Why I Think AA (etc) is a Double-Edged Sword

There's something about AA (and the spin-off 12-step programs for other issues) that definitely works. As one of their slogans says, "meeting makers make it" in recovery.

Specifically WHAT works seems to depend on whom you ask. From my perspective, however, I see social support as the program's #1 strength. There are 12-step meetings available every day of the week, at just about any time of day, in just about every corner of the globe. It's a powerful thing to find a community of people who really get what you're going through, because they've been there too. And it's an even more powerful thing to have one of those people (i.e., a sponsor) commit to doing whatever it takes to get you through the recovery process - including answering the phone in the middle of the night, coming to get you from wherever you've gotten yourself stranded, sitting with you in emergency rooms...and probably a lot of other scenarios my clients haven't shared with me.

I wish that kind of ready-made support group and mentoring were available to people without addictive or compulsive behaviors!

Beyond the support, some people really see the steps themselves as pivotal - an intentional changing of mind, body and spirit from willful to willing, by admitting powerlessness, accepting a higher power, taking moral inventory, making amends, and choosing to live differently moving forward. I have some theological issues with the specific steps, but on the whole, it's a decent description of the change process some go through.

Here's the thing, though: I'm not convinced that this process is necessary or helpful for everyone with this kind of problem. In fact, I think it can be counterproductive for people (often trauma survivors, but not exclusively) who are already struggling with learned helplessness, feelings of worthlessness and shame. To emphasize one's powerlessness and "moral failings" seems only to solidify these people's negative self-image. Sure, working the program may still help them stop their addictive or compulsive behavior...but at what cost?

The concept of "character defect" particularly gets under my skin. Here I am, working to empower my clients and build up their strengths, and they respond by telling me about their permanent, inherent character defects. From the perspective of narrative therapy it is incredibly challenging to develop a less problem-saturated view of oneself in the face of constant reminders to stay vigilant lest one's character defects cause relapse.

It's challenging to come up against this viewpoint in therapy, both because it flies in the face of much of what we're taught about practice, and because expressing disagreement with "the program" may feel threatening to clients who are very involved in AA (etc.). They may experience a loyalty bind between the program, to which they may feel they owe whatever sobriety they have, and the therapist - not a good scenario for client or clinician! Yet, when I feel like an aspect of the 12-steps (usually the character defect piece) is actually harming a client, I will introduce the idea that it's possible to take what works for them, and leave the rest - recovery doesn't have to be mindless acceptance of the whole AA package. However, because many clients are very attached to that model, I am always careful to affirm the excellent things AA teaches about sober living.

Since this is an issue about which many people have varied strong opinions, I'm curious how others address the 12 steps in their practice - particularly with folks whose perspective differs from your own. Leave a comment below!

In closing, another excellent contribution from AA, the "Serenity Prayer:"

God, Grant me the serenity to accept the things I cannot change,

The courage to change the things I can,

And the Wisdom to know the difference.

Journaling: An Intervention We Can All Agree On

Journaling - the act of writing out one's thoughts and feelings - has been done in one form or another for centuries. Much of what we know about great historical individuals comes from their own writing. Authors and spiritual/religious figures have found a natural affinity with the practice, as have scholars from myriad disciplines (witness the journals of Da Vinci). Even a blog like this one is a form of journal.

It's of no surprise, then, that therapists have come up with ways to harness the practice of journaling as a clinical intervention. After all, much of therapy involves trying to put one's internal experiences into words. Perhaps the bigger surprise is just how widely applicable journaling is, across diverse approaches to practice.

1) Cognitive-Behavioral Approaches 
    Journaling is a logical part of CBT and related approaches. Recording one's thoughts can be the first step in changing dysfunctional patterns. Tracking behavior can be enlightening to therapist and client alike, and simply tracking a given behavior can change its frequency. If mindfulness - awareness of the present moment - is a goal, a journal can be a place to practice recording all of one's present experience. I could go on, but you get the idea.

2) Psychodynamic Approaches
    Journaling is used quite differently is psychodynamic or psychoanalytical therapy - as a way of moving things from the unconscious or subconscious mind to the conscious mind. This process often involves free association (writing everything that comes to mind without censoring), from which themes can be identified over time. It may also include recording dreams and fantasies.

3) Existential and Humanistic Approaches
    These approaches focus on tapping into one's innate capacity for growth or adaptation by fostering awareness of the present moment, and matching one's thoughts, feelings, and actions with that awareness. Journaling can be used as a way of developing awareness of the present moment, as well as identifying those things that distract or detract from awareness.

4) Postmodern Approaches
    This category of approaches, which reject the idea of objective truth, instead seeing all reality as socially constructed, and therefore changeable. The most common postmodern therapies are Narrative Therapy and Solution-Focused Brief Therapy. Given these approaches' emphasis on helping clients to construct their own preferred versions of themselves and their lives/futures, journaling can be a place to practice constructing, and to "try on" different constructions. Furthermore, in Narrative Therapy, documents have a vital symbolic role in the change process, and a journal is of course a document.

