Thinking About Referrals to Alcoholics Anonymous in Relational Ways
By Chris Bitten, Registered Clinical Counselor

“If your talk [with a newcomer to AA] has been sane, quiet, and full of human understanding,
you have perhaps made a friend” - Alcoholics Anonymous, 4th ed., p. 94

Alcoholism is such a common condition that therapists will often have clients who suffer from it, whether the therapist is able to recognize it or not. If a client’s alcoholism does come into therapeutic view, the resource that Alcoholics Anonymous provides will probably be brought up by the therapist or client at some point. This article explores how integrative psychotherapists may assist their clients in using AA effectively from a relational perspective, with Richard Erskine’s eight relational needs as a lens.

The AA principles have been widely adapted to a number of other “twelve-step” programs, and the following remarks generally apply to them as well.

It is the writer’s experience that therapists rarely attend AA meetings, although “open” meetings that anyone can attend are available in every town and city. Because of this, therapists as well as clients may hold myths or misconceptions about AA – perhaps taken from depictions in the media -- that will be touched on in this article. As far as possible, quotations from the basic AA text (Alcoholics Anonymous, Fourth Edition, AA World Services, 2001) will be used to support this article’s concepts: they appear in bold face. Additionally, AA is a rich source of sayings, slogans and pithy guidance which on the surface can appear simplistic but in practice can be deep and effective. These appear in italics in this article.

Alcoholism is often characterized in its later stages by relational isolation as friends drift away, partners become bitter, and children become increasingly afraid of the unpredictable behavior alcoholism brings. The alcoholic may eventually find it easier to manipulate his brain’s pleasure centre with alcohol than undertake the hard work of initiating and maintaining relationships. In a non-alcoholic individual, emotional distress tends to motivate toward change and growth. In the alcoholic, as the disease progresses, emotional maturation can slow, cease or regress as that distress is medicated to some degree by alcohol. What follows is a failure to learn from emotional pain and a failure to develop more functional behavior.

Alcoholics Anonymous is clearly a relational therapy or a relational approach to healing. It is practiced in meetings, over coffee, through the development of close bonds with others in recovery, and by helping others achieve sobriety. AA encourages the alcoholic to relinquish old ways of relating: some of us tried to hold on to our old ideas, but the result was nil until we let go absolutely p. 59. This renovation of relationships to self, others and a higher power is central to AA. Over and over again, its literature emphasizes the importance of kindliness, patience, tolerance and love -- practices which are familiar to integrative psychotherapists -- instead of false ego display and competition.

Richard Erskine identified and elaborated eight relational needs in Beyond Empathy. Interestingly, while these were developed to understand clients’ relational needs in general, they also provide a window into how Alcoholics Anonymous functions to significantly re-socialize recovering addicted individuals. The therapist who understands the strengths and deficits in his or her alcoholic client’s relational sphere and understands as well how AA can meet relational needs will be able to help clients use aspects of AA in achieving a richer relational life.

The first relational need is for security in relationship (for a relationship to be secure, it must engender a sense of being protected and safe – a knowledge that openness and vulnerability will not meet ridicule or shame). AA provides this by encouragement of privacy (anonymity): take the stories but leave the names behind. In AA it is understood how difficult recovery can be and how profound isolation may not be overcome in days or weeks: come and let us love you until you can love yourself. The alcoholic who relapses is encouraged to keep coming back and to learn from the relapse: the door swings both ways. The laughter and good-natured humor at AA meetings act powerfully to defuse shame, sending the message that this is a place where you are understood and safe: your experience is considered normal here no matter how it is viewed elsewhere.

There are few places in the world where the recovering alcoholic cannot find an AA meeting. Even if he or she doesn’t understand the language, a warm welcome is likely, providing security against the stress of travel and a place where he or she will be deeply understood. The commonalities among alcoholics are striking – newcomers often find this eerie, even unbelievable -- and tend to outnumber the differences, even though untreated alcoholics may consider themselves terminally unique. It is both humbling and, paradoxically, a huge relief to understand that this is not so – at least, not within a room of other alcoholics.

