IS FREE CHEAP ENOUGH?
A psychiatrist’s argument in support of Emotions Anonymous
I have been in the clinical practice of psychiatry for over 20 years. Like my colleagues I have witnessed the massive erosion in mental health and social services available to my patients. Where I practice, in Volusia County in Florida, there is not a single day hospital program, no intensive outpatient programs, no psychiatric residential treatment facilities, no sheltered workshops and only two inpatient psychiatric units, one public and one private. The very busy public facility is staffed by nurse practitioners and, from what I hear, turn away a lot of people seeking help. They are continually bemoaning reductions in funding, responding by cutting programs and personnel. The private psychiatric beds are on a "crisis stabilization unit" with an average length of stay of 3 to 5 days. The burden of caring for people ranging from the ‘worried well’ to the newly psychotic therefore falls onto the outpatient medical community. The majority of this ‘care’ is delivered in the primary care physician’s office in the form of trials of psychotropic medications. There are also private practice counselors and therapists who provide mental health care but this is often time limited by insurance constraints. While officially these therapists subscribe to a wide variety of theoretical perspectives and practice techniques, it seems to me that most clients receive what I would describe as supportive therapy. A growing trend is to follow the DSM medical model of mental disorders and spend a lot of time in therapy sessions discussing symptoms, diagnoses and medications. It is becoming increasingly common for therapists in my area to practice a sort of psychiatry-by-proxy, utilizing primary care physicians to prescribe and adjust the medications they recommend. This impoverished, cost-driven mental health care delivery system is so clearly inadequate to the needs of mental health patients that one is forced to ask what psychiatry, psychology and society can and should do about it.
Steven S. Sharfstein MD, newly elected president of the American Psychiatric Association agrees that there has been an unacceptable deterioration in mental healthcare, arguing for the return of a biopsychosocial model of evaluation and treatment. While acknowledging that the profit motive of pharmaceutical and insurance companies have played a significant role, he also recognizes that the psychiatric profession itself has "allowed the biopsychosocial model to become the bio-bio-bio model" where "a pill and an appointment" have come to dominate treatment. Arguing for a revival of psychotherapy and psychosocial treatment he implores his fellow psychiatrists to "work hard to end this situation and get involved in advocacy to reform our health care system from the bottom up." He asks psychiatrists to embrace a "new professional ethic that the doctor-patient relationship should not be a market driven phenomenon." While this sounds very noble I believe it is a naive and self-serving position that ignores the most glaringly obvious reason for the deterioration in mental healthcare. Profit driven pharmaceutical companies didn’t force their way into the psychiatrist’s office by kicking the door down; they strolled in through a door flung wide-open to them by psychiatry’s uncritical acceptance and promotion of the medical model of mental illness. Unless and until we as a profession step back from our stubborn insistence that the only legitimate way to evaluate, understand and treat human mental health and illness is through a scientific discourse that mimics the rest of medicine, then it won’t matter if we call it the bio-bio-bio or the biopsychosocial model, because, at the core, it will always be about biology. As such psychiatric care will remain vulnerable to the same rationing of resources and cost-effectiveness analyses imposed on the rest of biological medicine. The way to truly reform mental healthcare is not to shut the door on the drug companies by refusing free pens and notepads, but to fling the door open more widely and allow perspectives and discourses back into psychiatry that the medical model has excluded! It is in that spirit of reformation that I propose that we invite the spiritually grounded 12 Step recovery model back into the psychiatric dialogue as a source for both understanding and treating all forms of human emotional distress, not just addiction.
Emotions Anonymous (EA) is a 12 step program formed in 1971.Unlike the better known 12 step recovery programs Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), participation in EA does not require an addiction to alcohol or drugs. As stated in EA literature: "The only requirement for membership is a desire to obtain emotional health". On the surface this sounds like an excellent adjunctive or alternative source of help and support for patients whose current options are limited to trials of medication and brief therapy. My concern, however, is that due to its grounding in a non-scientific "spiritual" discourse, mainstream psychiatry will be resistant to lending legitimacy to principles that guide 12 step programs, especially if it clashes with the medical model. Gergen and Mcnamee note that "Other traditions are capable of rendering intelligible what might otherwise be called depression. The ‘loss of meaning’ in life has been of chief concern to traditions of the spirit; in response, not therapy but teachings from the Bible or Koran, along with pastoral counseling services, are favored". A direct challenge to the treatment of depression as a physical illness of the brain is something that, I believe, mainstream psychiatry will not tolerate. But, doesn’t psychiatry already comfortably work hand-in-hand with spiritually based 12 step treatment programs for substance abuse and dependence? I would say the answer to that is yes and no.
