Journal of Substance Abuse Treatment, Vol

PERSONAL PERSPECTIVE

Altered States of Consciousness Therapy

A Missing Component in Alcohol and Drug Rehabilitation Treatment

JOHN D. McPeake PhD, BRUCE P. KENNEDY, MEd, AND SHARON M. GORDON, MA

Beech Hill Hospital, Dublin, New Hampshire

Abstract-Attaining altered states of consciousness is described as a basic human motive. The substance dependent population is distinguished from other populations because they pursue these states destructively by inappropriate use of alcohol and drugs. Despite a body of literature supporting the benefits of altered states of consciousness, alcohol and drug rehabilitation treatment programs fail to address this motive because of social disapproval, means-end confusion, and inadequate staff training. The authors maintain that Alcoholics Anonymous directs its members toward an altered state of consciousness called a spiritual awakening, which replaces the self-destructive pursuit of substance induced "highs. "Failure to address patients' need for alternative methods of achieving altered states of consciousness is presented as part of the reason for relapse. An Altered States of Consciousness Therapy (ASCT) program is described that can be used to teach patients to consciously manipulate affect and cognition to achieve a new consciousness.

Keywords-altered states of consciousness; Alcoholics Anonymous; therapy; relapse; 12 steps; alcohol and drug rehabilitation treatment.

ALCOHOL, NICOTINE, CAFFEINE, prescribed tranquilliz

ers, and illicit substances, for example, marijuana, cocaine, and opiates, are widely employed in the United States for the purpose of altering mood, mental state, and consequently behavior. Alcoholics and other drug-dependent patients, as well as other substancedependent people, for example, bulimics and anorexics, self-destructively pursue alterations in feelings, thoughts, and behaviors through substance use.

Part of the pathology of addiction lies in the unbridled pursuit of the altered states of consciousness (ASC) associated with the substances used. Even experienced clinicians and researchers are frequently amazed at the sacrifices that addicted individuals are willing to make to continue to use substances and to

Requests for reprints should be addressed to John D. McPeake, Vice-President for Therapeutic Services, Beech Hill Hospital, Dublin, NH 03444.

experience the states of consciousness induced by them.

A voluminous literature emerged in the 1960s and 1970s exploring the antecedents of altered states of consciousness, the characteristics of the states themselves, as well as the behavioral consequences of such experiences (Tart, 1969; Weil, 1972). While some of this literature was devoted to the production of altered states through substance use, most of the literature was devoted to alterations in consciousness produced by other means, for example, meditation, physical exercise, massage, biofeedback, hypnosis, etc.

In the literature referred to earlier as well as in the present article, ASCs refer to states of consciousness that are qualitatively different from ordinary waking consciousness. They appear to be distributed on a continuum based on how different they are from normal waking consciousness and from each other. As employed here, it is suggested that a normal untrained human observer can distinguish, for example, normal

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waking consciousness from dreaming, normal waking consciousness from sleeping or unconsciousness, normal waking consciousness from alcohol- or drug-induced intoxication, normal waking consciousness from states of sexual or religious ecstasy, normal waking consciousness from consciousness during peak experiences, or normal waking consciousness from trance. This usage is similar to that employed by Tart (1969), Weil (1972), and Harre and Lamb (1983).

Weil (1972) noted the apparently ubiquitous nature of techniques used to experience nonordinary or altered states of consciousness. He noted that the experience of nonordinary consciousness seemed so compelling and universal as to represent a common human motive. He also noted that without an opportunity to experience altered states of consciousness in constructive, ritualized, socially approved ways, individuals would seek other, less desirable ways of achieving this end. He argued that despite the significance of this need, our culture makes little provision for such experiences other than through the use of alcohol.

In the face of the facts that substance-dependent people seek self-destructively to alter their consciousness as part of their illness and that people in general are motivated toward such alterations in consciousness, it is surprising that alcohol and drug rehabilitation treatment programs spend so little time addressing these issues. Most such programs make little or no effort to systematically expose patients to constructive alternative methods for experiencing nonordinary consciousness. Even where minimal efforts such as stress management or meditation are present as part of a treatment program, they are rarely integrated in a manner that addresses the relationship between recovery and altered state issues.

What makes this even more surprising is that Alcoholics Anonymous (AA), which serves as the bedrock of much alcohol and drug rehabilitation, clearly directs its members toward an altered state of consciousness. The 12th step of AA directs the member actively involved in the steps toward a change in "consciousness and being" called a "spiritual awakening." This state of consciousness and its maintenance is the goal of all the steps and replaces the negative, self-destructive pursuit of substance-induced "highs" with what AA regards as the true, positive, life-enhancing "high," the spiritual awakening.