Do you use journaling as a therapeutic intervention, and/or in your own personal life? How do you approach it, and how have you seen it help (or not help)?

Laying the Groundwork

The kind of conversation one has in therapy is different from conversations one has in regular, day-to-day life. That's the point, after all - we think "talk therapy" helps people by engaging them in a unique form of dialogue in the context of a unique relationship. If just talking about something with a friend, or in one's own head, could solve the problem, people wouldn't be coming to see us to begin with!

For clients entering therapy for the first time, this new kind of interaction can feel very foreign. They may feel confused about what they're supposed to say or do, or why I am asking what I'm asking. They may feel awkward talking about themselves, or expressing feelings. They may not even know how to express feelings!

An important task for the therapist early in treatment is to introduce clients to the therapeutic process. Even if a client has been in therapy before, the previous therapist may have practiced from a different theoretical orientation, or have other stylistic differences from you. Clients want to know what to expect when they come to see you - and you want to set the stage for productive sessions.

Manualized CBT (e.g. Cognitive Behavior Therapy, Second Edition: Basics and Beyond) is quite structured, so it is fairly easy to establish a routine or agenda (addressing pressing concerns/crises, reviewing the last session and homework, identifying the next step based on outcomes). It's harder to orient clients to less directive approaches because they are, by definition, less concrete. To complicate matters further, the assessment process (often the first few sessions) is structured around the therapist asking quite specific questions. If clients come to expect that all sessions will be like that, it can lead to frustration all around.

Some clinicians (e.g. Becoming a Therapist: What Do I Say, and Why?) advocate taking a less directive approach in the first session, then doing the bulk of the assessment in sessions 2 and 3, as one way to both establish an alliance, and avoid establishing structured interviewing as the norm. Even then, the first treatment session post-assessment should begin with the therapist explaining the different structure and expectations for therapy vs. assessment.

A non-directive session structure may be particularly challenging for clients who are psychotic or otherwise cognitively disorganized. It can also be disappointing or frustrating for clients who have come in looking for an expert who will "fix" their problems. In some cultures and age groups, the image of therapy seems to be similar to the primary care doctor, and the role of the "patient" is to come to appointments and follow instructions - a more passive role than is actually expected of therapy clients!

So, given all these challenges, how do you set the stage for therapy with new clients - how do you orient them to the process, the roles of client and therapist, etc? What do you do during the first session, and later, to create a productive therapeutic environment?

Enough Already?

The radio station I listen to on the way to work has a segment every morning where people call or text in to vent (briefly) about what they've had enough of - tag line, you guessed it, "enough already!"

Something I've had enough of is clients asking for treatment, then backing out, or worse, disappearing after a few (or many) sessions. I understand that ambivalence and complicated lives are behind this phenomenon...but it's frustrating! I have open cases languishing because I'm not getting a response to outreach, I have half-completed charts because people only came once, or I have an unsettled feeling wondering what became of clients who came for awhile before disappearing without a trace.

Today, someone I was assigned as a new client in July, but never met because he didn't respond to any outreach, at the time, or after he left a message a month later, showed up unannounced wanting to be seen. I was suspicious, wondering why he keeps popping up sounding desperate, only to disappear when offered an appointment. The clinical director met with him to ask about this pattern, and learned that he has been having frequent flashbacks after seeing a triggering film. She told me that he does seem "desperate" as a result of these debilitating symptoms, and would probably come "every day if he could."

My (cynical) initial response was that he might come every day for a week, but then stop coming at all once he started feeling a little better. My feeling was, why bother starting treatment if he's going to drop out before we get to any "real" therapy?

But then I started thinking about it some more. Many therapists tend to see "real therapy" as longer-term work to resolve the core issues underlying whatever the presenting symptoms are - assuming that, even if the symptoms abate, the person may experience a relapse of the same or new symptoms if the core issues are left unresolved. In contrast, the theory behind "brief" therapies (and yes, there is theory rather than just insurance behind brief treatment!) contends that the most "work" in therapy happens in concentrated spurts, often fueled by some sort of crisis. People work through the crisis at hand, resolve or at least reorganize some issues, and when the acute discomfort has passed, lull into a less-fruitful use of therapy. So, since the work and the crises are episodic anyway, advocates of brief treatment recommend seeing people for a predetermined period of time, terminating, and then allowing them to return if they desire when another crisis occurs and they are ready to do another "piece" of the work.

This piecemeal approach to therapy isn't as pretty a theory as longer-term full therapy - but I do have to acknowledge that it may be just as useful. Having people come when there is an impetus for change, but not come once that impetus passes, could result in just as much progress as having them come consistently. Maybe the short span of treatment is "enough already" - or at least enough for now. It may leave some things up in the air, and I wouldn't get the pleasure of seeing how people are doing, and how their stories progress - but, it's not about me, anyway! And sometimes I think clients and clinicians continue therapy after the work is "done" because it's comfortable (but that's a topic for another post).

So, what do you think? Are short-term therapist just as useful, or more so, compared to long-term treatment? Or does the consistency and stability of a long-term therapy relationship matter more than momentum?