Books & Publications

Trends in the Lay Treatment of Addictions

Emmett Velten
Bay Area Addiction Research and Treatment, and
University of California, San Francisco


Until recently, the lay treatment community has had two important, clear differences from the scientific and research-oriented treatment community. First, it has for the most part seen no need for research and has had no interest in it unless it seemed to support or contradict the Disease Theory of addiction. Members of the lay treatment community have been prone simply to assert the validity of their procedures as plainly obvious, scientific facts. A typical devotee of lay treatment brand X may hear, for instance, that so-and-so recovered because s/he attended brand X's meetings, and will consider this proof enough of brand X's efficacy. On the other hand, those who do not profit from attendance at brand X's meetings are "not working a good program" or "in denial." Adherents of popular lay treatment procedures often express suspicion about the motives of scientists and researchers. "You can prove anything with statistics," they say.

Second, the lay treatment community has had immense popular success. In contrast, the scientific and research treatment community has had little presence outside the groves of academe. Its findings circulate at professional meetings, appear in journals and books, can have an impact at other academic and research centers, and that is usually that. The degree of overlap between addiction research and lay treatment (to say nothing of mainstream clinical practice) has been meager.

The lay treatment community has consisted almost entirely of the 12-steps and the practices and theories built up around them. Laypeople--and mainstream clinical practitioners--almost never question the validity of the 12-step approach. From an assumption that AA "is the only thing that works" with alcoholics, the 12-step method now extends to an astonishing variety of addictions and nonaddictions. The latter include most if not all of the psychiatric disorders as well as unhappiness, poor relationships, lack of purpose in life, other self-defeating behaviors, and bad events. There are 12-step meetings concerning depression, bipolar disorder and schizophrenia, impotence, incest, spending too much money, bulimia, phobias, codependency, ritual Satanic cult abuse, and many others. "Once you invent a hammer, everything becomes a nail," Abraham Maslow is said to have remarked.

The application of the 12-step approach to seemingly every possible self-defeating behavior humans have yet invented is part of its evolution and overgeneralization from a method that targeted only alcoholics. The very success of this expansion may have sewn seeds of doubt. A method that claims that almost everyone suffers from a disease it and only it can cure, is asking for trouble. Indeed, pointed challenges to the AA approach and its 12-step progeny are increasingly frequent.

This review of trends in the lay treatment of addictions will briefly look at the expansion of AA from a modest fellowship, which operated through attraction and targeted a subset of like-minded heavy drinkers, to a juggernaut with exaggerated claims about the disease it claims to treat and the effectiveness of its treatment for it. Then, this paper will examine in detail the Rational Recovery Self-Help Network movement in terms of its implicit and explicit challenges to AA and its methods of offering an alternative to 12-step approaches. This will take place in a context provided by the review of four recent, important articles selected by the journal editors as shedding light on issues concerning the lay treatment of addictions.

The evolution of the 12 steps

A first important step in the expansion and evolution of AA and its 12 steps was the formation of Al-Anon. As originally constituted, Al-Anon was a group of people who gathered to learn methods for coping with practical problems caused by the behavior of the heavy-drinking loved one or family member. These problems included emotional problems.

In time, the idea that having an alcoholic parent contributes to one's current problems, including emotional problems, gave rise to the idea that having had an alcoholic parent does the same thing. The Adult Child of an Alcoholic (ACOA) was born. The ACOA movement remained strongly 12-step but broke ranks with AA by offering written materials not approved by the AA World Services, Inc., which never was true of Al-Anon. More important, ACOA emphasized childhood events as crucial to personality formation and as the cause of one's present disturbed behavior and unhappiness. In AA itself, on the other hand, this sort of attribution had been almost completely absent although psychoanalysis was very popular at the time "the Big Book" was written.

ACOA rapidly proliferated into a major social movement guided by the explanation that one's past experiences causes one's present problem behavior. Until the Inner Child came onto the scene, the Adult Child movement was arguably the greatest success of psychoanalysis. Like psychoanalysis, ACOA groups have had little to offer beyond insight in terms of processes to promote change.

The Adult Child movement has not become a self-parody as have the Inner Child and especially the codependency movements, which followed it. After all, it would seem difficult to claim that 96% of the population had an alcoholic parent! A close examination of a central writing in the ACOA world (Woititz, 1983), however, suggests that ACOA-dom escaped widely publicized critical and satirical examination largely because it was upstaged by the far more astonishing claims of the codependency writers. In addition, the general ACOA theory does generate testable hypotheses and may have some empirical support. This, however, may apply mainly to the ACOAs who self-identify. Random samples of people who had alcoholic parents may well show that they are little different from the rest of the population.

Near Alcoholics

In Adult Children of Alcoholics (1983), Woititz provided 13 statements to use as a questionnaire about the characteristics of children of alcoholics. For example, ACOAs are either highly responsible or highly irresponsible; when ACOAs act, they tend to fail to look ahead to long-term consequences; ACOAs have difficulty finishing projects; and ACOAs constantly seek approval and affirmation. Woititz summarizes these as follows:

excessive dependency, inability to express emotions, low frustration tolerance, emotional immaturity, high level of anxiety in interpersonal relationships, low self- esteem, grandiosity, feelings of isolation, perfectionism, ambivalence toward authority, and guilt. (1983, p. 105)

Upon consideration, however, these characteristics seem normal, human tendencies toward self-defeat. The same characteristics would describe most neurotics, people with personality disorders, and probably from time to time almost everyone. If ACOAs have such characteristics due to having been reared by an alcoholic, why do so many people not reared by alcoholics have the same characteristics?

It is possible that the same question occurred to Woititz. In her chief writing (1983), she introduced a term that itself did not become popular. The idea behind the term, however, is prevalent in the ACOA, codependency, and Inner Child worlds. It is "near alcoholic." This term refers to a parent who drank, but had few or no drinking problems.

Adult Children of Near Alcoholics have, according to Woititz, 13 characteristics. In her list she lumps two or three characteristics under one heading. For instance, she puts together "false hope, disappointment, and euphoria" as one characteristic. The others were:

denial; protectiveness, pity--concern about the drinker; embarrassment, avoiding drinking situations; shift in relationship--domination, takeover, self-absorptive activities; guilt; obsession, continual worry; fear; lying; confusion; sex problems; anger; and lethargy, hopelessness, self-pity, remorse, despair. (1983, p. 105)

If you were an Adult Child of a Near Alcoholic, your problems in living--the same ones most people may experience from time to time--become understandable in Woititz's theory: you were reared by a near alcoholic. Of her two lists of characteristics of ACOAs and ACONAs, Woititz says (p. 105), "This demonstrates very clearly how adult children of alcoholic parents are the products of their environment."

The ACOA theory is that a certain type of childhood leads to certain problems later in life. Then the theory claims that anyone who has those problems must have had that type of childhood. The fact that most of the people with those problems did not have an alcoholic parent led to the invention of "near alcoholics." It could lead to an infinite regress, to Adult Children of Adult Children of Alcoholics (A-CACA), to accentuation and overfocusing on memories of bad happenings, and to creation of false memories of childhood traumas that never happened but that "needed" to have happened for the theory to be correct. This process may have resulted in the phenomena addressed by the False Memory Syndrome Foundation. In rational emotive behavior therapy there is a saying, "Seeing is believing, but also believing is seeing."

Codependency Reaches Epidemic Proportions

The ACOA explanation for human unhappiness began to spread widely. Soon the same explanation extended to the friends, lovers, co-workers, and other associates of the alcoholic or other substance abuser. The codependency mass movement was born. It began with the simple, practical observation that people, usually the loved ones and family members of the substance abuser, often inadvertently contribute to the continued downfall of the beloved for reasons of their own. This sensible idea was immediately extended to the point that anyone making any effort--no matter how sensible or compassionate--to cope with or help a substance abuser became a "co" or an enabler. In addition, the symptoms said to reflect "the disease of codependency" include essentially all aspects of human unhappiness or self-defeating behavior. Codependency theorists (as does Bradshaw) claim that almost 100% of the population has the "disease."

In Codependent No More, Melody Beattie (1987) lists almost 250 characteristics diagnostic of codependency and says that her check list is long but not all-inclusive. Many of these are variations of normal human experience, and it is absurd to view them as diagnostic of "the disease of codependency." For instance, Beattie lists these and many other normal-sounding characteristics: Taking things personally, fearing rejection, helping others, leaving your routine to help another person, lying, feeling pressured, feeling different from others, wishing that good things would happen to you, having many shoulds, worrying, getting frustrated and angry, believing lies, saying everything is your fault, saying nothing is your fault, having strong sexual fantasies about other people, not feeling happy, and worrying whether other people love or like you.

Beattie also lists dozens of problematical and neurotic behaviors that indicate "the disease of codependency." They include relationship problems, anger, depression, anxiety, jealously, guilt, shame, overeating, overspending, insomnia, unassertiveness, obsessive-compulsive behavior, and substance abuse.