The failure to understand the need for such ASCs and the failure to see that AA directs individuals toward such experiences by a different method represents a curious lacuna in therapy for addiction. Some portion of the outcome variance associated with relapse may be explained as a failure to address the issues considered here. The purpose of this article is to explore why treatment has ignored the pursuit of ASCs and to further delineate AA's pursuit of such states. The nature of ASCs in general will be explored as well

as suggestions for a new type of therapy offered as an integrated component of alcohol and drug rehabilitation: Altered States of Consciousness Therapy (ASCT), which will be outlined.

THE ETIOLOGY OF SUBSTANCE DEPENDENCE

Attempts to explain substance dependence have become increasingly sophisticated, particularly since the identification of the genetic basis of alcoholism (National Institute on Alcohol Abuse and Alcoholism, 1985). There is widespread agreement that substance dependence is determined by many variables: drug availability, drug choice, environmental stressors, genetic predisposition, peer, family, and broader sociocultural attitudes and practices, etc. Usually in discussions of the etiology of substance dependence, the use of alcohol and other drugs to manage dysphoric thoughts, feelings, and emotions is also emphasized. Thus, while it is common to use negative internal states as one of many variables explaining dependence, it is rare to find substance dependence explained by the desire to experience more sought-after states. These otherwise sophisticated explanations leave out the "joy," "ecstasy," "bliss," "buzz," and "high" so often described by the drug-dependent person as the state being sought.

Some researchers have, however, pointed in the direction of the pursuit of new experiences and altered consciousness as a central element of drug use, abuse, and dependence. Naditch (1975) identified experience and/or pleasure seeking as one of the three primary dimensions of motivation for using drugs in a college population. Segal, Cromer, Hobfoll, and Wasserman (1982) identified an expanded awareness-insight motive as one of three reasons for drug use among adjudicated juveniles. Zuckerman (1970, 1979) has demonstrated that sensation seeking, the individual's tendency to seek out varied, novel, and complex experiences, is closely associated with substance abuse and dependence. Jaffe and Archer (1987) compared several objective inventories, using normal subjects, including the MMPI Pd scale, the MacAndrew Alcoholism Scale (MAC), the Millon Alcohol Abuse Scale, the Millon Drug Abuse Scale, and the Sensation Seeking Scale (SSS). They concluded that the SSS score was most closely associated with the primary reason given by their subjects for using substances.

Weil (1972), from a more clinical perspective, argued that the need to alter one's state of consciousness emerges developmentally in children and that some of their play, such as spinning to dizziness or holding their breath, is specifically designed to produce nonordinary consciousness. As children develop, the adult world discourages such practices, and consequently such activities disappear or go underground. One promise society holds out is that later, alcohol may be enjoyed to

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accomplish the same result. Meanwhile, children and adolescents continue approved and disapproved practices to experience ASCs such as listening to music or using drugs other than alcohol.

Weil (1972) argued that attempts to suppress such practices are doomed to failure because these practices represent a primary motive. Strivings to experience ASCs are consistent with some of the highest and most noble spiritual and religious goals of humanity. While individuals may use alcohol and drugs to attain states similar to those attained by meditation, prayer, fasting, etc., such states are transitory and illusory. Individuals need to learn that permanent and beneficial altered states of consciousness may be attained without drugs and, further, that drug use impedes such attainment.

There is good reason to believe that clinical research and clinical opinion confirm that an important motive for all individuals who use substances, whether they become dependent or not, is to experience new, nonordinary states of consciousness. AA clearly suggests that the pursuit of such states is also the aim of recovery.

ALCOHOLICS ANONYMOUS AND THE

SPIRITUAL AWAKENING OF STEP 12: AN ALTERED STATE OF CONSCIOUSNESS

AA, as well as other 12-step programs, do not have as their goal the simple cessation of the behaviors on which they focus. AA and Narcotics Anonymous (NA) only see not drinking and not drugging, that is, abstinence, as a preliminary method. Abstinence alone, that is, "being dry," is, in fact, viewed as an unhappy, pathological state that could only be maintained with considerable pain. From a more psychological point of view, if alcohol and/or other drugs have been integrated into a person's life, removing them also removes important adaptive behaviors without which the individual cannot function.

