Adlerian theory and the philosophy and twelve steps of Alcoholics Anonymous: A theoretical examination of an integrated approach for treating alcohol dependence
Vll Table of Contents Title 1 Approval i Acknowledgments ii Curriculum Vitae iv Table of Contents vii Abstract 2 Chapter 1 3 Chapter 2 9 Chapter 3 49 Chapter 4 65 References 73 Appendix 81
2 ABSTRACT The integration of psychological theories, such as Cognitive Behavioral Theory, with the philosophy of practices of Alcoholics Anonymous, as a way of making treatment more encouraging and effective for the client has been well documented. While those practicing from an Adlerian orientation have also noted congruence between the two philosophies, little examination of the congruence between the two and the implications for an integrated treatment approach has occurred. Some Adlerians have even argued that the philosophies of Individual Psychology and Alcoholics Anonymous are incongruent and that treatment of substance abuse should best be left for group settings. The purpose of this study is to examine and explicate the ways in which Adlerian theory mirrors the philosophies and practices of Alcoholics Anonymous, with an emphasis on holism, social interest, and the life tasks, and how these similarities make Adler's theory an ideal one for integration when working with clients struggling with alcohol dependence.
3 CHAPTER 1 Introduction The treatment and understanding of alcoholism has long been the subject of innumerable debates both within the field of psychology and in our society at large. Prior to the advent of the field of psychology, much less a unified theory of alcoholism and its treatment, there were those who sought to understand the nature of individuals who frankly, drank too much. The early Greek and Romans wrote of "drunkenness" as a force influenced by three factors; the "human cause," the "wine cause," and the "divine cause" (Thompson, 2010). The human cause being related to properties of the individual drinker and the effects alcohol had on the body, the wine cause being the property of the beverage, and the divine cause relating drunkenness as influenced by the whims of religious deities, most notably Dionysus and Bacchus. The Greeks and Romans, not unlike those who came after, struggled to understand "drunkenness," and never agreed on a concept of cause much less questioning the need for treatment. The prevalence of alcohol problems and alcoholism, along with other addictive disorders, makes it almost inevitable that the issue will arise in one way or another in our work with some of our clients, whether or not it is the direct focus of treatment. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA, 2010), in the United States alone, approximately "17.6 million people ... abuse alcohol or are alcohol dependent" and over 30% of
4 Americans have met the DSM-IV Diagnostic criteria for an alcohol-use disorder at one point in their lives (Hasin, Stinson, Ogburn, and Grant, 2007). Many times, however, alcohol problems and alcoholism are the direct focus of treatment or are related to the issues being addressed in therapy. Therefore, it is important for clinicians to have an understanding not only of alcohol dependence but of the manner in which it can be addressed. Like the ancient Greeks and Romans, various theories for the cause of alcohol problems and alcohol dependence have been put forth in an effort to understand not only alcohol but the effect it has on individuals and society at large. Over time, these theories have risen in popularity both within the field and our larger society, only to be challenged, debated, and sometimes ultimately rejected. Social movements, advances in medicine and psychology have all driven the ways in which we understand and treat individuals struggling with alcohol problems and dependence. Freud, arguably the father of our modern day field of psychology, "proposed that alcoholics were orally fixated (i.e., stuck at an early developmental stage) and thus unable to cope with the demands of adult life. Thus they used alcohol to 'escape from reality' (Barry, 1988)." Alfred Adler, a contemporary of Freud's who's break with him in the mid-twentieth century represented a significant shift in the conceptualization of human behavior and mental illness (Ansbacher, 1956), viewed alcoholism not only in the context of the individual, but society as well. Adler believed that understanding the problem
5 of alcoholism could only be understood, "when we regard the relationship of the whole person to his responsibilities to society (Adler, 1931)." From these early psychologically focused attempts to understand alcoholism, theories have continued to unfold and evolve, both within the field and without. Theoretical orientations within the field have developed and presented various ways to conceptualize alcoholism and its treatment, some more successfully than others. Medical, behavioral, spiritual, psychological, social, and moral theories have arisen, been challenged, and continue to evolve. The end result being there is still no one way to view alcoholism and its treatment, nor, should there necessarily be. One of the more prominent approaches to addressing and treating alcoholism has been the rise of Alcoholics Anonymous, an international mutual aid recovery program. Founded by Bill Wilson and Dr. Bob Smith, "Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism" (Alcoholics Anonymous World Services, Inc., 1984). The program of Alcoholics Anonymous is based on the concept that alcoholism is a progressive illness for which there is no cure but which can be "arrested" through sobriety maintained by following the 12 Steps (Alcoholics Anonymous World Services, Inc., 1984). The Twelve Steps and its companion, the Twelve Traditions, outlines a program for "living," the scope of which is not limited solely to the intake of alcohol.