Some codependency authors struggle to provide a succinct definition of it, but for the most part they merely provide lists. Mellody, Miller, and Miller (1989) list five major characteristics in Facing Codependence. They say that codependents have problems with self-esteem, in setting functional boundaries, in owning and expressing their own reality, in taking care of their adult needs and wants, and in experiencing and expressing their reality moderately.

Most of those characteristics have to do with relationship problems, unassertiveness, dependent personality features, depression, attempts to find and keep love at any cost, attempts to control others, grandiosity, lack of purpose in life, and substance abuse. They represent neurotic problems, relationship problems, and difficulties in daily living, but they are nothing new. It is the codependency writers' unfamiliarity with the psychological literature that helps them think they have made important new discoveries.

The codependency movement has labeled almost every aspect of human experience, especially neurotic or troubled aspects, as "codependent." A word that means almost everything is almost meaningless. When people use "codependent," they usually think they are specifying some particular behavior, but they are specifying almost any behavior. Given the immense array of behavior and feelings said to be codependent, "codependent" may really mean no more than to say that the person is displaying some problematic aspect of human nature.

Once some aspects of a person's behavior have led to the diagnosis of codependency, there is a distinct tendency for the labeler to think he or she has explained the behavior. That is, if someone leaves her or his routine to help others, that behavior is "explained" by saying that the person is "codependent." This, however, does not explain the origins and maintenance of the actions in question. It just names them "codependent."

The evolution of the 12-steps into codependency shows increasing recognition that people can be unhappy and emotionally disturbed even if they do not abuse substances. The originators of the codependency movement and related offshoots of AA's 12 steps have noticed (at last) the same problems dealt with by mental health practitioners for a century. To maintain theoretical conformity with their preexisting ideas about addictions, they have made up a new name--codependency--for all unhappiness, problems in daily living, and neurosis, and they have invented the "disease of codependency" (aka "the addictive process") to explain everything. This myopic conclusion can distort and dilute personal problems and encourage people who really do not have addictions to think they do. The theory says that the addiction exists independently of the rest of people's lives and drives all their actions and feelings. Further, the theory holds that the addiction inevitably worsens unless the victim joins a 12-step group and achieves salvation.

Women's problems with codependency

The recovery world has changed enormously since its early days when AA did not admit women. Now, women appear to be the major consumers of 12-step oriented recovery literature and other services (Kaminer, 1992). The codependency movement has developed a huge self-help following as well as creating multimillion dollar markets in both the publishing and treatment industries. The disease/recovery movement--with its codependents, Adult Children, Inner Children, Toxic Parents, and assorted victims endlessly processing their "stuff"--disproportionately affects women. Women have harshly criticized codependency in particular but also the whole 12 step movement as the familiar male-dominated value system in which women are told to kowtow to the male Diety and their disease forever.

Individuals, particularly women, self-diagnose themselves as codependent, often seek treatment--professional and otherwise--and frequently enter costly inpatient recovery programs. Yet the very concept of codependency has generated a great deal of controversy and is under attack as conceptually weak, empirically unsubstantiated, politically regressive, and dangerously iatrogenic in that it pathologizes gender-based behaviors related to altruism and caring (Gordon, 1992).

Just as there are important alternatives to traditional disease models of addiction in the substance abuse field based on social learning theory, there had better be alternative theoretical models for people who identify with codependency and yet can be served better with frameworks and interventions that do not stigmatize them as victims of a disease.

Wolfe (1992) suggests that 12-step programs such as Codependents Anonymous (CODA) and Adult Children of Alcoholics (ACOA) have provided useful support networks and safe and validating environments for many women. However, overinvolvement in such programs, with their emphasis on endless processing of past traumas and present negative affect, can frequently slow emotional growth. Many women develop an overdependency on the groups and fail to take risks outside the group. Or they may develop an identification as victim that often keeps them locked into their past.

Wolfe emphasizes an effective alternative: All-women's rational emotive behavior therapy (REBT) groups. She outlines specific procedures for helping women overcome the negative effects of early sex role conditioning, recognize and rechannel their anger, set new emotional and behavioral goals and move more effectively toward them, and work on a societal level to promote change. Wolfe emphasizes the use of the group to promote women's developing "emotional muscle" and taking charge of their own lives.

In a similar vein, L. Trimpey (1992) states that fat is still a feminist issue decades into the modern women's movement. Women's love affair with hating their bodies--and themselves because of their bodies--continues. America's fat phobia may be mirrored not just in compulsive dieting and women's permanent dissatisfaction over their shapes, but in rising rates of bulimia and anorexia.

Trimpey asserts that weight issues, and other problems related to women's traditional roles as appendages of men's roles, still afflict millions of women and that behavioral therapies have not come to women's rescue. Even the most sophisticated and thorough of therapists often fail to help women achieve and maintain weight loss. Reviews of weight loss research typically find that the chances are generally slim for permanent removal of unwanted fat (Garner & Wooley, 1991).

Trimpey argues that the relative failure of weight loss programs, behavioral and otherwise, stems considerably from their failure to assess, and address, demands for slimness and consequent contingent self-esteem, that underlie and drive many women's (and men's) weight loss efforts. Her thesis is that the stronger one's inner demands for slimness, the more likely one is to diet (and eat) compulsively and to feel depressed, anxious, self-hating, "fat," and out of control.

Trimpey contends that "spiritual healing" programs, such as Overeaters Anonymous, which emphasize adoption of a philosophy of powerlessness and lack of self-control and advocate surrender to a Higher Power, are at least on the right track in that they do encourage dieters to adopt a new philosophy of life, not just new habits. However, Trimpey asks, how wise is it to advocate that women capitulate to powerlessness? In addition, a further deficit of the spiritual healing program is that it does not empower women to combat the cultural injunction to be slim.

Trimpey outlines how the value system of Albert Ellis's rational emotive behavior therapy, which emphasizes self-interest, self-direction, self-acceptance, and self-efficacy, as well as cognitive-behavioral techniques, can empower women (and men) to (a) free themselves of cultural "musts" not just about their weight, but their wrinkles, and their roles; (b) decide what is right for them; (c) non compulsively choose to move in that direction; and (d) feel good about themselves whatever choices they make and whatever results they obtain.

The Advent of the Inner Child

John Bradshaw is probably the single most influential figure in the world of addiction treatment since Bill W., and he is far better known. He combined the 12-step, ACOA, and codependency movements, borrowed from transactional analysis and family therapy models, and possibly from Freud, Sandor Ferenzci, and Arthur Janov. Then he added charisma. He fathered the Inner Child, a concept that has found immense popularity in his best-selling books, his workshops, rallies, and Public Broadcasting System appearances.

Bradshaw took the ACOA theory that bad events--usually at the hands of one's "toxic" parents and "dysfunctional family of origin"--cause current disturbances. Then he extended it to include the idea that bad non-events can cause even more such disturbances. The non-event Bradshaw most commonly mentions in his writings and lectures is "not being loved for yourself." Using the ideas of ACOA and codependency writers before him, Bradshaw argues that having a wounded Inner Child leads to the propensity to use and overuse alcohol and other drugs and to engage in other, nonchemically-mediated addictions.

Bradshaw defines the Inner Child by pointing to its putative effects when "wounded." When it is healed by the ever-present pain work, grief work, and anger work of the Bradshavian world, it is called the Wonder Child.

While some of the examples Bradshaw gives of people with wounded Inner Children do suggest child abuse, and occasionally severe abuse, in most instances it is clear that the main component of woundedness is what in rational emotive behavior therapy (REBT) is called "the dire need for love." Most of the people Bradshaw diagnoses as having a wounded Inner Child are engaging in what Albert Ellis humorously terms "musturbation." They are not merely wishing, preferring, wanting, or desiring to have had more love from their parents--assuming their reports of non-love are accurate. They are demanding it and feel they absolutely needed it. Were they operating only from desire, they might go on to say, "But, my parents weren't that loving. Too bad. Clearly I don't need them to have been different from what they were. It would have been nice, but it is not written anywhere but in my head that I have to have had what would have been preferable, namely a history of having been loved 'for myself'." Instead, they cry with self-pity, clutch teddy bears, rage at their parents, beat with their bataka bats, and get lots of hugs in Bradshaw broadcasts on the Public Broadcasting System.

On page x of the prologue of Bradshaw's Homecoming: Reclaiming and championing your inner child (1990), for example, an unhappy elderly woman is doing her pain work, grief work, and anger work in a Bradshaw workshop. She says in a letter she'd written to her mother--dead and gone for decades--"You never loved me for myself." On page ix, an older man reads from a letter he had written to his father, accusing him (though presumably deceased) of never playing with him and never taking him to a ball game, with the clincher, "If only you could have told me you loved me. I wanted you to care about me."