The second relational need is to be validated and affirmed as significant (this is the need to be valued, appreciated, cared for and respected not only for what one can do, but for who one is). AA has long understood that the door has to be open to anyone with an alcohol problem who wants to be there. The Third Tradition of AA states: the only requirement for membership is a desire to stop drinking. pg 564. No-one can be excluded; all are valuable. The respectful listening that is granted to even the most chaotic “sharing” provides validation and affirmation. Another form of valuing is expressed in the maxim: the newcomer is the most important person at the meeting. Established members offer their telephone numbers and e-mail addresses to newcomers so that a beginning may be made on the warm contact that is a key to the success of AA.

Yearly anniversaries of members’ sobriety dates are honored in the home AA group with special recognition and valuing. Newcomers are offered tokens to celebrate a week, a month of sobriety and so on.

Valuing is also demonstrated in the very structure of AA. Each group is independent and elects its trusted servants for a short term by vote according to the group’s “conscience”, then others have a chance to serve. No one is seen as more important than another, but service to the group is appreciated and encouraged. The altruism this represents is believed in AA to be important to the reduction of false ego displays and destructive willfulness, and to the development of humility:

…the principle of anonymity has an immense spiritual significance. It reminds us that we are to place principles before personalities; that we are actually to practice a genuine humility. This to the end that our great blessings may never spoil us…. p. 567

The third relational need is for acceptance by a stable, dependable and protective other (the need to be able to look up to and rely upon caregivers, mentors, teachers and elders to gain protection, encouragement and information from them). Newcomers to AA are often offered “temporary sponsorship”: the guidance of a member more experienced in using the AA program. A major principle of AA holds that the maintenance of one’s own abstinence from alcohol is enormously assisted by helping others achieve sobriety. Established members therefore frequently offer to newcomers both unconditional regard and assistance, without strings attached, in using the tools AA offers. Naturally, these are lay people, psychologically speaking, and their skill level in active listening and unconditional regard will vary greatly; there is no need to stay with a temporary sponsor who is poor at these things.

Later, newcomers are encouraged to seek a more permanent sponsor, someone who values them, helps them with the steps which are suggested as a program of recovery p. 59 and stays in regular touch. Here, sponsorship as discussed above and the companionable closeness of others in recovery can, over time, supply this relational need in significant ways. AA groups have a core of committed members who are there every week and show interest: ninety percent of life is showing up. Protection against cravings and urges to use alcohol and other drugs is provided by having people to call and meetings to attend. The structure this provides may seem insignificant to someone who is well socialized, but addicts tend not to be, and reliable structure and accountability are of immense help.

AA suggests also that alcoholics come to relate to and rely upon on a power greater than themselves. This is commonly understood in the sense of a stable, protective other rather than a punishing, judgmental power. This can be God, if one is so inclined, the power of the group’s experience and wisdom, or an internal sense of one’s own higher good (and there are many more conceptions of a higher power). Many alcoholics report feeling spiritually protected by gaining a sense of a guiding higher power in their lives, however they conceive it. And there is the broadest latitude in such matters -- agnostics and atheists can also thrive in AA: there are no “musts”.

It is incorrect to think, as many do, that AA is a religious program or cult. AA certainly encourages the nurturing of one’s spirituality, but is enormously tolerant of how this is achieved, and supportive of those who tend to ignore spirituality in favor of AA’s other relational components. It is also incorrect to think that AA views the alcoholic as helpless. AA is focused on the challenge of changing behavior, attitudes and relationships. The concept of powerlessness is limited to powerlessness over addiction without help through relationship: a powerlessness sometimes described as doing the same thing over and over again and expecting different results. Connectedness and warm contact – as integrative psychotherapists well know -- can bring recovery.

The simple, cost-free and wide availability of AA can seen in itself as a stable, dependable and protective other. It has existed since 1935 and is not about to disappear.

