Twelve-step and mutual-help programs for addictive disorders.

Psychiatrists may wonder why both addiction treatment and the 12-step programs recommend abstinence. In his 50-year follow-up of two groups of alcoholics, Vaillant compared those who established secure abstinence with those who continued to drink. Secure abstinence was associated with: Living longer Better mental health Better marriages Being more responsible parents Being successful employees In considering the various routes to secure recovery, Vaillant recommended that clinicians: Offer the patient a nonchemical substitute for alcohol Remind the patient ritually that even one drink can lead to pain and relapse Repair the social and medical damage that the patient has experienced Restore the patient's self-esteem The preponderance of the research data now available indicates that the 12-step programs of AA, NA, Cocaine Anonymous, and Al-Anon are most helpful for alcohol-dependent and other drug-addicted patients as they seek to achieve secure, long-term abstinence. A growing number of clinicians is recommending that physicians become more knowledgeable and skilled in referring and supporting patients in working 12-step programs of recovery. Specific recommendations include: 1. Be familiar with 12-step activities and tools. These include meetings, home groups, sponsors, the Twelve Steps and Twelve Traditions, books, pamphlets, and slogans. To be able to discuss the meanings and applications of these tools for recovery is useful. Physicians can select those that are most suitable for the individual, recognizing that meeting attendance might not be the most important activity. 2. Support referral by facilitating a meeting between the patient and a temporary contact from the 12-step program. This means becoming familiar with local 12-step programs. Phoning the local AA or NA central office or hot line makes connecting patients to someone who will take them to a meeting that same day possible. AA and NA have committees whose members are interested in working with physicians to help get patients to meetings and to get information to physicians. These are the Cooperation with the Professional Community, Treatment Facilities, and Hospitals and Institutions committees. 3. Work with the resistance of patients. Many addicted patients are resistant to the idea of attending 12-step or mutual-help programs. Reminders of their painful personal database associated with the use of alcohol or other drugs can help break through denial. Involvement of family members and friends in the network therapy developed by Galanter can be effective in reducing resistance. Being patient and persistent in developing the therapeutic alliance helps to maintain contact during the first difficult year of recovery. Physicians should be prepared to work with patients as long as necessary to stabilize their sobriety. Zweben has suggested ways psychotherapy can help deepen work with the steps. 4. Help dual diagnosis patients understand AA's and NA's singleness of purpose. These programs work only with addiction; they do not try in any way to deal with other mental disorders. All patients have to say is, "I want to stop drinking or using drugs," and they will be welcomed and accepted at meetings (see Tradition 3). If they talk only about their psychiatric symptoms or medications, someone may suggest that they go elsewhere for help. Occasionally, well-intentioned AA or NA members tell patients to stop taking their medications. The authors always direct patients to the pamphlet The AA Member: Medications and Other Drugs. This pamphlet tells AA members not to play doctor and to take the medications their doctors prescribe. Copies of the pamphlet are widely available at many AA meetings, or they can be ordered by physicians from Alcoholics Anonymous World Services, General Service Office, Box 459, Grand Central Station, New York, NY 10163 (212-870-3400). 5. Get comfortable with the spiritual dimensions of healing. Zweber and Brown offer good suggestions for getting com