6 The program of Alcoholics Anonymous has been so influential that a large portion of alcohol rehabilitation and treatment centers have incorporated the concepts of A.A. into their treatment models (Roberson, 1988). Further, over 33% of A.A. membership comes from treatment center referrals (Alcoholics Anonymous, 2008). Even more interesting is that individuals who attend A.A. are also likely to receive outside treatment or counseling which coincides with their A.A. attendance (A.A., 2008). Approximately 63% of A.A. members report receiving counseling and 74% say that counseling played an important role in their recovery (A.A., 2008). While the organization of Alcoholics Anonymous does not officially affiliate itself with any treatment center, nor endorses that its members seek outside counseling or treatment, it is obvious that many A.A. members either found their way to the program through outside treatment or continue to benefit from treatment while attending A.A. Given this, what role can Adlerian therapists play when working with an individual who is also a member of Alcoholics Anonymous? While Carl Jung's influence on the Bill Wilson and the program of Alcoholics Anonymous has been well documented (Finley, 2000), very little attention has been paid to the influence of Alfred Adler. While Wilson never specifically speaks of Adler, his mother had left the family while he was very young to study in Vienna under Alfred Adler. Any influence this may have had on Wilson's development of the A.A. program is speculative at best, but it is an interesting connection to note.
7 What other connections are shared between A. A. and the philosophy of Alfred Adler? Data indicates that many treatment centers already incorporate the A.A. philosophy into their work with individuals and that some A.A. members have found counseling to have been an important part of their recovery (A.A., 2008). Therapists and psychologists have explored the ways in which they can most effectively work with individuals struggling with alcoholism, often relying on their chosen theoretical orientation to guide their work. While theoretical orientations differ (sometimes widely), all offer their own unique perspective on human personality and dysfunction, and research indicates that the most successful therapeutic outcomes are often more related to the relationship between clinician and client than on the particular orientation that clinician practices from (Fischer, Paveza, Kickertz, Hubbard, & Grayston, 1975). Yet as all orientations have their share of strengths and weaknesses, some may be more closely aligned with the philosophies and principles of Alcoholics Anonymous. It is the intention of this dissertation to explicate the shared concepts found in the program of Alcoholics Anonymous and the Individual Psychology of Alfred Adler. Further, this dissertation will examine the ways Adlerian theory can be integrated into our work with members of Alcoholic Anonymous. The theoretical similarities that can be drawn between the program of Alcoholics Anonymous and the Individual Psychology of Alfred Adler allow for a
8 discussion of how these two models can be used together to enhance the clinical work of those in the field of substance abuse counseling. While the integration of Adlerian theory and the philosophy of Alcoholics Anonymous is not necessarily a novel idea, its full potential has yet to be examined. In particular, the parallels between Adler's concepts of the life tasks, gemeinschaftsgefiihl (or community feeling), and his emphasis on holism, and the 12-steps and philosophy of Alcoholics Anonymous can be explored in depth in an effort to expand our understanding and ability to treat addiction. While it is beyond the scope of this dissertation to examine whether or not an Adlerian theoretical orientation may be more effective when working with members of Alcoholics Anonymous than say, a Psychoanalytical orientation, or even if the ways Adlerian theory can be integrated is effective from a standpoint of evidenced based practice, this dissertation will serve as a first step towards better understanding the particular strengths this orientation has to offer. Integrating the core concepts of Adlerian theory with the philosophy and 12 steps of Alcoholics Anonymous can enhance the work we do with our clients, benefitting not only them, but ourselves in the process.