The fourth relational need is for mutuality or confirmation of personal experience (this is the need to be in the presence of someone who is similar to you – someone who understands because he or she has been there too: there is therefore little need for explanation). Here is where the AA meeting is central. A meeting may focus on AA literature, on a specific recovery topic, or may feature a member giving a “lead”: telling his or her story. Yet in all these formats it is the sharing of one’s personal experience and insights -- what it was like, what happened, and what it’s like now – and listening to those of others without judgment or comment, which fill this relational need. Members will regularly discuss their own emotional vulnerabilities, the shaming parts of their alcoholic career, why they decided to try to recover, and what they are working to achieve in the AA program at the moment. They are not interrupted in so doing (cross-talk or commenting on what someone has said is firmly discouraged). This creates a safe environment in which respectful nods or encouraging smiles are the common form of feedback to a member sharing his or her experience, strength and hope. The likelihood of unwanted, mistuned advice is thus minimized.

As the newcomer observes this process, he or she can feel normalized and may be emboldened to open up, although there is no requirement to do so (he or she can simply “pass” if asked to speak). AA members often comment that meetings seem greater than the sum of their parts. This is an acknowledgement, perhaps, of the mysterious power of relational healing through mutuality:

…there exists among us a fellowship, friendliness, and an understanding which is indescribably wonderful. We are like the passengers of a great liner the moment after rescue from shipwreck when camaraderie, joyousness and democracy pervade the vessel from steerage to Captain’s table…. The tremendous fact for every one of us is that we have discovered a common solution. We have a way out on which we can absolutely agree, and upon which we can join in brotherly and harmonious action. p. 17

The fifth relational need is for self-definition (the need to have others recognize, accept and respect our uniqueness). Media portrayals of AA meetings seem to emphasize the AA custom of self-introduction: “I’m John, and I’m an alcoholic”. This can give the idea that self-definition is limited in AA. The purpose of this optional introduction is to remember that alcoholism is not a disease that disappears after a period of abstinence. It is chronic and recovery requires self-care, similar to that needed with diabetes. But to define oneself only as an alcoholic would be very self-limiting. Members are of course free to introduce themselves in any way they choose. These include: “I choose sobriety”, “I have a desire to stop drinking”, or simply, “I’m John.”

The respect and tolerance for individuality in AA can indeed encourage positive self-definition. Carl Jung, who was generous in his assistance to the founders of AA, is quoted in the AA text as believing that recovery from alcoholism necessarily involves

“…huge emotional displacements and rearrangements. Ideas, emotions and attitudes which were once the guiding forces of the lives of these men are suddenly cast to one side, and a completely new set of conceptions and motives begins to dominate them.” p. 27

With this in mind, it can be seen that the process of recovery will likely cause an upheaval in the sense of self and ego states which integrative psychotherapy can address effectively. Additionally, therapists may want to be alert to recovering alcoholic clients who use their alcoholism as a sole self-definition or in limiting ways such as, “I guess I behave that way because I’m an alcoholic.” Such clients can be assisted by the therapist’s exploration and affirmation of their richness, vitality, skills and attributes. In the writer’s experience, AA groups vary in their effectiveness in supplying this relational need, so clients should be encouraged to find groups in which they find people to inspire them and relate to, processes that enhance self-definition. A simple way of doing this is to suggest the client ask the people they like and relate to in one group which other groups they are attending, then tag along (AA groups are “drop-in”, except for certain study groups).

The sixth relational need is to make an impact on the other (the need to experience some potency in affecting or influencing another person’s thinking, behavior or emotion). In AA, this need supplied by the equal opportunity to speak about one’s own experience and recovery process. While critical feedback and advice from other members are discouraged, quiet statements of appreciation such as “I got a lot out of what you said”, or “Wow, I really identified with that”, are common ways of acknowledging impact. If a client attending AA is getting unwanted advice rather than gentle education and encouragement (AA members with rigid, prescriptive approaches are sometimes referred to as “bleeding deacons”), he or she can be encouraged to explore other AA groups in the community or focus on others in the group.

