Special Section: From the SFMMS Addiction Conference
THE INTERSECTION OF PSYCHIATRY AND 12-STEP RECOVERY Jason Eric Schiffman, MD, MA, MBA Until the founding of Alcoholics Anonymous in 1935, there were essentially no standardized treatments for addiction, and it is likely that few, if any, individuals with addictive disorders prior to that time substantially recovered from the condition. Historically, the field of medicine had little interest in addiction, and for many years after its inception, Alcoholics Anonymous and the numerous other 12-step programs derived from it remained the only standardized interventions for addictive disorders. As a consequence, 12-step based approaches have been a mainstay of addiction treatment and to this day remain one of the most commonly utilized interventions for addictive disorders worldwide. Because 12-step programs are a non-clinical, communitybased intervention that developed outside of the healthcare field, integrating their use with treatment within the healthcare system has presented some challenges. Three points of intersection in which these challenges are most evident are as follows: 1) discomfort in some factions of the 12-step community with the use of psychotropic medications (particularly opioid agonist/partial agonist maintenance therapy for opioid use disorder),
2) the historical and continuing exclusion of addiction treat ment centers from regulation by state medical boards and the corporate practice of medicine laws governing the rest of the healthcare industry, and
3) the fact that 12-step programs claim to achieve their efficacy through a spiritual mechanism.
This third point, which is the focus of this article, has often caused discomfort among physicians who find themselves in the difficult position of defending a treatment recommendation for which there is good empirical evidence but for which the purported mechanism of efficacy is outside the biological model of illness. In the modern healthcare system, prescription of a purportedly spiritual intervention is unlikely to be well received in any other field of medicine, so it should not be surprising that physicians have struggled with finding a way to recommend and explain 12-step based interventions to their patients with addictive disorders. A series of recent studies have both supported 12-step interventions as effective1 and shed some light on the mechanisms through which this efficacy is mediated2. The studies evaluated the following six potential mediators of Alcoholics Anonymous efficacy: • spirituality • social abstinence self-efficacy (i.e., confidence in one’s ability to remain abstinent when confronted with high-risk social drinking situations) 12
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• negative affect abstinence self-efficacy (i.e., confidence in one’s ability to remain abstinent when experiencing • depression/anxiety) • depression symptoms • negative social networks (i.e., removing heavy drinkers from the social network) • positive social networks (i.e., adding abstainers/recovering individuals into the social network). What was found was that the primary mediators of 12-step efficacy were facilitation of changes in social networks and increases in social and negative affect abstinence self-efficacy. Spirituality did mediate some benefit, particularly among individuals with more severe symptoms, but this benefit was minor compared to social and self-efficacy mediators.3 The fact that spirituality appears to be a minor contributor to 12-step efficacy, despite what 12-step groups say about themselves, is useful in helping the physician recommending 12-step participation explain the recommendation by reference to social and psychological mechanisms rather than spiritual mechanisms. Nonetheless, given the emphasis 12-step approaches place on spirituality and the fact that spirituality appears to mediate at least some of 12-step’s efficacy, it would be useful to have an explanation for what this mechanism is that uses a psychological rather than spiritual framework that was thus consistent with the biopsychosocial model used in modern medicine. First, let’s summarize how 12-step interventions benefit individuals with addictive disorders according to Alcoholics Anonymous itself. The following is from a section of the Alcoholic Anonymous literature entitled “How it Works”: (a) We were alcoholic and could not manage our own lives. (b) Probably no human power could have relieved our alcoholism. (c) God could and would if He were sought.
As stated above, Alcoholics Anonymous believes neither the alcoholic nor other people have the power to relieve addiction, and that 12-step interventions work via facilitation of “conscious contact” with a higher power. It is then the higher power that alleviates the addiction through removal of the individual’s obsession to use the substance or behavior to which they are addicted. The 12 steps are meant to accomplish this connection through removal of ego-related blocks between the individual and their higher power. This is depicted in the following schematic. WWW.SFMMS.ORG