9 CHAPTER 2 Review of the Literature A large body of literature covering the nature of alcoholism, addiction treatment, Alcoholics Anonymous, Adlerian theory, and the integration of theory into substance abuse treatment, provides the basis for the theoretical exploration of the compatibility of Adlerian theory and the philosophy of Alcoholics Anonymous. This chapter will examine both the theoretical and empirical knowledge currently available in these areas in the field. Alcohol Dependence Alcoholism, or Alcohol Dependence, as discussed in the field of psychology and psychiatry, is an issue with a number of factors relating to its' development and ongoing maintenance. These factors cover a broad range including medical and biological aspects, social and cultural factors, as well as psychological. Current addiction models view alcohol dependence as a biopsychosocial problem (Grant, Dawson, Stinson, Chou, Dufour, & Pickering, 2006) but alcoholism is most often classified as a mental, rather than medical disorder. Definitions Substance abuse is considered the regular use of a substance (sometimes illegal) which causes problems in some aspect of an individual's life. Substance dependence, on the other hand, includes not only use of a substance which is
10 problematic but includes the behavioral, psychological, and physiological symptoms that, "indicate the continual, compulsive use of a substance despite the problems related to the use of this substance" (Howard & Stipple, 2005, p. 36). For the purposes of this study, only substance dependence, and alcohol dependence in particular will be examined. The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000), otherwise known as the DSM-F/-TR, defines Alcohol Dependence as a "maladaptive pattern of alcohol use " which during a 12-month period leads to "clinically significant impairment or distress" and is manifest by at least three out of seven factors (p. 192). These factors include tolerance, withdrawal, increased use (amount) over time, attempts to cut down, problems in social and occupational functioning, and continued use despite having experienced negative consequences (APA, 2000, pp. 1921-195 ). The International Statistical Classification of Diseases and Related Health Problems (World Health Organization, 2010), otherwise known as the ICD-9, similarly classifies Alcohol Dependence as a mental disorder, "characterized by a pathological pattern of alcohol use that causes a serious impairment in social or occupational functioning" (WHO, 2010). Prevalence, Impact, and Comorbidity According to the World Health Organization (2011), the "harmful use of alcohol is a worldwide problem resulting in millions of deaths" and "it is not only
11 a causal factor in many diseases, but also a precursor to injury and violence" (p. v) the negative impact of which can be seen not only on an individual level but in communities and countries as well. Although the consumption of alcohol and problems related to alcohol dependence vary widely around the world, the consumption of alcohol is, "the world's third largest risk factor for disease and disability . . . , the casual factor in 60 types of diseases and injuries and a component cause in 200 others (WHO, 2011, p. x). Even more shocking is that almost 4 % of deaths worldwide can be attributed to alcohol, which is greater than the percentage of deaths caused by HIV/AIDS or violence. Alcohol consumption varies throughout the world in relation to social customs, availability, gender, and economic status, among other factors. In their recent study, the World Health Organization (2011) found that the highest levels of alcohol consumption were in more developed countries, particularly in the Northern Hemisphere but also, Australia, Argentina, and New Zealand. Further, the "adult per capita consumption" of alcohol is higher in countries with higher recorded incomes. Income is also related to types of alcohol consumed, with wine being the largest proportion of alcohol consumed in many European countries with higher incomes. Spirits and beer constitute 45% and 36%, respectively, of total recorded consumption although this percentage increases as income decreases (WHO, 2011, pp. 4-12).