The seventh relational need is to have the other person initiate (the need to have those in our life reach out to us; any relationship in which we always have to take the first step will eventually become dissatisfying). The frequent telephone and social contact in AA supply this need. Well-run AA groups pay attention to this need by greeting, calling and attending, especially newcomers. Poorly-run groups suffer from cliques. It can be beneficial to give clients the idea that groups of all kinds have their own little culture; AA is no exception. Finding the right “home group” is important.

And finally, the eighth relational need is to express love (the need to show caring and to have it valued and accepted; this might be gratitude, affection, doing something for the other). Non-alcoholic visitors who attend “open” AA meetings are frequently struck by the loving atmosphere. AA members are not shy about expressing their fondness for each other and the value of the bonds they develop. This, and AA members’ penchant for hugging, may be wonderful but can also surprise and frighten a shy newcomer or one who has previously suffered abuse. The therapist of such clients can work with boundaries and encourage the measured integration of the safe expression of love, given and received:

You are going to meet these new friends in your own community. Near you, alcoholics are dying helplessly like people in a sinking ship. If you live in a large place, there are hundreds. High and low, rich and poor, these are future fellows of Alcoholics Anonymous. Among them you will make lifelong friends. You will be bound to them with new and wonderful ties, for you will escape disaster together and you will commence shoulder to shoulder your common journey. Then you will know what it means to give of yourself that others may survive and rediscover life. You will learn the full meaning of ‘Love thy neighbor as thyself.’ p. 153

With the eight relational needs in mind, the integrative psychotherapist will want to consider as well the relational history and scripts as the client reports on his or her experience of AA. Indeed, a client’s views of AA may be deeply colored by scripts and history, and not necessarily an accurate depiction of the meetings themselves. A few examples follow. A client who has been exploited by others in her life may be incapable of believing that altruistic attention exists, and therefore concludes that the person offering that – a temporary sponsor for example -- must have a hidden agenda. A client who sees the meetings as nothing more than a litany of complaints without solutions perhaps grew up with someone wedged in a victim stance; this client is likely to tune out the constructive aspects of what AA offers unless the therapist can assist with understanding his projections. A client who believes “no one cares about me” may display that script by ignoring the fact that she has been given telephone numbers of other members and has been encouraged to receive loving support. A client who grew up in a fundamentalist prescriptive religion may project that onto AA and see it as a controlling cult. A client who is reluctant to get a sponsor may be protecting herself against the disappointment or betrayal experienced with important people in her life. Both therapeutic attunement to the client’s history and continuing enquiry will help integrate what AA can offer. The process is synergistic: integrative therapy can allow a deeper appreciation of AA concepts and relationships; and the AA contact can fertilize the therapy:

God has abundantly supplied this world with fine doctors, psychologists, and practitioners of various kinds. Do not hesitate to take your health problems to such persons. Most of them give freely of themselves, that their fellows may enjoy sound minds and bodies. Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward. p. 133

References:

Alcoholics Anonymous, Fourth Edition, AA World Services, 2001.

Erskine R, Moursund J, Trautmann R, Beyond Empathy: A Therapy of Contact in Relationship, Brunner/Mazel, 1999.
Stewart L, “Relational Needs of the Therapist: Counter transference, Clinical Work and Supervision. Benefits and Disruptions in Psychotherapy” presented at the Integrative Psychotherapy Conference, 2006. This article is available at integrativeassociation.com.

_____________________________________

1. Erskine R, Moursund J, Trautmann R, Beyond Empathy: A Therapy of Contact in Relationship, Brunner/Mazel, 1999, pp 121-155.

2. The brief expansions of all eight relational needs appearing in parentheses are adapted from Stewart L, “Relational Needs of the Therapist: Counter transference, Clinical Work and Supervision. Benefits and Disruptions in Psychotherapy” presented at the Integrative Psychotherapy Conference, 2006