Bradshaw also seems to fall prey to the codependency and ACOA tendencies to explain all the ills of people--and the whole world--with his hypothetical construct, the Inner Child. In doing this, he also sets himself up for lampooning because of the excesses of his use of the Inner Child.

On the jacket of Homecoming, Bradshaw says, for example, "I believe that this neglected, wounded inner child of the past is the major source of human misery" (1990). Not war, poverty, famine, ignorance, bigotry, pestilence, organized religion, overpopulation, depletion of the ozone layer, or consumer fraud, but the neglected, wounded Inner Child of the past. Bradshaw says this wounded Inner Child is responsible for "much of the violence and cruelty in the world." (p. 10) He even attributes World War II and the holocaust to the wounded Inner Child!

On page 10 of Homecoming, Bradshaw claims that Hitler's Inner Child was, indeed, neglected and wounded, and that Hitler was the victim of "toxic shame." Bradshaw explains that Hitler's father gave the wounded Inner Child and the toxic shame to him, and Hitler's father--"the bastard son of a Jewish landlord"--in turn got his mishegoss from his father. With Hitler's Jewish landlord grandfather, the chain of cause and effect identified by Bradshaw--the sins of the fathers being passed on to the sons--ends. Bradshaw says nothing about the Jewish landlord having had a wounded Inner Child or even parents.

In the epilogue of Homecoming--"Home, Elliott, Home!"--Bradshaw reveals that millions of people in every culture in the world wept when they saw the movie, ET, ". . . because we are still divine infants in exile." Then provides information that bears on the issue of recovering versus recovered. He writes, "No matter how hard we work to reclaim and champion our inner child, there is a level of emptiness and absence in us all. I call it the 'metaphysical blues'." (p. 286)

Bradshaw ends the epilogue and the book by saying we will not be truly happy until we are in heaven living with God, and that no matter how fulfilled we are in this earthly life, we always experience a disappointment. "So much so that even after Dante, Shakespeare, and Mozart, we say: Is that all?" (p. 286) "I believe this sense of disappointment arises because we have another home where we all belong. I believe we came forth out of the depth of being, and being calls us back. I believe we came from God and we belong to God. No matter how good it gets, we still are not home. The wounded child Augustine said it well: 'Thou hast made us for Thyself, O Lord, and our hearts are restless till they repose in thee.' That will be our true homecoming at last." (p. 286).

The Emperor's New Clothes?

In the last five or six years, criticisms of the prevalent theories regarding the etiology and treatment of addictions held by members of the lay treatment community and the mainstream clinical treatment community (nearly indistinguishable from the lay treatment community) have gone public. Many of those criticisms had appeared in the more scientific literature for years (Fingarette, 1987). Stanton Peele, for instance, has critiqued the Disease Theory of addiction for a decade or more (1984; 1987). It seems possible that the extreme and excessive claims of the codependency movement in particular, but also Inner Child and ACOA movements, stimulated the beginning of the pendulum swing back toward choice and rationality and created a favorable climate for more popular critiques of the 12 step/Disease Theory theories and claims. "Codependency" was virtually sacred in mainstream addiction treatment circles only a few years ago, but now its mention often provokes apologies, groans, or laughter.

In particular, two of Stanton Peele's books widely available in bookstores and reviewed in the popular press, powerfully attacked the exaggerated claims of the 12-step movement. His titles alone--The diseasing of America: Addiction treatment out of control (Peele, 1989), and The truth about addiction and recovery (Peele & Brodsky, 1991)--would have been unthinkable mere years earlier. Peele was quickly joined by other writers whose books viewed with alarm, cited abuses, poked fun at, seriously challenged, or posed alternatives to the overinflated theory of codependency or to AA itself. These include The codependency conspiracy: How to break the recovery habit and take charge of your life (Katz & Liu, 1991); How to quit drinking without AA: A complete self-help guide (Dorsman, 1991); and When AA doesn't work for you: Rational steps to quitting alcohol (Ellis & Velten, 1992).

Easily the most humorous book (and best title), I'm dysfunctional, you're dysfunctional: The recovery movement and other self-help fashions (Kaminer, 1992), did not recommend any solutions to the preposterous excesses of the codependency and Inner Child movements that it clearly illustrated with abundant quotes. Kaminer's biting satire showed the pomposity of an ideology that claims it is scientific, but is not; which claims it is not a religion, but is; and which claims universal applicability and effectiveness, but has no proof.

Cracks continue to appear in the hegemony of 12-stepism in the lay treatment community. Secular Organizations for Sobriety, Women For Sobriety, and now Rational Recovery sprang up in the mid-1980s and achieve mention in the popular press. These are all non-12-step, and even anti-12-step self-help groups. Their purpose is to provide an alternative to the 12 steps and they have no quarrel with the people who prefer the spiritual healing approach. However, Rational Recovery in particular is the first self-help modality to go on the offensive and to say that the 12-step approach is not just unproven, but may harm many people and the culture at large.

The rise of Rational Recovery

The existence of alternatives to the 12-step approach has been a lay treatment correlate of an important trend in the scientific and research world: client/ treatment matching. Where individuals can select the approach to lay treatment they prefer, they may match themselves to what would work best for them. Having real choices, too, can increase people's sense of empowerment and self-efficacy. Rational Recovery's approach recognizes that most people recover on their own, without self-help or therapy. RR also incorporates elements of the theories of stages of change and motivational interviewing, because it focuses on the individual's decision to drink or not drink and how the person makes that decision, offers but does not prescribe tools, does not see non-attendance at meetings as bad, does not claim to work for everyone no matter how motivated, eschews diagnostic labels, and does not represent itself as the only way to recover. Further, RR speaks of "recovered," not just recovering, and it refers to "recovery group disorders" and "recovery from recovery." RR offers tools to accelerate that natural human process. The RR view is that many individuals may profit from attending only one or two meetings, and that there is no need for permanent attendance at meetings. The mainstream 12-step/Disease Theory approach says that those who self-change successfully "weren't real alcoholics."

The rise of the Rational Recovery Self-Help Network is a major crack in the wall of the 12-steps. First, it promises to be a popular movement and is in many ways similar to AA. It has the same aims as AA, of course. Its meetings are free, lay led, and abstinence-based. An extremely important similarity between AA and RR is that both advocate the adoption of a new Belief System, a new philosophy of life. Both AA and RR see the crucial importance of meaning, purpose, and values in people's lives.

RR derives from a psychotherapy, namely Albert Ellis's rational emotive behavior therapy (REBT). Rational emotive behavior therapy is unusual among psychotherapies in that it was the original cognitive-behavioral therapy. It also is a phenomenological and existential theory and philosophy. RR could only have come from REBT because of the latter's emphasis on the importance of one's philosophy of life, of creating of meaning in life, of one's values and purposes. In REBT, irrational and rational are defined in terms of blocking or promotion of one's purposes. RR's belief system, however, values skepticism rather than faith. It is a problem-solving methodology using an experimental, logical-empirical approach to goal attainment. It values feedback that points out its errors and unsupported predictions, because then it has a chance to increase its effectiveness.

Most of the remainder of this review will concern Rational Recovery and will suggest that it may be an important vehicle for integrating diversity, skepticism, and research findings--such as those on client/treatment matching into the lay treatment community. However, let us first briefly examine four articles selected by the editors for review to see what light they may shed on these trends.

Article Reviews

In "Social and cultural preconditions of Alcoholics Anonymous (AA) and factors associated with the strength of AA," Klaus Mäkelä (1991), examines AA's spread from 1935 in Akron, Ohio, throughout the world to find what intrinsic and extrinsic preconditions may be necessary for that diffusion. Mäkelä describes the first wave of AA's expansion through the Anglo-Saxon and Protestant world; the next wave through the American and European Catholic countries; and its most recent bridgeheads in some newly industrialized, nonwhite, non-Christian countries. Mäkelä points out that AA's structure and the tenor of its meetings differ somewhat from one society to another, but still he concludes that AA mainly remains a phenomenon of developed and wealthy societies. Though self-help may seem to provide an inexpensive solution to many social and health problems in developing nations, self-help movements such as AA have remained alien to most non-industrialized countries.

Intrinsic preconditions for diffusion of AA. According to Mäkelä, AA is a system of beliefs and an interactional system based on a set of rules of talk. Mäkelä saiys that an imporant feature of AA is that members enter it as individual atoms cut off from their social matrix. In addition, he points out that people are not supposed to bring their social status to AA meetings. He speculates that a precondition for AA is individuation, defined as the process by which individuals become the basic units of social action that supersede such units as the family, the household, the kinship group, the work team, or the village community.

Mäkelä's point stands that AA is a belief system and a way of making sense of aspects of reality. Mäkelä speculates that one can expect that AA can diffuse particularly when communal systems of giving meaning to the world are breaking down. Mäkelä also asserts that the AA belief system is a highly individualized way of making sense of the world, because there is nothing between the individual and the Higher Power, and this makes AA more adaptable.