The 12-step programs' methods are much more complicated than mere abstinence. Recovering persons are expected to admit and accept utter and complete humiliation and defeat at the hands of their addiction. They are also expected to acknowledge the total unmanageability of their lives, the need for total, unconditional surrender, and the fact that they cannot recover by relying only on their own resources. It is assumed that for people to admit these things, they must have experienced a sufficient amount of pain and suffering (i.e., hit bottom).

Next, recovering persons are expected to come to believe that only a power greater than themselves, God, can restore them to a sound mind. Having accepted this, they must then turn over control of their lives to God, according to their own definition of God. This calls for the cultivation of willingness and

a new understanding of independence and dependence, where the proper use of the will is conformance with God's will. This turning over of control is epitomized by the Serenity Prayer, which is offered as a cognitive strategy, particularly with its final, frequently omitted phrase, "Thy will, not mine, be done" (Alcoholics Anonymous, 1987, p. 41).

In rapid succession, individuals are expected to assess their liabilities in an inventory which they share with another and with God and then become ready to have these "character defects" removed by asking God to remove them. In these endeavors, the recovering person comes to grips with the self as it is, becomes less isolated, experiences forgiveness, and learns humility and honesty. Subsequently, they seek to identify and make amends to people they have harmed and through the amendatory process to become more insightful about the self and less isolated from others.

On a daily basis, the recovering person is expected to continue the self-examination and to admit promptly and to correct defects of character and instances of unethical behavior continually. Prayer and meditation are to be cultivated to improve "conscious contact" with God and conformity to the will of God. This routine is regarded as a method of living and a way of life to be practiced in all the person's affairs. The result of these practices is an alteration of consciousness and being called a spiritual awakening (step 12), which leads to enhanced competence and behavior as described in the Promises:

We are going to know a new freedom and a new happiness. We will not regret the past nor wish to shut the door on it. We will comprehend the word serenity and we will know peace. No matter how far down the scale we have gone, we will see how our experience can benefit others. That feeling of uselessness and self pity will disappear. We will lose interest in selfish things and gain interest in our fellows. Self seeking will slip away. Our whole attitude and outlook on life will change. Fear of people and of economic insecurity will leave us. We will intuitively know how to handle situations which used to baffle us. We will suddenly realize that God is doing for us what we could not do for ourselves. (Alcoholics Anonymous, 1976, pp. 83-84)

This spiritual awakening is a central issue in recovery. Although there are differences among the spiritual awakenings of different recovering people, AA (1987) describes the commonalties of such experiences:

The most important meaning of it is that he has now become able to do, feel, and believe that which he could not do before on his unaided strength and resources alone. He has been granted a gift which amounts to a new state of consciousness and being [italics added]. He has been set on a path that tells him he is really going somewhere, that life is not a dead end, not something to be endured or mastered. In a very real sense he has been transformed, because he has

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laid hold of a source of strength which, in one way or another, he had hitherto denied himself. He finds himself in possession of a degree of honesty, tolerance, unselfishness, peace of mind, and love of which he had thought himself quite incapable. What he has received is a free gift, and yet usually, at least in some small part, he has made himself ready to receive it. (pp. 106-107)

It is interesting to note that some spiritual awakenings are dramatic and unusual, whereas most are slow, gradual, and ordinary. Further, people who have had such experiences, while powers of example within the AA fellowship, are seen as relatively ordinary, nonmystical, individuals.

WHY ARE ASCs EITHER IGNORED OR NOT INTEGRATED INTO ALCOHOL AND DRUG REHABILITATION TREATMENT?

commonly offered or understood by treatment professionals as an important goal of treatment. This may in part be simply an extension of the social repression described above, or it may suggest a lack of training among professionals about recovery from substance dependence. It may also stem from a failure to see that the 12 steps are part of a long historical tradition of altering consciousness through spiritual discipline. Spiritual discipline, of course, is at variance with the materialism that dominates the culture presently and accommodates therapeutic, psychological, psychiatric, and medical interventions as real while perceiving spiritual interventions as somehow "not professional" or "unrealistic." While some parts of medicine, notably cancer treatment, are moving to integrate spiritual variables into recovery, the very field that points in that direction, addiction treatment, seems to be rejecting its roots.

Despite the rich literature on ASCs in psychology and spiritual writings, and despite the fact that AA clearly points its members toward an ASC, reviewing the published literature on rehabilitation treatment or surveying current rehabilitation treatment programming reveals a paucity of writing or treatment programming that clearly integrates ASCs with recovery. Despite this, some methods that have historically been used to achieve ASCs are included in treatment and recommended by some writers as responses to selected treatment problems, for example, relaxation, meditation, art, physical activities, cognitive therapy, video and audio experiences, hypnosis, and biofeedback: Such techniques are rarely consciously employed as illustrations of producing ASCs or as illustrations of the potential benefits of such altered states of consciousness.

