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Integrating 12-Steps and Psychotherapy: helping clients find sobriety and recovery.

Integrating 12-Steps and Psychotherapy: helping clients find sobriety and recovery.

Kevin A. Osten & Robert Switzer. London: Sage

This book seeks, as the title suggests, to integrate the ideas and processes of the 12-step movement (such as Alcoholics Anonymous and Narcotics Anonymous) with more conventional psychotherapy. This may strike the UK or European psychotherapist as a somewhat strange endeavour. However this must be understood in the context of North-American addiction work where the 12-step traditions have enormous influence over the clinical tradition. As most readers of this journal will understand psychotherapy more than the 12-step traditions, this often misunderstood tradition needs some exploration.

Alcoholics Anonymous (AA) began rather accidentally in 1935, when one self-proclaimed alcoholic, Bill Wilson, found relief in talking to another alcoholic (Kurtz, 1979). Wilson soon organised to meet regularly with others and from this regular meeting, so-called self-help or mutual-aid was born. Later the 12-steps programme, which postulates a route to recovery, and the twelve traditions, which govern the organisational life of AA, were introduced. Soon other variations were spawned, such as Narcotics Anonymous (NA), Cocaine Anonymous (CA), and Gamblers Anonymous (GA). While the former are well known there are numerous other less well known groups, such as Overeaters Anonymous, Debtors Anonymous, Sexaholics Anonymous and Co-Dependents Anonymous (CoDA). There are also Twelve Step groups for family members affected by addiction such as Al-Anon and Nar-Anon.

These groups grew exponentially from first inception and now claim to treat millions of individuals each year. In addition, the unwritten philosophy of these groups, particularly AA, has subtly dominated ideas about addiction and recovery ever since. These include the following: addiction is a disease; abstinence is the only path to recovery; attending meetings is essential to recovery; a spiritual orientation is necessary for recovery.

These groups are practical and the process combines a variety of elements which involve identity ('I am an alcoholic'); which are cognitive (adhering to various advises e.g. 'live life on life's terms' and 'one day at a time'); which are narrative (telling one's story repeatedly); which are social or communal (attending meetings); which are interpersonal (working with a sponsor and later being a sponsor); spiritual (as the member is happy to do--although meditation and prayer are promoted). Greil & Ruddy (1983) have argued that the 'conversion process' in AA has the following stages: hitting rock bottom, starting the first step, making a commitment, accepting your problem, telling your story, and doing 12-step work. George Vaillant (2005) has suggested that AA has the following ingredients: external supervision, substitute dependency, new caring relationships and increased spirituality. In summary the 12-step traditions consider addiction to be a 'disease', but not in a strictly medical sense. Rather addiction is a 'spiritual disease' and thus a spiritual change must accompany recovery. However, the damaging effects of addiction include damage to identity and relationships and these are in need of repair also. These traditions thus have multiple ways in which its fellows are supported to make changes beyond just spiritual conversion.

Twelve-step groups and the movement have been regularly and widely criticized, mostly for advocating the disease concept of addiction; suggesting a lack of control over behaviour and promoting spiritual recovery. From an existential-phenomenological perspectives a number of issues are apparent. There is no consistent agreement amongst members and commentators on what constitutes the 12-step conceptualisation of addiction. The very concept of addiction itself is elusive. Many advocate the disease concept, although this is not endorsed in the official literature. Others promote the spiritual lack in contemporary society and how these groups counteract this deficit. Still others argue that the 12-step process deconstructs the modern over-controlling individual (Kurtz, 1982). The 12-step conception and process have been criticised from perspectives, which are broadly existential (Beasley, 2002; Schaler, 1999; Szasz, 2003). The persistent criticism is the need to submit to the 12-step process, which in many ways obviates or negates existential responsibility. It does not seem to occur to these critics that the very act of submission itself is an act of existential choice.

While much of the discussion of the 12-step groups and processes from an existential perspective is negative, there are those who have connected the AA practice and literature with phenomenological and existential philosophy (Flores, 1988; Kurtz, 1982; Thune, 1977). Kurtz argues that what AA essentially achieves is to break down the over-controlling propensities of the alcoholic. This is then replaced by an acceptance of reality and the contingent and intrinsically relational nature of human existence. This relationality is rebuilt in the AA member in a wider sense than is usually acknowledged; to individuals (to the sponsor), communally (to the AA group and community) and spiritually (to a loosely defined 'higher power'). I have supported Kurtz's conception connecting it to the transcendent finitude of Dasein (Kemp, 2013).

Returning to the book under review, the authors have sought to translate the tradition into a conception which is understandable to psychologists and psychotherapists. In other words, although these traditions may consider that they are doing one thing, it may be they are doing something else entirely. They therefore argue for a 'blended' approach, which combines the 12-step approach with more traditional psychological approaches such as motivational interviewing and CBT. It should be noted that 'existential' is a word completely absent from the text, as far as I could tell. Having said all that I, as an addiction specialist, found the book very useful. Each page has a practical wisdom and a humility which was difficult to find fault with. The book is well organised and I suspect can be read in any order or used as a resource for particular issues that may arise. I am not sure it is necessary for the reader to 'adopt' the 12-step ethos to find it useful. However anyone who is completely opposed to the movement will probably struggle to benefit from what is offered. Perhaps thus not completely suited to existential practitioners, all in all I found it a very admirable attempt at making 12-step approaches more useable by professionals.


Beasley, R. (2002). An existential analysis of the twelve-step approach to chemical dependency. In Du Plock, S. (ed) Further Existential Challenges to Psychotherapeutic Theory and Practice. London: Society for Existential Analysis.

Flores, P.J. (1988). Alcoholics Anonymous: a phenomenological and existential perspective. Alcoholism Treatment Quarterly, 5(1-2): 73-94.

Greil, A.L., & Rudy, D.R. (1983). Conversion to the world view of Alcoholics Anonymous: A refinement of conversion theory. Qualitative Sociology, 6(1): 5-28.

Kemp, R. (2013). Rock bottom as an event of truth. Existential Analysis, 24(1): 104-116.

Kurtz, E. (1979). Not-God: A history of Alcoholics Anonymous. New York: Hazelden.

Kurtz, E. (1982). Why AA works; the intellectual significance of Alcoholics Anonymous. Journal of Studies on Alcohol and Drugs, 43(01): 38-80.

Schaler, P.D.J.A. (1999). Addiction is a Choice. Chicago: Open Court.

Szasz, T. (2003). Ceremonial chemistry: The ritual persecution of drugs, addicts, and pushers. New York: Syracuse University Press.

Thune, C. E. (1977). Alcoholism and the archetypal past; a phenomenological perspective on Alcoholics Anonymous. Journal of Studies on Alcohol and Drugs, 38(1): 75.

Vaillant, G.E. (2005). Alcoholics Anonymous: cult or cure? Australian and New Zealand Journal of Psychiatry, 39(6): 431-436.
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Author:Adams, Martin
Publication:Existential Analysis
Article Type:Book review
Date:Jan 1, 2015
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