AA may be a form of Protestantism, and the Oxford Group Movement from which AA sprang aimed to recapture primitive, first century Christianity and to be free of the fetters of organized religion. While it is true that individuals may give their own particular meanings to a belief system, for instance Roman Catholicism or 12 stepism, it is questionable that either belief system is individualized. AA, however, is far from an amorphous system where the individual's interpretations and preferences are supreme. A concordance of the 164 pages of Bill W.'s section of Alcoholics Anonymous (3rd edition) (up to the beginning of the Personal Stories section) indicates that God appears by name 132 times and as a capitalized pronoun 80 more times (C., 1986). On the other hand, "Higher Power" appears only twice--putting it on a par with "Wallace Beery movies"--but is called Power (always capitalized) 12 more times, usually in close association with God. However, disbelievers in "the God part" of AA are routinely told in AA meetings to tell themselves what is patently false according to all of AA's main writings, namely that their Higher Power can be anything. Part of AA's adaptability may stem from this AA deception. The afflicted, often physically ill and mentally demoralized person is told by very kind, acceptant people in AA meetings to put aside his or her basic convictions and to "keep coming back--it works!" The exhortations of a sponsor may lead to capitulation. This is the exact scenario played out in chapter 4--"We Agnostics"--of Alcoholics Anonymous.

Part of AA's ability to diffuse, asserts Mäkelä, is that "AA does not advocate any theological . . . beliefs." This is untrue. The 12 steps are exceptionally explicit in their views of God and of the proper way of relating to Him. Thus, Mäkelä overlooks that the God of the 12 steps is vitally interested in human doings; likes to be supplicated in quite specific, prayerful ways; can restore people to sanity; likes to have people turn their will and their lives over to Him; listens to people's searching and fearless moral inventories and likes them to admit to Him the exact nature of their wrongs; removes all defects of character from some people if they are entirely ready; prefers to be approached humbly by people asking Him to remove their shortcomings; likes to have people seek through prayer and meditation to improve their conscious contact with Him; and likes to have them pray for knowledge of His will and the power to carry it out.

Therefore, it may be speculated that the actual source of the diffusion of AA is the tendency for many humans to believe that God is vitally interested in and observing their daily doings and is apt to take helpful action if asked properly. People with a more non-interventionist view of God or some Supreme Being might tend to be less susceptible to AA.

Mäkelä also asserts that the 12 steps were toned down and revised to accommodate the world view of those early AA members who were agnostics or atheists. However, chapter 4 in the Big Book about "We Agnostics" is thoroughly contemptuous of agnostics and atheists. It repeatedly asserts that they are deluded, are trying to deny God when deep down they know He exists; that they cannot achieve salvation from alcoholism without belief in God; and that they will eventually come round to God in the end, as happens with the agnostic depicted by Bill Wilson in chapter 4 of Alcoholics Anonymous.

Nevertheless, Mäkelä admits that the 12 steps are clearly rooted in a particular religion and cultural tradition and that some affinity to Christianity may increase the local readiness for AA, whereas strong non-Christian convictions may raise barriers to the AA ideology.

Extrinsic preconditions for diffusion of AA. Mäkelä indicates that proximity to the United States seems to be a factor promoting the growth of AA. It diffuses well into prosperous, Protestant, capitalistic, Anglo and Anglo background (versus French background) countries, and throughout the American continents. AA has done worst in poor countries, Islamic countries, and socialist countries. Communist political systems have blocked AA's diffusion. Patterns of drinking also have something to do with AA diffusion. Where alcohol problems tend to be connected to disruptive drinking of a public sort, AA may have more attraction than it does where alcohol dependent people are less socially visible and less deviant. The level of beer drinking is positively correlated to the strength of AA.


2nd Article

In "In search of how people change: Applications to addictive behaviors," Prochaska, DiClemente, and Norcross (1992) summarize research on self-initiated and professionally-assisted intentional change of addictive behaviors, as opposed to societal, developmental, or imposed change. Prochaska et al. use the key transtheoretical constructs of stages and processes of change. To modify addictive behaviors involves progression through five stages--precontemplation, contemplation, preparation, action, and maintenance--and individuals typically recycle themselves through these stages several times before they terminate the addiction in question. Many studies provide strong support for the existence of these stages and for a finite and common set of change processes used to progress thorough the stages. An individual's stage of change is usually a better predictor of change than age, socioeconomic status, problem severity and duration, goals and expectations, self-efficacy, and social support. Further, differing interventions seem effective for people in different stages of change. The idea is to tailor the treatment to the person, not tailor the person to the treatment.

Prochaska et al. suggest that people rarely assess their stage of change and tailor their processes of change in a conscious and meaningful manner in the natural environment. Instead, they tend to have, say Prochaska et al., vague notions of willpower, mysticism, and biotechnological revolutions. One may speculate that people would use more refined tools for self-change if they had such tools.

Nevertheless, stages of change and readiness for change may some day replace some of the usual concepts used to account for lack on change on the part of substance abusers. The most important of those--denial--is the traditional and predominant concept in the mainstream lay treatment, 12-step community to explain why anyone would not profit from or like its belief system. The traditional way to handle so-called denial is to hammer at the person said to be "in denial." Other traditional explanatory concepts include inadequate motivation, resistance to therapy, defensiveness, and inability to relate.

In Prochaska et al.'s writings, precontemplation is the stage at which there is no intention to change behavior in the foreseeable future. People falling into that stage may not agree that they have a problem or may be unaware or underaware of their problems. Contemplation is the stage in which people are aware. When contemplating, people may weigh the pros and cons of the problem and the effort involved in the solution to the problem. Contemplators appear to struggle with their positive evaluations of the addictive behavior and the amount of effort, energy, and loss it will cost to overcome the problem. Serious consideration about doing something to resolve the problem is the central element of contemplation.

Large numbers of people sent to AA and other self-help meetings are likely to be contemplators or precontemplators. The group encourages them to admit they have problems. People at the action stage and maintenance stage are poorly served by AA and other 12-step approaches because of implications that they had better attend meetings the rest of their lives and that the meetings are the main thing that can keep them from ever-imminent relapse. RR founder Jack Trimpey, on the other hand, suggests that people attend no more than two meetings a week.

Preparation is the stage that combines intention with behavioral criteria. People in the preparation stage indicate that they intend to take action in the next month, and they have taken action unsuccessfully in the last year. Action is the stage in which people modify their behavior, experiences, or environment to overcome their problems. The hallmark of the action stage is that people to modify the target behavior to an acceptable criterion and make significant overt efforts to change.

Maintenance is the stage in which people work to prevent relapse and consolidate the gains they made when they took action. The last stage of change for most people is relapse. People lapse or relapse, revert to an earlier stage of change, and then they may begin to move forward again. Each time relapsers recycle themselves through the stages, they potentially learn from their mistakes and can try something different the next time around. Many people remain in contemplation or precontemplation stages of change prolongedly after relapse. However, the more action they took in the past to change, the better the prognosis.

Prochaska et al. have found that the amount of progress clients make following intervention tends to be a function of their pretreatment stage of change. Further, treatment programs designed to help people progress just one stage in a month can double the chances of their taking action on their own in the near future. (Prochaska & DiClemente, 1992). If interventions are tailored to the stage of change of the individuals in them, then there may be more chance that they will change.

On the other hand, Prochaska et al. identify the "mismatched stage effects." Most substance abusers are either preparing for change, or in earlier stages of change--contemplation or precontemplation. If treatment programs do not assess the stages of change of their clients, they are likely to underserve, misserve, or not serve the majority of them. For example, most drug-free outpatient programs refuse to treat anyone who is still drinking or using drugs. Therefore, they largely work with people in the maintenance stage of change. Instead of relapse prevention, however, such programs devote much of their treatment effort to "drug education" and other consciousness raising activities.

Another sort of mismatch is that many self-changers appear to rely primarily on change processes most indicated for the contemplation stage --consciousness raising, self-reevaluation--while they are moving into the action stage. Still another common mismatch occurs when would-be self-changers rely primarily on change processes most indicated for the action stage--reinforcement management, stimulus control, counterconditioning--when they do not have the requisite awareness and have not made the requisite decisions that occur in the contemplation and preparation stages.


3rd Article

In their article titled "Self-help quit smoking interventions: Effects of self-help materials, social support instructions, and telephone counseling," Orleans, Schoenbach, Wagner, Quade, Salmon, Pearson, Fiedler, Porter, and Kaplan (1991) reported their study of the effectiveness of three smoking cessation interventions: a self-quitting guide, that guide plus a guide to help would-be quitters mobilize social support, and both guides plus four brief telephone calls from counselors to promote and reinforce adherence to the self-quitting protocol. They also had a control group using a guide providing motivational and quit tips and referral to locally available resources and programs.