It would seem that there are several reasons why ASCs are not specific goals of nor integrated into alcohol and drug rehabilitation treatment. First attempts to achieve ASCs are generally socially disapproved. This may stem from the social perception that such alterations in consciousness have an inherently revolutionary and socially subversive quality (Tart, 1969; Weil, 1972). Others argue that such experiences are potentially personally dangerous, linked to depression, psychosis, or self-destruction, and therefore need to be carefully prescribed and controlled.

Second, ASCs have become so intertwined with one method of achieving such alterations, namely, taking substances, that people reject the method and the goal simultaneously without giving this confusion much thought. The tremendous harm with which the use of licit and illicit substances has been associated during the past few decades often has prevented calm discussion of the underlying needs for consciousness alteration that are implicit in substance use.

Further interpreting the steps as a route to a permanent alteration in consciousness and being is not

ALTERED STATES OF CONSCIOUSNESS THERAPY: UNDERLYING ASSUMPTIONS

It is necessary to help substance dependent patients understand and accept their need to experience altered states of consciousness. They need to be exposed to substance-free methods that can be utilized to achieve ASCs. These attempts are called Altered States of Consciousness Therapy (ASCT), which are a natural compliment to and lead in the direction of the 12-step recovery programs discussed earlier. This program is predicated on the following set of assumptions:

1. ASCs are defined as alterations in consciousness awareness, predominantly subjective experience, which may be produced by a variety of methods, that is, prayer, meditation, relaxation, hypnosis, biofeedback, exercise, fasting, etc.

2. ASCs may have some unique behavioral or physiological characteristics, but are primarily defined by the subjective report of individuals that their consciousness is different from normal in some marked or qualitative way. The correlates of these differences may be defined by such characteristics as positive mental attitude, goal directedness, certain types of cognitions or self talk, certain types of imagery, as well as consciousness of a power greater than self.

3. Every person has a desire to alter his or her state of consciousness from time to time. As in other motives, this may vary in individuals from a more intense to a less intense need.

4. Experiencing ASCs leads ultimately to personal growth and development and may be associated with what appears to be "super normal" behaviors. These behaviors are not super normal but are within the behavioral range of any normal person who wishes to invest time and effort in personal development.

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5. The potential to have ASC experiences is an innate characteristic of the nervous system.

6. The underlying neurochemical substrates of ASCs will be found in the rapidly expanding field of endorphin/enkephalin neurotransmitter research as well as related research evidence for endogenous neurochemicals that are analogues/agnonists to other exogenous substances of abuse (Goldberg, 1988; Pert 1986; Pert, Ruff, Weber, & Herkenham, 1985; Snyder, 1986).

7. ASCs can be arranged hierarchically from transient, impermanent states produced by exogenous methods with modest potential for personal growth and development, to more permanent states that are endogenous, within the individual's control, and that lead to potentially dramatic and positive changes in functioning.

8. Drug-dependent individuals have become stuck, as a result of genetic predisposition, using alcohol and other drugs to produce ASCs and, therefore, are stuck in a life-threatening situation.

9. The treatment of choice for many such addicted individuals is abstinence from alcohol and other drugs combined with treatment based on AA or other 12-step programs that emphasize a spiritual methodology to attain a particularly sophisticated and desirable ASC called a spiritual awakening. 10. Recovering individuals will be aided in their recovery by being taught to experience many different ASCs. This allows them to enjoy and benefit

from nonsubstance-induced ASCs as well as to learn the general characteristics of ASCs. 11. The goal of this process is to enhance the individual's ability to attain the spiritual awakening described in step 12 of AA.

AN ASCT PROGRAM IN PRACTICE: PROGRAM COMPONENTS AND THERAPEUTIC PROCESS

Using ASCs in practice means first educating patients and staff to the fact that the steps point the way toward alterations in consciousness and that nondrug-induced alterations in consciousness are desirable. Preceding portions of this article, as well as the assumptions listed earlier, present the key ideas and topics that need to be discussed with both groups. Inservice training of staff and patient education seminars addressing these issues provide the framework within which ongoing therapeutic activity is interpreted.

ation, offer mechanisms for appropriate ventilation of emotion, and provide behaviors for more effective use of leisure time. Although exercise has been frequently cited as a source of an ASC, for example, "runner's high," opportunities for patients to utilize exercise for this purpose do not seem common. In an ASCT program, the feelings engendered during exercise are explicitly connected to ASCs. Patients are taught that physical activities access some of the same neurochemical subsystems of emotion and feeling that are activated by alcohol and drug use.

