as a physician and had trouble listening to people who were not physicians or at least other highly credentialled professionals. Steve attended A.A., it was part of his contract with the board of registration, but felt it was a waste of his time and quite beneath him. Steve also attended a support group for physicians, dentists and other doctoral level health care professionals where he felt more comfortable. One evening when Steve was expressing his discontent another physician-surgeon said, "When I was using I thought I was the best surgeon on the planet. Sometimes you need that kind of confidence, but I was beginning to make mistakes and I had a close call with a patient and shortly thereafter my partners intervened on me. I went to treatment and when I returned to the practice my partners said, `That was like medical school, now we're going to apprentice you to Eddie M. and he's going to teach you what it takes to stay sober and live sober. You'll do what Eddie says or you can find a new medical group.' Of course I was pissed but I felt trapped and Eddie turned out to be a genial old guy who simply said, `Look Doc get out of the driver's seat for 90 days. We'll travel around together and I'll show you how it works.' I did that I "Got out of the driver's seat." and despite myself I learned from Eddie just the things I needed to know, it was like being a resident all over again just that the hours and the coffee were better." Steve said that was a turning point of sorts for him, the idea that recovery was about learning a new set of skills was what he needed to hear.

9-12                                                                                                                 Eco.Rel. CBT CRT

11. The Self and Being Alone

Twelve Step oriented therapies offer the opportunity for intense, structured, community experience within a sub-culture. This contrasts with the common implicit assumption "I can do it myself." This may involve inpatient treatment programs of varying duration from detoxification to multi-month programs. A.A. itself, to which an individual often is referred, has a "program" which is comprised of the Twelve Steps and the Twelve Step work which they encompass, both on a daily and long term basis. Such programs like the Alcoholics Anonymous Way of Life (AAWOL) programs may be quite formal and institutionalized. There are then various types of meetings both for the general recovering community, e.g. open meetings, discussion meetings, and meetings specialized by sub-group, e.g., men women, gays, etc. In addition, there is the "fellowship" of A.A., the communal structures which include numerous informal contacts, e.g., extensive phone networks, socializing over coffee or meals, group anniversaries and other communal celebrations, retreats, travel to and from meetings, shared living space, and special interest groups such as recovering Harley Davidson riders etc. The emphasis is on community and the necessity of a community that endorses and emphasizes abstinence and recovery. The individual may participate in as much or as little of this sub-culture as he needs or wishes.

In early recovery A.A. suggests immersing the individual in this subculture which "holds" the person until he has developed a stable recovery. Tom reported in group that he heard someone say at a meeting, "When you're alone you're in bad company." He related the following reaction, "This expression really annoyed me when I first heard it and my sponsor repeated it to me. Today I know that even though I'm still sick, when I heard it I was very sick and left to my own devices I would have been overcome by my illness in a short time. Naturally I argued because I didn't understand, but mostly because I still wanted to drink and drug which I went ahead and did anyway, but I could only do it by isolating myself from other A.A,s and they persisted by calling me or actually coming by the house. I needed people around me to keep me sober, to keep me from drinking and drugging, to teach me about living sober until I could acquire enough skills to occasionally be by myself in safety. Eventually, A.A. gave me the wonderful luxury of being able to be alone with myself and enjoy my self. Today I am aware that I need other people and should not remain isolated from people who understand me, lest the illness rear its ugly head." The group discussion about self and others that followed his comments was stimulating and productive.

12. A Higher Power

Twelve Step programs are overtly spiritual in their emphasis and frequently reference God. Nevertheless, individuals who are agnostic or atheist can and do benefit from the great flexibility and inclusiveness found in actual A.A. practice. Frequently, for example, the A.A. group is offered as a power greater than the individual and therefore an appropriate substitute for a higher power. Sometimes the sponsor, the initial mentor in A.A. or N.A., is identified as the higher power. Or the notion of spirituality is broadly interpreted to include any ethical or philosophical tradition that fosters positive personal

10-12                                                                                         Eco.Rel. CBT CRT

growth and development. Twelve Step programs usually bend over backwards to make it easy for the newcomer to enter the system. Nowhere is this flexibility clearer than in the re-framing of the word God in the following case vignette.

Joe was quite hostile to the idea of God when he finally became willing to explore A.A. He would not say the "Our Father", a prayer that typically closes A.A. and N.A. meetings, nor the "Serenity Prayer." He expressed his belief that "higher power" was simply a thinly disguised euphemism for God. Joe was so desperate as a result of the adverse consequences of his alcohol and other drug use that he continued to participate. He realized that many of the people he met were similar to himself and they were able to stop using. He needed, and to some extent wanted, to stop use too. But he struggled with God until at one meeting a man with whom he identified was speaking about a similar problem. He talked about how he didn't believe in God, didn't want to hear about God nor the higher power. He said that someone said, "If you put periods in the word G.O.D. it really can simply stand for group of drunks or group of druggies. Let a group of drunks be your higher power. How about that?" Joe said that was one of those eureka moments in two ways. First, the idea worked for him. He could relate to the idea that individuals who had learned to stay sober could help. Second, he perceived how hard people in A.A. tried to make the program fit the needs of the individual alcoholic and he felt very grateful for that thoughtfulness.

Conclusion

Slogans and sayings from Twelve Step programs provide an additional tool in the clinical armamentarium. They have the advantage of emerging from the context and experience of Twelve Step programs and offer the therapist rapid insight into the issues Twelve Step programs have historically regarded as important to recovery. Slogans and sayings challenge destructive cognitions and offer behavioral strategies. Such slogans and sayings stimulate group discussion and serve as easy to remember symbols of more complex topics. On occasion they appear to produce rapid insight in clients about some recovery issue. In addition, they often have a wry, good humored flavor that make sensitive topics more palatable.

REFERENCES

Anonymous. (1983). The Tip of the Iceberg. Dublin, NH: The Dublin Group,Tnc.

Kadden, R., Carroll,K.M., Donovan, D., Cooney, N., Monti, P., Abrams,D., Litt, M. and Hester, R. (1992). Cognitive-Behavioral Coping Skills Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals with Alcohol Abuse and Dependence. NIAAA Project MATCH Monograph, Vo13, DHHS Publication No. (ADM) 92-1895, Washington: Government Printing Office.

11-12                                                                                                                 Fcn.Rel. CRT

McClellan, A.T., Lewis, D.C., O'Brien, C.P., and Kleber, H. Drug Dependence, A Chronic Medical Illness: Implications for Treatment, Insurance, and Outcomes Evaluation. Jounral of the American Medical Association, 284, 1689-1695.                                                                                         . McCrady, B.S. (1998). Recent research in Twelve Step Programs. In Graham, A.W. & Schultz, T.K. (Eds.), Principles of Addiction Medicine, (pp. 707-717). Chevy Chase, MD: American Society of Addiction Medicine, Inc.

Monti, P.M., Abrams, D.R., Kadden, R.M. & Cooney,N.L: (1989). Treating Alcohol Dependence. New York: Guilford Press.

Project Match Research Group (1997). Matching Alcoholism Treatments to Client Heterogeneity: Project MATCH Post treatment Drinking Outcomes. Journal of Studies on Alcohol, 58,7-29.

Alcoholics Anonymous (1981). Twelve Steps and Twelve Traditions. New York: Alcoholics Anonymous World Services, Inc.

17-17                                                                                                                 Eco.Rel. CBT CRT