Previous research had already indicated that quit rates correlate with the amount of materials read and with degree of adherence to prescribed quitting activities (Cummings, Emont, Jaen, & Sciandra, 1988). However, the phenomenon of nonadherence is common. About half the subjects do not use the self-help materials provided in programs.

Another factor identified in previous research as aiding the quit process is degree of naturally occurring social support. Those with more such support tend to do better. Orleans et al. wanted to know whether social support could be augmented. They hypothesized that quit rates would be higher for subjects who received brief telephone calls that sought to (a) provide positive, nonjudgmental feedback and reinforcement appropriate for the quitter's particular stage of change (contemplation, action, maintenance, relapse); (b) address personal quitting barriers; (c) elicit commitments to carry out stage-appropriate quitting actions; and (d) increase subjects' sense of self-efficacy and their self-attributions for progress in quitting.

Orleans et al. randomized to the four conditions several thousand smokers who were patients in a health plan and who requested help in smoking cessation. Most of the subjects were predominantly moderate to heavy smokers with a history of multiple previous quit attempts and treatments.

The results of this experiment were that the control subjects achieved quit rates similar to those of smokers using the experimental quitting guide. They did so, however, using fewer behavioral prequitting strategies and more outside treatments. Telephone counseling increased adherence to the quitting protocol and quit rates, but the social support guides had no effect on perceived support for quitting or on 8- and 16-month quit rates. The authors found that subjects' use of the self-help guide plus brief telephone counseling yielded quit rates that approximated the 20-25% long-term quit rates typically achieved with more intensive treatments (Glasgow & Lichtenstein, 1987; USDHHS, 1989).

Orleans et al. concluded that there are many pathways to recovery. Control and experimental subjects appear to have reached abstinence through somewhat different routes. Those who got the telephone calls did not read more of the guides but they followed them more closely. They used more of the prequitting strategies. Subjects receiving the experimental guide were more likely to use behavioral prequitting strategies (like setting a quit date, switching brands, listing quitting reasons); subjects receiving the control guide were more likely to use outside treatments (other guides, group treatments, nicotine gum). Orleans et al. indicate that it would be a good idea in referral practices to include specific, detailed advice on how to "self-triage" either to self-help or to more intensive treatments.

Orleans et al. also indicate that many subjects who did not stop smoking made progress nevertheless. More than three quarters of the subjects in all groups reported making at least one serious attempt to quit smoking during their participation in the research. In addition, continued smokers reported significantly lower daily smoking rates and estimated nicotine intake at the 16-month follow-up. These findings may be less important as evidence of reduced smoking than as indication of progress from contemplation to action stages of change (Prochaska & DiClemente, 1983). Treatment interventions that help smokers move ahead even one stage can double the chance that they will later take further action on their own (Rossi, 1989).


4th Article

In "A randomized trial of treatment options for alcohol-abusing workers," Walsh, Hingson, Merrigan, Levenson, Cupples, Heeren, Coffman, Becker, Barker, Hamilton, McGuire, and Kelly (1991) report that most research has shown no advantage to inpatient treatment for alcohol abuse over outpatient treatment, which usually is much less expensive. In the current study, 227 newly identified alcohol-abusing workers at a factory in Massachusetts were mandated by their Employee Assistance Program to obtain treatment or lose their jobs. At the outset of the research, the subjects averaged 6.3 drinks a day and 19.8 drinking days in the month preceding the first interview. More than 90% were scored as alcoholic on the SMAST, 77% scored as "definitely alcoholic" on the Rand behavioral impairment index, 57% were classified as late or very late stage alcoholics on the Iowa Stages Index, and 56% were rated as alcohol dependent according to criteria of DSM-III.

These heavy-drinking workers were randomized to three, year-long treatment conditions: compulsory attendance at AA meetings, compulsory inpatient treatment (followed by outpatient AA), and a choice of options. All those treated were on a year's probation at work. They were followed at work and by the researchers for a year and by the researchers for an additional year.

The compulsory inpatient treatment option lasted 23 days and featured AA meetings, after which the subjects were required to go to outpatient AA meetings three times a week for a year. The compulsory outpatient AA condition featured AA meetings at least three times a week, and daily if possible, for a year. The third treatment option termed by Walsh et al. "choice," was one in which subjects could choose their own treatment. This was thought to enhance the subjects' sense of self-efficacy and also to facilitate their matching themselves to appropriate treatments. In this study, the major choices were the two previously mentioned AA conditions: inpatient (followed by outpatient) and outpatient. Walsh et al. give no information about how the choices (including the choice of no treatment) were offered to the subjects, other than to say "the staff of the employee-assistance program sometimes encouraged them to do one or the other," (p. 776) namely either inpatient AA treatment or outpatient AA treatment. Indeed, about half of the subjects chose the inpatient AA treatment, and about half chose the outpatient AA treatment. Three (3) subjects selected outpatient psychotherapy and six (6) selected no treatment at all.

There was no indication in the study as to whether the EAP (or researchers) monitored the subjects' attendance at outpatient AA meetings. However, data from collaterals as well as from job supervisors were collected systematically. The major outcome measure was job performance, including personnel records regarding hours of work missed, supervisors' assessments, and terminations. There were also self-reports of drinking and drug use as well as employee assistance program and supervisor's records.

Outcomes. The outcome Walsh et al. were most interested in was (a) how many and how long were any hospitalizations later required of the compulsory outpatient AA subjects and of the choice subjects? and (b) were any additional hospitalizations required of the subjects who had initial compulsory hospitalization? The additional hospitalizations were suggested by the employee assistance program based on job performance indicators. Walsh et al. found a very significant difference, namely that 23% of the compulsory hospital subjects were hospitalized for additional treatment. However, 38% of the choice subjects and a whopping 63% of the compulsory outpatient AA subjects had to be hospitalized during their outpatient treatment.

Costs of Treatment Outcomes. The total cost of treatment during the two year follow-up per subject was as follows: The compulsory hospital group was the most costly, averaging $10,040 per subject; the compulsory outpatient AA group was next, at $8,840 per subject; and the choice group was slightly less expensive, at $8,800 per subject. When the choice group was broken down into those who initially elected hospitalization vs. those who initially elected non-hospitalization (outpatient AA for the most part, but a few had psychotherapy and a few elected no treatment of any kind), it emerged that that hospital choice group was the most costly of all, at $14,080 per subject, and that non-hospital choice group was least costly, at $5,280 per subject.

The results obtained by Walsh et al. indicated that there were no significant group differences on job outcomes. The subjects in all three groups showing substantial and sustained improvement in all measured aspects of job functioning. Further, all three groups had substantial and fairly stable improvement on all 11 of the self-reported measures of drinking, with some decline over time. On seven (7) of those measures of drinking and drug use, however, there were statistically significant differences among the three treatment groups at one to four follow-up points. "On most, the compulsory AA group did the least well." (p. 778). The choice group fell midway between the hospital group and the outpatient AA group.

In their discussion of results, Walsh et al. state that all three treatment groups evidently brought their drinking problems under sufficient control at work for group differences in job performance to be rendered statistically insignificant. However, Walsh et al. then state that the compulsory hospitalization with AA follow-up addressed drinking problems significantly more effectively than did compulsory AA alone. The results of choice were intermediate between the two. Walsh et al. say "with considerable confidence" that the higher-cost inpatient intervention produced superior results. They also conclude that for problem drinkers with reasonable job stability and no serious medical needs, an initial referral to AA (or the offer of a choice of treatment) is somewhat less costly (about 10 percent) than initial referral to inpatient hospitalization. However, Walsh et al. say that because of the high rate of hospitalization of the AA attendees during the two year follow-up, initial outpatient referral entails "extra risk."

Walsh et al.'s data are susceptible to different conclusions. Treatment for the compulsory AA group was less expensive than the compulsory hospitalization group, and there were no group differences in terms of job outcomes. The outpatient AA subjects apparently drank more than did other subjects, but at the conclusion of the study it had not significantly affected their job performance. It is unwarranted to assume as a proven fact that those subjects would have gone on to drink more and more and to imperil their jobs again.

As for the "extra risk" entailed in referral to outpatient AA, a different perspective is gained from looking at the whole two years for all subjects. Sixty-three percent of the compulsory AA attendees eventually needed hospitalization, but 100% of the compulsory hospitalization subjects (of course) had already been hospitalized. (In addition, 23% of them needed more hospitalization.) The compulsory hospitalization group had more treatment and far more contact hours. Since the average amount of treatment was different, there may be some question about the meaning of comparisons between groups.

Outcome data for the choice subjects clarify the AA first/hospital first issue and also shed light on patient/treatment matching strategies. The data indicate that those who chose hospitalization stayed in the hospital about ten days longer on the average than did the compulsory hospitalization subjects. Though the average expense for the hospital choosers was higher than the average for the compulsory hospital group, the total hospital costs were less for the choosers than for the non-choosers because there were far fewer people who voluntarily chose hospitalization. Therefore, as is shown by Walsh et al.'s data, it would be less expensive for employers to let alcoholics-in-trouble choose their treatment than to require hospitalization of all, and it would entail no extra risk.