12 When examining worldwide rates of alcohol consumption in terms of gender and age, alcohol use has been found to be particularly harmful to men and is a leading risk factor for death in men aged 15-59 and "globally 6.2% of all male deaths are attributed to alcohol, compared to 1.1% of female deaths" (WHO, 2001, p. x). Men also outnumber women almost four to one in episodes of binge drinking, which is defined as drinking excessive amounts (five drinks for men, four for women) in a relatively short time period (National Institute on Alcohol Abuse and Alcoholism, 2004). Women also have higher rates of abstinence from alcohol than men (WHO, 2011) which is likely regulated by cultural norms. However, studies have indicated that alcohol consumption is on the rise for both men and women, especially those between the age of 18-25 (Gruzca, Bucholz, Rice, & Bierut, 2008; Hasin, Stinson, Ogburn, & Grant, 2007; WHO, 2011). In the United States, alcohol abuse and dependence are also associated with "car crashes, domestic violence, fetal alcohol syndrome, neuropsychological impairment, poor medication adherence, economic costs and lost productivity, and psychiatric comorbidity (Hasin et al., 2007, p. 830). In 2001/2002 the National Institute on Alcohol Abuse and Alcoholism (NIAAA) conducted the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), one of the largest and most comprehensive comorbidity studies ever conducted in the United States, showed that within a 12-month period, "8.5% of adults experienced alcohol use disorders . . . while 30.3% experienced alcohol use
13 disorders during their lifetimes" (Hasin et al., 2007, p. 837). While this survey found men were at greater risk of alcohol use disorders than women, Grucza et al. (2008) found that there has been a "substantial" increase in drinking and alcohol dependence among women (p. 763) and 42% of men and 19.5% of women qualified for an alcohol use disorder during their lifetime (Hasin et al, 2007). The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, 2000) reports that, "at some time in their lives, as many as 90% of adults in the United States have had some experience with alcohol, and a substantial number (60% of males and 30% of females) have experienced negative consequences due to alcohol use" (p. 212). Risks for alcohol dependence were higher among Native Americans (both lifetime and within a 12 month period) and lower for African American and Asians than for whites. Hasin et al. (2007) and Gruzca et al. (2008), also found, similar to the findings in the World Health Organizations (2011) Global Status Report on Alcoholism and Health, that drinking and alcohol use disorders were on the rise, particularly among younger individuals. Younger individuals showed a higher risk of alcohol dependence and the highest risk for lifetime alcohol abuse was in the generation X and baby boom cohorts (ages 30-64), the first time such an age distribution has been found within the United States (Hasin et al, 2007 and Grant et al, 2006). Further, alcohol abuse and dependence were shown to be highly comorbid with other disorders.
14 Not only was alcohol abuse and dependence associated with other drug use and nicotine use disorders but significant associations remained with other Axis I and II disorders (Hasin et al, 2007; Grant et al, 2006; Grant et al, 2004). Results from the National Epidemiologic Survey on Alcohol and Related Conditions found that twelve-month alcohol dependence was not only strongly associated with other substance use disorders but with bipolar disorders. Further, it was significantly associated with antisocial and histrionic personality disorders (Hasin et al, 2007). Lifetime alcohol dependence was similarly associated with these disorders but also a notable increase in other mood and anxiety disorders and antisocial personality disorder as well (Hasin et al, 2007; Gruzca et al., 2008). Laudet, Magura, Vogel, and Knight (2004), studied the perceived reasons for substance use and abuse in individuals with a co-occurring disorder and found that over 38% of individuals had experienced problems or symptoms of a mental illness prior to using substance and 12% reported utilizing substances as a way to manage the symptoms of their mental illness. Treatment of Alcohol Dependence In the United States, the first discussions of the treatment of addiction and substance use disorders emerged in the mid 19l century. While substance use disorders had long been problematic prior to this in both the United States and other parts of the world, it was a combination of the changing patterns of drug and alcohol use, the rise of social and personal recovery movements, and the changing
15 role of medicine in understanding addiction, which paved the way for more organized treatment approaches (Tracy, 2005; White, 1998). The following section briefly outlines the changing nature of addiction treatment in the United States. Early Views of Alcoholism One of the earliest and most influential writers on the subject of alcoholism in America was a colonial physician by the name of Benjamin Rush (17746-1813). Rush had a profound influence on early American medicine and as the "father of American psychiatry," was the foremost authority on alcoholism in early American history (White, 1998, p. 1; Tracy, 2005). Rush was the first to suggest that alcoholism was not a reflection of a moral depravity (the prevailing theory on alcoholism at the time) but rather a progressive medical condition, a destructive and "self contained disease" (White, 1998, p. 2), that could be successfully treated through abstinence, as well as other means (Lender and Martin, 1987). Rush described not only psychological aspects of alcoholism such as personality changes but he made note of physical effects of consumption and was one of the first to write of how 'drunkenness' appeared to occur in families. Rush also laid out his understanding of the best way to treat alcoholism and "presented what today might be called a multiple-pathway model of alcoholism recovery" utilizing "religious, metaphysical, and medical" aspects (White, 1998, p. 3).