Physical activities staff focus patients' attention on the positive feelings they experience during physical exercise and its relationship to a spiritual awakening. Patients are shown, and experience, the benefits of the physical activity both mentally and physically. Furthermore, it is suggested that this is similar to, although not as powerful or as intense as, the spiritual awakening that can emerge through practicing the steps.

Adventure-based activities are also included among the physical activities offered to some of the patients. Rock climbing is used for the opportunities it presents to enhance communication among patients, engender trust, enhance self-esteem through overcoming an apparently difficult task, and as a metaphor for the recovery process. When such exciting and strenuous activities are utilized, the altered state components are identified and processed by the treatment team. For example, during rock climbing, there are almost always some frightening and anxiety-provoking moments. During such moments, or shortly afterwards, participants often experience "natural highs" that are combinations of sympathetic nervous system arousal, and satisfaction and relief at accomplishment of the climb. Focusing attention on such alterations in consciousness contributes to patients' understanding that alternative highs are available and again suggests the similarities to AA's spiritual awakening.

These activities are offered as beginning methods for achieving an ASC without alcohol or other drugs. It is explained to patients that physical activities are preferable to substances as methods of achieving ASCs and serve as a metaphor for the process of attaining nondrug-induced ASCs. These are not the primary treatments for the patients' illnesses, but are activities that will assist them while they move toward a more complete recovery.

Relaxation Training

Physical Activities

Physical activities such as running, aerobics, weight training, and swimming are included in the treatment program as methods to encourage physical wellness, serve as examples of healthy competition and cooper

Relaxation training is one of the most common and obvious methods that we employ. Originally suggested by Jacobsen (1938) and popularized in the work of Wolpe (1958), progressive relaxation has been modified and influenced by many schools of thought. It has become a technique that is ubiquitous in alcohol and

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drug rehabilitation and psychological and psychiatric treatment for many disorders, and is a cornerstone of behavioral medicine.

In relaxation training, patients learn physical exercises that contrast the subjective feelings when muscles are tensed followed by attention to the feelings in the same muscle groups when they are relaxed. Patients learn to be attentive to increases in muscle tension in target situations and with practice gain some control over the onset of anxiety. Often, breathing control techniques borrowed from yogic disciplines are paired with muscle relaxation techniques.

Frequently, this relaxation training is coupled with an exploration of cognition's or "self-talk," which are sometimes seen as the "worry" component of anxiety and which are translated into physical tension, for example, "This is a terrible situation. I'm not going to survive this. I can't do this." Through a variety of cognitive-behavioral techniques, patients learn to still such cognitions and substitute for them more constructive reality-based cognitions, for example, "This is a difficult situation but I can survive it comfortably if I reach out for help from my therapist and fellow patients. Other people have survived such events and so will I. Now calm down and practice your relaxation exercises."

In addition, patients are often taught the use of vivid imagery that supports efforts at relaxation and calmness, for example, imagining themselves functioning in a specific and effective manner, experiencing enhanced self-esteem, etc.

While undergoing such training, patients often report spontaneous alterations in consciousness. Patients say they "feel better" or "feel different," and such changes in consciousness are linked by treatment staff to the specific activities in which they have been involved: relaxation training, self-talk, and imagery.

The essential message for the patient is that through specific behaviors and mental activities, they can alter consciousness as they did taking alcohol or other drugs. It is suggested that the patients are accessing the same neurohormonal and brain pleasure-pain centers that they did when actively drinking or drugging, only now they are doing so without substances. Patients seem excited by the concept that they can bring these very same neural systems under some type of voluntary control in a healthy manner. Patients are taught that to gain mastery with this technique, they need to practice daily.

prime example of this is the use of the Serenity Prayer, which is employed regularly with patients to help them sort out cognitions and behavioral strategies into those that need to be acted upon and those that need to be "turned over." Once patients learn to use this type of cognitive strategy, they often are much better prepared for dealing with the recovery process with its many unsettling events. Patients learn that when they successfully employ a cognitive strategy, they alter their feelings and mood states, that is, they alter their state of consciousness.