Though they had little to choose from, the least expensive group were those subjects given choice who did not choose hospitalization. (Walsh et al. do not provide a breakout for those who chose AA versus those who chose therapy or no treatment.) Walsh et al.'s report suggests that the EAP tilted those subjects toward the two AA conditions--inpatient or outpatient. One can speculate what the results of real choices would have been. Even so, Walsh et al. provide some evidence for success of patient/treatment matching strategies in which people can match themselves to treatments they prefer.

Rational Recovery

Just as there are some people who are receptive to the 12 step philosophy and the ideas about spiritual healing it involves, many other recovering individuals do not see as helpful ideas of spirituality, dependency, transpersonalism, and submissiveness. The Rational Recovery Self-Help Network, or RR for short, is a not-for-profit organization that sponsors and manages a international network of self-help groups. Rational Recovery extrapolates rational emotive behavior therapy (REBT) (Ellis, 1988; Ellis, McInerney, DiGiuseppe, & Yeager, 1988) into the self-help sector to deal with problems of substance abuse. Unless participants have a basic understanding of REBT as described in RR's main text, The small book (Trimpey, 1988; 1992), they are less likely to profit from attending meetings. RR groups now meet in approximately 500 American cities and towns. Two hospitals now offer RR options, and others are in the planning stages. A residential treatment setting now offers people the opportunity to work on their chemical addictions with ideas of self-mastery rather than self-surrender.

RR's self-help purpose is to offer people a method using REBT for achieving and maintaining sobriety while affirming positive human values. RR reflects and advocates the REBT values and criteria of mental health. These include self-interest, social interest, self-direction, commitment, flexibility, acceptance of uncertainty, risk-taking, scientific thinking, nonutopianism, self-responsibility for one's own emotional disturbances, long-range hedonism, and skepticism.

RR aims to build a strong alternative to the 12-step approach to self-help and professional treatment. Such an alternative is important for people who are not suited to the 12-step approach. Therefore, RR has a political purpose in addition to its aim to provide self-help tools.

When first established, RR was intended only for people who were chemically dependent. However, people with eating disorders, problems with gambling, love, sex, and other addictions and compulsions sought out RR. Most RR groups now are comprised of a mixture of alcoholics and other substance abusers and addicts. The first major exception to mixed groups was specialty RR groups of people with eating disorders. These "RR - Fatness" groups, which are also proliferating, use Rational recovery from fatness: The small book (Trimpey, L., & Trimpey, J., 1990) as their main text.

In addition, people have formed RR "SoDA" groups in several American cities. They provide a rational alternative to Codependents Anonymous (CoDA). The acronym, "SoDA" stands for "Sodependents Anonymous," and it is meant to highlight the RR belief that overdependence is the problem rather than "the disease of codependency." The term "SoDA" also satirizes the codependency movement, which RR considers quite excessive in scope and claims. Moreover, RR holds that the lengthy group attendance encouraged by CoDA promotes dependency and thereby helps make participants "so dependent."

The rational mode of recovery. RR tends to accept DSM-III-R's descriptive definitions of drug and alcohol dependence as disorders marked by chronic use, intoxication, and psychosocial impairment. RR puts little emphasis on the etiology of alcoholism and other addictions. Instead, it focuses on helping participants identify and change factors that maintain their addictions. Rational Recovery views addiction as a set of dependency-creating irrational beliefs. This dependency includes both psychosocial and physical dependence on specific mood- and mind-altering substances. Whether there is some inherited or constitutional basis for the emergence of these dependencies is largely irrelevant in RR. The solution to the resulting problems is the same either way: The individual will begin to suffer less from the use and abuse of certain substances when he or she chooses to stop using them. The issue is how best to achieve that solution.

RR recognizes that most of the people who recover from chemical dependencies do so without any form of treatment and without attendance at meetings of any sort, rational or otherwise. Thus, RR's purpose is to help people augment and make more efficient their natural self-directed growth processes. It is when self-guided bibliotherapy at home is insufficient that attendance at local Rational Recovery meetings can accelerate the learning process and support the individual's sincere efforts.

Competence versus powerlessness. The traditional Disease Theory as espoused by AA holds that people are powerless over their alcohol and drug cravings, and therefore not responsible for what they put in their mouths, noses, and veins. The RR view is that people have considerable voluntary control over their hands and facial muscles. RR also disbelieves the idea that people have little control over their feelings and actions. Instead, RR believes that people feel the way they think, and thus have considerable control over their emotions, actions, and disturbances. RR holds that people cannot really "be" alcoholics, but just people who believe some of the central ideas of the alcoholism philosophy.

RR also disagrees with the traditional belief in the chemical dependency field that if one "is" an alcoholic or drug addict, then one needs something or someone stronger or greater than oneself upon which to rely. Instead, RR holds that dependency is such a person's original problem, and it is better to start now to take the risks of thinking and acting independently.

RR states in clear terms that each of us had better learn to control our own moods and behaviors because, as individuals, we are ultimately alone in our struggle against alcohol or drug dependence. In RR, spiritual/religious matters are considered private and separate from recovery. Rational Recovery relies on no Higher Powers in teaching people to become and remain sober. In RR, such dependencies are discouraged in favor of personal responsibility.

The emphasis on abstinence is a point of agreement between AA and RR. In RR, however, the decision to abstain will preferably be based on rational assessment of consequences in the light of self-interest rather than upon belief that a "disease" causes powerlessness over voluntary actions. In addition, without abstinence, many substance abusers fail to learn to recognize and combat their irrational beliefs and may not learn new coping skills (Ellis & Velten, 1992).

Instead of presenting abstinence as an extremely difficult task, one that cannot be achieved without outside, divine help, RR presents abstinence as a relatively easy goal to reach. It regards the ability to abstain from intoxicants as within the sphere of human competence and considers ideas of powerlessness to be self-defeating. RR participants try to discover and dispute residual ideas of powerlessness. This is especially so in connection with the future use of drugs or alcohol. It also applies to negative emotions that may lead to an intensified desire to use intoxicants or that otherwise interfere with personal happiness.

The motivation to abstain. Many people seek help with alcohol and drug dependence in order to feel better about themselves. They have feelings of guilt and shame that stem from a litany of disapproval and failure, and they view sobriety as a way to build self-esteem: "If I were sober and doing better, I could earn some self-respect." While such an idea may motivate a person to start a plan of recovery, RR challenges such newcomers with the question, "Do you believe that sober people are more worthwhile than intoxicated people?"

RR disagrees with the idea that one must stop drinking in order to feel like a worthwhile person. Instead, RR holds that it is because one holds oneself as worthwhile to oneself that one had better decide to stop drinking and build a better life. RR also disputes the common irrational belief that in order to feel like a worthwhile person, one must be competent, intelligent, talented, and achieving in all possible respects, and to fail in any significant way, such as having an alcoholic relapse, constitutes proof of what one probably has always suspected and feared -- that one is defective, inferior, and worthless as a person. In RR, accepting oneself unconditionally as a fallible human being is entirely possible and highly desirable.

A major purpose in RR meetings is to help participants develop unconditional self-acceptance. This is done by directly teaching REBT ideas about self-rating and self-blaming and how to stop those processes and develop self-acceptance. Coordinators and other participants in RR meetings may suggest REBT readings. Pamphlets may be available in meetings. Discussion in the RR group, or just reading The small book, may help the newcomer to comprehend that feelings of guilt, shame, and feelings of worthlessness are caused by irrational beliefs that one's worth depends on doing well and gaining approval. RR teaches the rational emotive behavior therapy ideas that succeeding does not make one into a success, and failing does not make one into a failure. In RR, slips, lapses, and relapses are looked at as feedback and learning experiences.

The conscious value in RR on enlightened self-interest and on influencing one's own destiny is a major distinction between RR and AA. In the latter, putting oneself first and believing that one is captain of one's own ship is considered pathological. Self-control, however, is a matter of degree, and it is different from control over others. In RR, the self-centered motivation to abstain is based on reverence for human life starting with "Number One." The purpose of stopping using or drinking is the same one that may have originally inspired the addiction: To obtain pleasure, fun, and satisfaction with life.

One day at a time. The most revered saying in chemical dependency treatment -- "One day at a time" -- has only limited usefulness in RR, where the interest is in closing the chapter on chemical dependency. The RR idea of graduating from addiction and from being "in recovery" and getting on with life is quite different from the traditional approach in which being a victim of a "disease" and attendance at meetings are drawn out indefinitely. A further difference is that RR encourages people to think of themselves as ongoing processes, rather than as "having" an immutable identity ("I am an alcoholic"). The RR view is that when sobriety is undertaken for only one day at a time, there is always some room for negotiation: The addictive voice checks back tomorrow and tomorrow and tomorrow.