16 From this early understanding of alcoholism and its treatment American cultural attitudes towards alcohol and consumption changed. The 1790s marked the beginning of a 40 year period in which the consumption of alcohol by Americans was at its' highest ever in recorded history (Tracy, 2005), intensifying the impact of alcohol related problems, and spurring the evolution of a temperance movement which first advocated moderation and then total abstinence (White, 1998; Faupel, Horowitz, & Weaver, 2004; Tracy, 2005). Prior to this shift, political leaders including George Washington, John Adams, Benjamin Franklin and religious leaders, most notably Anthony Benezet and Dr. Billy Clark, called for a change in the way Americans approached drinking. In 1808, Dr. Billy Clark found the Union Temperance Society, the first of its kind, which advocated weekly meetings, public education, and abstinence from all distilled forms of alcohol (White, 1998) but allowed for, if not encouraged, the consumptions of other forms of alcohol such as beer (Tracy, 2005). The initial goal of the temperance movement wasn't complete abstinence from alcohol, but the moderation of drinking, nor did it encourage political or public debate on the criminalization or moralization of addiction. As temperance societies expanded in America, one thing became clear, moderation of alcohol consumption was not possible for the majority of society members (Tracy, 2005) and the problems of alcohol use and abuse continued. Members and leaders shifted the focus from moderation to abstinence and from a
17 focus on "individual struggle to shared recovery" (White, 1998, p. 6). Societies such as The Washingtonians advocated for abstinence, met regularly to share their stories and experience, reached out to other alcoholics, or "drunkards' as they were commonly called then, and essentially held the first open and closed meetings for members and the public (Tracy, 2005; White 1998). From this first group came other fraternal orders and societies focusing on creating a social and communal space for alcoholics to attempt to achieve abstinence while attempting to influence public opinion towards a disease model. By the early twentieth century, the effects of alcohol use and abuse had become so problematic that the pendulum of public opinion swung away from viewing alcoholism as a medical issue or disease and back towards a moral position which criminalized individuals who were alcoholic. Richmond Pearson Hobson, a "moral entrepreneur" (Faupel et al, 2004, p. 43) and popular Naval Captain, labeled alcohol as the "great destroyer" and popularized the view that the battle against alcohol was a battle pitting good against evil (Epstein, 1977, p. 24). Social movements and fraternal orders were not the only way American society attempted to deal with and treat alcoholism. Institutions and asylums which specialized in the care of "the inebriate" exploded in the mid 19th century. In 1870, there were only 6 known institutions which specifically focused on the treatment and care of alcoholics, by 1878, this number had grown to 32, and by 1902 there were well over 100 specialized institutions and asylums in the United
18 States (White, 1998, pp. 22-23). These institutions were largely privately funded but many were state operated facilities and could be placed into two categories, institutions or asylums which served as sober living environments with little formal care or treatment and institutions which were more medical in nature and offered interventions ranging from detoxification with the help of medications, group activities, and care for those individuals deemed insane and no longer physically or psychologically able to care for themselves (White, 1998). The majority of these institutions were shut down by the 1920s, often deemed unnecessary given new laws against the sale and distribution of alcohol but also contributing to the rapid decline in available options for addiction treatment were economic, social, and political factors. In addition to these common factors, White (1998) theorized that a lack of coherent protocol for treating addiction and the subsequent conflict both within the field and with allied professionals undermined the viability of addiction treatment. Following the rise and fall of prohibition laws in the United States, the question and challenge of treating alcoholism still remained. Treatment strategies once again shifted, this time medical and physical approaches taking precedence. Prominent approaches in the early 1900s included such drastic measures as sterilization of individuals who struggled with alcoholism and other eugenics programs designed to cull alcoholics from the general population. The first wave of involuntary sterilization laws came from 1907-1913, the second from 1923-