Thus, a patient who learns that his wife has decided to separate from him can be coached to assess what he can constructively do to make a difference in the situation. He can grieve and discuss with others his loss, fear, anger, and anxiety. He can express his concern to his wife with honesty and vigor while recognizing that he cannot control the behavior of another person. He can try to recognize and empathize with his wife's pain and suffering while he was actively using substances, and he can hope for reconciliation based on his demonstrated willingness and ability to refrain from alcohol and drugs and change his life. Moreover, he can concentrate on his own recovery because substance use will only worsen an already difficult situation. Since ventilation and cognitive restructuring of this sort is often new to patients, it can be a model for a whole array of techniques that are, in the long run, better than drugs for creating positive feelings.

The whole "slogan and saying" aspect of the recovery movement is full of similar opportunities for cognitive reformulation and cognitive strategies, all captured in pithy aphorisms. "Live and let live" helps sort out interpersonal interaction. "All you have to do is not drink or drug" constructively uses denial in early recovery. "Bring the body the mind will follow" seeks to overcome the early confusion and resistance of the newly recovering person overwhelmed by the multiple tasks of recovery. The Tip of the Iceberg (1983) summarizes the use of such tools in recovery.

When patients develop the ability to use the Serenity Prayer, the slogans and sayings, or other cognitive techniques, they often report a sense of calmness, a sense of being in control, a freedom from worry that is new to them. This subjective experience represents an important aspect of an ASC, a new consciousness that can be used again to illustrate the direction in which recovery should be moving.

Cognitive Therapy

Most alcohol and drug rehabilitation programs utilize overtly or covertly some form of cognitive therapy in their treatment armamentarium (Beck, Rush, Shaw, & Emery, 1979; Ellis, 1962; Meichenbaum, 1977). The

Art/Aesthetic Experience

One common outcome of artistic activities is the turning of patients' attention away from obsessional concern with self, other, and the world and a focus on manual activities, sensory input, perceptual, and aesthetic processes. Sometimes this results in periods of

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non-awareness, somewhat similar to meditation, culminating in the "high" of creating a very personal and unique piece of art work. Similarly, such an experience can be obtained from contemplation of a work of art. Such activities are often utilized in treatment for their enhancement of self-esteem, the opportunity they present to teach improved leisure time skills, and their possible value in reducing isolation and fostering communication.

These activities are used to emphasize their connection to altered states of consciousness. Patients are encouraged to understand that their creative or aesthetic experience is similar to the consciousness obtained from using alcohol and drugs. They are asked to consider the artists who have lost their creative and inspirational genius through the use of alcohol and drugs.

Meditation and Prayer

Meditation and prayer, which are specifically recommended to the recovering person in step 11, are also employed in the treatment program. Meditation is framed within the context of chapter 11 of Twelve Steps and Twelve Traditions (Alcoholics Anonymous, 1987). The patients are encouraged to read the chapter and follow the simple instructions outlined in the step in conjunction with the Prayer of St. Francis. The instructions are:

. . . reread this prayer several times very slowly, savour every word and try to take in the deep meaning of each phrase and idea . . . drop all resistance . . . rest quietly with the thoughts . . . so that (you) may experience and learn . . . as though lying upon a sunlit beach . . . relax and breathe deeply of the spiritual atmosphere with which the grace of this prayer surrounds (you) ... become willing to partake and be strengthened and lifted up by the sheer spiritual power, beauty, and love of which these magnificent words are the carriers. (When distracting thoughts occur about the process think of how much time was wasted fantasizing with alcohol and drugs.) Perhaps the real trouble was our almost total inability to point imagination toward the right objectives ... read the prayer again try to see what its inner essence is ... think now about the man who first uttered the prayer ... he asked for the grace to bring love, forgiveness, harmony, truth, faith, hope, light, and joy to every human being he could ... this much could be a fragment of meditation. (pp. 99-101)

Patients are asked either to use the pray of St. Francis or to choose some other such work that provides them with inspiration, and meditate on aspects of this that they find meaningful. This is often a difficult task for patients, and readings more consistent with their belief systems and values are adapted to their needs. Sometimes it is useful to encourage patients to use Eastern techniques, that is, transcendental meditation or Zen-like meditation that involve focus

on mantras or problems (koans). The therapy staff may modify these techniques and employ AA slogans and sayings as the point of concentration.

This type of meditative practice builds on concepts and techniques the patient has already learned at an earlier point in treatment. Patients are initially introduced to these concepts in educational seminars. The concepts are elaborated by the patient's clinician who provides specific instruction and guidance to help develop the