The illusion of denial. RR avoids giving people things to deny, because it does demand that people label themselves as alcoholics. RR does not use certain other 12-step/Disease Theory musts and other ideas that large numbers of people have difficulty believing. RR does not say one must admit powerlessness and character defects or that one must believe in Higher Powers to get better. RR does not extend "denial" to partners, relatives, and friends of the substance abuser by stating or implying that they, too, "have a disease." On the other hand, RR does assume that persons who appear at meetings accept that they have a significant problem. It teaches them that they are responsible for their own choices and that they are not forced to drink or use drugs by their current circumstances, their past histories--no matter how bad--or by their genes.

Substance abusers do experience ambivalence. In the contemplation stage, they weight the pros and cons of using and the pros and cons of stopping their using. On one hand, they genuinely enjoy and desire the altered states of consciousness that the intoxicant brings. However, they also wish that they did not have to suffer consequences of their drinking and drugging behavior. Soon after they have suffered poor results from substance abuse, addicts typically "see the light" and may get on the wagon. As time passes and the distance from the poor results increases, many addicts easily refocus on the substance's positive results. They then invent that they can have the positive results "this time" without getting negative results. Then they resume drinking or using drugs.

Contemplation, precontemplation. While people who attend RR meetings are warmly greeted by the Coordinator, they are not pressured to continue to attend or to make commitments to attend forever. They are not told, "Keep coming back--it works!"

Some people who do not participate when present and/or who do not return for additional meetings may be in contemplation or precontemplation stages of change, not denial. One way that RR looks at people "in denial" is that they are in a state of ambivalence. They have two distinct, opposite values on the same behavior. They see and want the positives of drinking and drugging, but they see and do not want the negatives. In the consciousness of each chemically dependent person, there is a conflict about the dependency. Sometimes the wish to be sober is a faint one, but rarely will anyone attend RR meetings who does not recognize that there is a better life than intoxication can provide.

Issues of maturity. Because each person is directed toward emotional independence, RR does not diagnose or otherwise indict a substance abuser's immediate family or family of origin. There is simply no expectation that family members will bear a burden of change because another has become addicted. The recovering addict's chief responsibility is to come to accept others as they are instead of expecting them to participate reluctantly in treatment.

Instead of calling the substance abuser's overly dependent significant others "codependent," RR regards them as showing the morbid dependency that some family members have on the love and approval of others in the family system. For those who are so dependent that they expose themselves to long-term abuse by an addicted person, we recommend The small book or other literature from the Institute for Rational-Emotive Therapy, consultation with an REBT or other cognitively-oriented therapist, or Sodependents Anonymous (SoDA) groups where they exist. People who are unhappy with such self-labels as Adult Child, codependent, or Wounded Inner Child, as well as those who want to separate confidently from a codependency group may also find rational readings helpful.

What Are Rational Recovery Meetings Like?

Like AA meetings, RR meetings are free of charge and self-supporting. In some meetings, participants pass the hat to collect money to pay the rent for the meeting room or to purchase REBT and RR literature or refreshments. RR meetings typically last an hour to an hour and a half. The only requirement for participation is desire to work on one's addictions. Rational Recovery meetings welcome people who themselves are not working on personal substance abuse problems, but who know rational emotive behavior therapy or other cognitive-behavioral therapies and who want to commit themselves to becoming a Coordinator or Advisor of an RR meeting. There is no assumption in RR that you have to have been one to be able to help one.

RR is a youthful movement and its meetings do not yet have--and may never have--one set format. At this time, creativity is given quite a bit of play as Advisors, Coordinators, and other RR meeting participants experiment with various formats. All the formats, however, highlight the elective aspect of drinking and drugging, look at the ABCs of REBT, and utilize AVRT (addictive voice recognition training).

The RR Coordinator secures a meeting room, opens and closes the room, stocks flyers and literature, handles the room rent and other expenses, maintains a record of donations and expenses, does publicity for RR, learns basic REBT, and is first among equals in RR meetings. The RR Advisor is usually a mental health professional whose chief purpose in attending meetings is to teach REBT, to provide occasional rational input to the group, and to survey the group members for unusual problems that may indicate need for a higher level of care. Like Coordinators, Advisors are volunteers. They do not act as therapists or counselors to the RR group and do not make referrals to their practices (if any), but they are free to introduce information that is relevant to the group discussion. They can participate in any way they wish in meetings. Sometimes, Advisors may suggest readings, teach cognitive-behavioral self-help techniques not included in the basic RR writings, and encourage participants to help each other (and themselves) using those techniques.

The chief activity at RR meetings is discussion. "Cross-talk," the interrupting of or responding to others that is forbidden in traditional 12-step meetings, predominates in RR meetings. Group members refer to rational literature, challenge and dispute each other's "stinking thinking," and learn to think rationally. The goal is for each participant to become a rational counselor to her- or himself as well as for others. Those attending RR meetings are not "clients" of anyone, but simply participants in an open discussion meeting.

RR meetings are structured more loosely than are traditional AA-type meetings. RR meetings are discussions that focus on the problems of chemical dependence and staying sober. Participants refer to The small book as a guide to rational relapse prevention methods and no-higher-power sobriety. Everyone in the group, and especially the Advisor and the Coordinator, is supposed to know the contents of The small book well enough to mention specific sections that deal with certain problems. As already mentioned, professionals interested in volunteering their services may attend meetings and participate. Group Coordinators and Advisors need not have a history of substance abuse. When they facilitate or lead a meeting, different ones of them do it differently. The RR dogma is that there are no dogmas. This idea is consistent with REBT as well as with the current status of knowledge about substance abuse and relapse prevention. One way in which RR works against dependence is to see it as unhelpful for group leaders to present themselves as having all the answers.

RR Coordinators post meeting schedules and advertise the availability of meetings. The meeting may be held in a community room, a private home, library, or even a church. The Coordinator arrives early, opens the room, arranges chairs in a circle, and sets out literature. Participants arrive, and the meetings start on time. The Coordinator, the Advisor (if present), or a designated group member will give a brief introduction to RR for newcomers, explaining its ground rules, such as confidentiality, and some of its distinctions from AA meetings.

An RR group is neither a fellowship nor a support group. Instead, it is a task-oriented self-help discussion group in which members engage in open discussion of the common difficulties they have in staying clean and sober. The agenda involves learning and practicing REBT concepts, discussion of self-defeating thoughts and actions, identification of ABCs, and members helping each other dispute irrational Beliefs and formulate more self-helping ways to think. Member are expected to become rational counselors both for others and themselves. The goal is to become one's own therapist.

The RR view is that people are capable of learning to act in their own interest and had better not lean on the group prolongedly. An RR Coordinator is not a sponsor or a therapist, a leaning post, or a spiritual, financial, marriage, or sex counselor. Coordinators do not make decisions for others and are not responsible for how others behave. What others do with their lives is their own choice; in RR, no one is the other's keeper.

Meetings typically begin when the Coordinator or Advisor asks the question, "Who's been thinking of drinking or using drugs this week?" and lively discussion ensues. If that question produces no input, then the second question, "Then who has a trouble to talk about" may be asked. Here a spectrum of issues may come out, and whatever problem is identified can very likely be traced to one of the common irrational beliefs -- or "central ideas of alcoholism," as they are called in The small book.

One of the Coordinator's roles during meetings is simply to point out that certain ideas that are being expressed are irrational--that is, self-defeating--explain why, and then to offer a rational concept as a better alternative. The easiest way to do this in a discussion group is by asking questions of a person who holds an irrational idea.

RR actively encourages independent functioning whenever possible. RR founder Jack Trimpey recommends that people attend no more than two meetings a week. Meeting participants sometimes ask for a list of meetings so they can attend RR around the clock, as they may have done with AA meetings in the past. In that case, the RR Coordinator and group members encourage the person to make an active plan for alternative activities. The person may say, "But if I don't have meetings to go to, I'll drink." Typically, group members point out that the person actually attended only one or two meetings a day in the past, but kept himself or herself from drinking twenty-four hours a day. "What did you tell yourself in your head to keep yourself from drinking?" they may ask. Or, "OK, so you went to ninety meetings in ninety days, but you did go back to drinking. What did you tell yourself to go back to drinking?"

If an RR meeting participant reports she or he was clean and sober for a while, but then resumed drinking or drugging, a common question in RR meetings is, "How did you decide to start up again?" This questions focuses the discussion on the heart of lapses, relapses, and continued substance use, namely the fact that the person makes a decision to use or continue to use the substance. From the rational emotive behavior therapy viewpoint, the question focuses on the belief system, or the B in REBT. The question implies that the person could decide not to use, which of course is the object of the RR meetings.

Addictive Voice Recognition Training (AVRT). The object of discussion in RR is to bolster the decision not to use, to label the thinking in the decision to use as self-defeating, and to link the using thoughts to the non-using rebuttal thoughts. RR writings often refer to the self-defeating "addictive voice" (irrational beliefs, automatic disturbing thoughts, rationalizations) as "the Beast." Many RR participants find it useful to dramatize the irrational belief system. "The Beast" personifies people's self-defeating tendencies, and the RR hypothesis is that this tool helps many people by clearly labeling "the enemy."

Once the RR group has brought out a participant's self-defeating thinking, a follow-up question is,"What could you say back to the Beast?" The group Coordinator or other groups members ideally then encourage the person to practice these rebuttals vigorously, rather than relying on "intellectual insight."

Typically, the addictive Beast voice does not simply say, "I want what I want when I want it, and the consequences be damned." Instead, it produces more subtle, derivative thoughts and rationalizations. The newcomer to RR frequently is unable to rebut rationalizations. Some typical rationalizations heard at RR meetings are, "One won't hurt," "I can afford it," "I deserve this one," "I'll stop tomorrow," "I've got to work through my issues before I can stop," "to hell with it," and numerous others. Almost always the person's track record has established these statements quite well as rationalizations that are contradicted by the accrued evidence. However, the person believes them again and again. Why? Because underneath the rationalizations may lie the belief, "I should be able to have what I want when I want it without any ill effects." People want to believe this, and then they decide to follow this belief even though they know at another level that it is a poor decision.

The central task in the rational mode of recovery is to help participants strengthen their skills in pursuing their rational goals of survival and personal happiness. The rational voice can then dominate the commanding addictive voice that argues endlessly for short-range hedonism and intoxication. Instead of beseeching the addict to surrender to a Higher Power, RR teaches group participants to dispute the "musturbatory" addictive voice.

A key insight for RR participants is that they do in fact think or decide something before they drink or use drugs. However, they usually have practiced their thoughts and decisions so much that they need not go to much trouble to repeat those decisions and thoughts.

Participants in RR groups are taught the three main REBT insights: They decide to drink or use drugs; wherever the original tendency to make such decisions came from, they themselves are responsible for such decisions now; and it takes work and practice to change one's habits. Emphasis in RR groups is on the "work and practice" insight, since most participants want the first two insights to change their lives.

The course of recovery. Two of the most important ingredients of Rational Recovery are (a) lack of dogma, creed, or articles of faith to follow, and (b) the meetings are relatively unstructured and freewheeling. In these ways, RR meetings reflect real life, because there seem to be no absolute or perfect truths and because life seldom provides a structure to keep people out of trouble or on the best course. In RR, participants are encouraged to learn to give structure to their own thinking, and then live an unpredictable life without resorting to drugs or alcohol.

Because RR perceives that recovery is about as difficult as one makes it out to be, it is not expected or considered desirable that people attend recovery meetings forever. Each person is the final judge of when recovery is complete, and one Rational Recovery Self-Help Network ground rule is that there will be no predictions that any group member will have future problems with relapse or with other personal difficulties. When a member announces her or his intention to leave the group, the group's most useful response is sincere well-wishing. It is acknowledged in RR that more people recover from chemical dependency in the privacy of their own homes than get better in recovery programs.

Possible future trends. There is a growing awareness that 12-step approaches may have victimized themselves with exaggerated claims about the need for them and their success rate. Because of their virtual monopoly in America's agencies and hospitals, as well as in the self-help community, a strong tendency has arisen for many people to say that there is only one way. "Resistance to the 12-steps" is often treated as another "disease" symptom. As a result many seeking help with their addictions have been left out in the cold or else are compelled to undergo treatment methods they disapprove. RR's emergence into the mainstream of addiction care offers another option to consumers and is an antidote to the widespread notion that the 12 steps are good for all comers. With RR groups available, Higher Power-resistant people need not be deceived that "anything can be your Higher Power" and then taught to depend on other humans or inanimate entities as Higher Powers.

Many people who seek out RR feel refreshed to find other people like themselves, who do not wish to be humble, who want to learn to depend on themselves, and who are skeptical that Higher Powers are needed to undo for us what we did to ourselves, and that must be contacted with prayer. Usually such people tried the traditional approach and were told that there was something wrong with them that they were unable to get traction on their chemical dependencies. They often felt as though they have failed to "work a good program," but they were probably in the wrong program all along.

There has been increasing concern about the "addiction to recovery meetings" phenomenon in which people acquire compulsive moods and attitudes and believe they must attend meetings forever. RR provides affirmation and vindication to all of these people. It offers them an avenue to kick the recovery habit and get on with life (Katz & Liu, 1991; Peele, 1989; Peele & Brodsky, 1991).

Matching clients and treatments. The scientific literature recognizes that there are subtypes of alcohol and drug dependent people. Due to many factors including cognitive style, some individuals will respond better when "matched" to a corresponding recovery program. Receptiveness to rational versus spiritual concepts is a most important determinant of treatment outcome. However, mental health and other professionals routinely refer -- and courts routinely mandate -- clients to AA and at best tell them to overcome any objections they may have to such components as "the God part," group prayer, and permanent attendance at meetings. At worst, they consider objections to religious and dependency concepts to be "the disease talking" and tell the client so.

This lack of sensitivity to clients on the part of professionals is partly because of the relative lack of availability of self-help alternatives. There is also the widespread but mistaken notion that it has been proven that "AA is the only thing that works." In fact, this notion is supported by little more than testimonials. These inequities are being addressed now by the activist stance of RR that provides advocacy for people who want to seek legal recourse for ill-advised referrals and mandated attendance at spiritual healing meetings.

Selecting the correct recovery program is just as important as choosing the correct medical treatments before administering them. Treatment is based on proper assessment. Often, the client has a good idea of which recovery approach is going to be most relevant, so one method of assessment is to ask questions about past attempts to stop drinking or using drugs. Questions about what the client does or does not like about the 12-steps approach are highly appropriate. The client's preferences for non-spiritual healing programs are signs of individuality, not psychopathology. It is far more likely that these comments are indicators for referral to Rational Recovery or other non-spiritual programs. A single past failure in the spiritual healing approaches is sufficient to suggest that a rational mode of recovery may be indicated.

Treating clients and patients with methods from which they have failed to profit time and again raises uncomfortable clinical and ethical questions. When clients are also stating that they do not want to undergo such an approach, there may also be legal problems. Moreover, repeated exposure to any treatment modality without success can expose the client to unacceptable risks, including death.

Summary and Conclusions

From its modest beginnings as a self- and God-help method meant to attract people voluntarily and assist them with their alcohol problems, some of AA's methods and assumptions and its 12 steps have been extended and generalized to all addictions and numerous behavioral problems. Hundreds of thousands of people attend lay-led "step" meetings daily throughout the United States and the world. The 12-step approach has been so successful in the United States that lay treatment methods are hardly distinguishable from mainstream professional treatment. Common knowledge is so certain that the 12-step approach is the only thing that works, that governments and employers--normally phobic for even minute possibilities of litigation--unhesitatingly mandate large numbers of people to attend AA and similar meetings.

The expansion and evolution of the 12 steps beyond AA now has two major branches. In their extreme form, one branch represents nature and the other nurture. One is the Minnesota Model, which includes the basic Disease Theory, but is known for extreme confrontational methods of treatment. The second branch follows a Psychoanalytic Model, and treatment based on it delves into the addict's upbringing, family dynamics, and developmental traumas and is marked by the assumption that certain types of upbringing must have taken place in order to have caused current adjustment problems. With the advent of the Minnesota Model Disease Theory and the Psychoanalytic Model have come intense marketing endeavors and increasingly farfetched claims about the numbers of people suffering from the disease only it can treat. In the last five to seven years, however, a backlash has begun to develop based on skepticism or dislike of many aspects of the 12-step approach and its offspring. Three lay-led, free, recovery methodologies analogous to AA now are available in many American towns and cities: Secular Organizations for Sobriety, Women For Sobriety, and the Rational Recovery Self-Help Network.

Rational Recovery (RR) is unusual in that it explicitly derives from a cognitive-behavioral therapy, namely Albert Ellis's rational emotive behavior therapy (REBT). RR in particular challenges assumptions about the necessity for permanent attendance at meetings and permanent disease status, states in its basic writings that many if not most people recover from addictions unassisted by professionals or meetings, strongly advocates against labeling of individuals as "an alcoholic," and not only does not pressure people to attend its meetings forever, but suggests that people not attend more than twice a week and feel free to not attend or to graduate from meeting attendance at any time.

RR also endorses research, patient-treatment matching strategies.

This paper's review of articles pertaining to the stages of change model, patient-treatment matching, and cost containment.

Pt-treatment matching reduces costs. Questioning the usefulness of the 12 steps.

12 steps are out of hand. Inflated claims, deceptive practices, no choices available, those who dislike it are diseased, confrontational attitude--arrogant, assumes it knows best for everybody. Back lash. RR, an avenue for research and to reach the lay treatment community; CBT, REBT, incorporates SOC and p-t matching strategies; endorses research.

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