The most widely used 12 step model is Alcoholics Anonymous. In AA alcoholism is characterized as a "disease". However, this is basically a didactic concept because the treatment in AA is clearly described best by the fuzzy, unscientific term, spiritual. Mainstream psychiatry also characterizes addiction as a "disease" but in their case the meaning is literal; addiction is an actual physical disease of the brain. Carefully sidestepping the questions of mechanism and proof, "evidence" from genetic data to PET scans are cited as support for this conceptualization of the neurobiological basis for susceptibility to addiction, response to the reinforcing properties of drugs and the way in which a diseased brain causes drug urges and relapse. The unspoken promise is that one day the problem of drug addiction will yield to a simple biological explanation and intervention. In a 1997 New Yorker article about the 12 Step treatment program for addiction at Hazelden Hospital the then head of the National Institute on Drug Abuse, psychiatrist Alan Leshner MD is quoted as saying: "I believe that five years from now you should be put in jail if you don’t give crack addicts the medications we’re working on now." While this "miracle" drug to combat crack addiction has yet to emerge, the implication of Leshner’s statement is clear. As the author of the article notes, the domination of the medical model has resulted in "the elimination of entire fields of therapeutic practice by cheap and powerful psychoactive drugs" and that the literal concept of addiction as a physical disease "challenges the premise of a spiritual cure" and the need for 12 step treatment. Mainstream psychiatry’s negative impact on the spiritual model of addiction and recovery is evidenced by the near disappearance of AA based inpatient treatment facilities and the explosive growth of the unprovable and sometimes destructive concepts of dual diagnosis and its corollary, drug and alcohol abuse as ‘self-medication".
12 Step programs have stubbornly refused to subject themselves to scientific scrutiny and offer no efficacy data to support or refute the demands of "evidence based" psychiatry. There is no mention of anything even remotely resembling spiritual in the DSM diagnostic criteria for substance abuse or dependence. Ironically, research conducted on new anti-addiction drugs typically involve study groups in whom drugs are contrasted with placebo in patients also enrolled in some sort of supportive outpatient treatment, typically a 12 step program. Many clinical psychiatrists accept the help that AA or NA offers to their addicted patients, although, in my experience, unless they are recovering themselves or have worked directly in substance abuse treatment, most psychiatrists have little or no idea what goes on in the meetings or what the 12 steps are or how they work. So let us examine these 12 steps of treatment along with other important principles and concepts in 12 step programs and examine how they relate to other, perhaps more familiar, non-medical discourses and practices in philosophy, psychotherapy and religion.
In your handout is the full text of the twelve steps of recovery from EA. I’d like to share an abbreviated version with you and then comment on the process of recovery they promote. In shorthand the 12 steps are: 1.) Saw the problem, 2.) Heard there was help, 3.) Decided to trust that help as best I could, 4.) Took an honest hard look at myself, 5.) Shared what I saw with another person, 6.) Prepared myself to accept help, 7.) Asked for help with specific problems, 8.) Thought about those I’ve harmed, 9.) Made it right when I could, 10.) Did regular check-ups, 11.) Worked on trusting high power, and 12.) Practiced what I learned in all areas of my life.
In a recent guest editorial in Clinical Psychiatry News Marsha Epstein, MD commented about a change she noticed in her patients who took her advice to attend Al-Anon meetings (a 12 Step program for the families of alcoholics). She said: "Many did try Al-Anon. Soon, their visits to my practice decreased. One woman used to come in almost every month with something, and after she started going to Al-Anon, she stopped coming except for her annual checkup. People also seemed happier". In my practice I see a mixed population of patients from all walks of life. Aside from a small percentage, most of my patients do not fully ‘respond’ to the psychopharmacology I or their previous doctors try. I would hardly call most of my patients "happy" and, like for Dr. Epstein, they are always coming in with ‘something’. "I think I’m getting depressed again, I’m not sleeping, my anger problem is coming back, I don’t think the medicines are working anymore, I think I’m bipolar or maybe ADD, what about that new medication I heard about, Cymbalta". Some of these patients are also in psychotherapy and I will inquire as to what the therapist thinks is going on. More and more, as I discussed above, the answer is along the lines of: "The therapist thinks I’m getting depressed again and that I should talk to you about changing my medicines". But there is an exception to this rule and that exception is for my patients who, along with seeing me, are working a 12 Step recovery program. I use the term working the program because the benefits of a 12 Step program require more than just going to meetings, even if, for example, you are maintaining sobriety. I’d like to therefore explain how the 12 Steps work by describing what is different about my patients who are working the program. (I will employ the language of narrative and social constructionist theory in my description).
The singular most striking difference between my recovering patients and those who are not is how rarely those in recovery employ a victim narrative in their self understanding. From victimization by childhood experiences, endless lists of ‘traumas’, obscure chronic fatigue and pain syndromes and the most powerful and compelling victim narrative of all, the chemical imbalance (or as Kaiser calls it, the "broken brain" storyline), most of my patients expectations of what medical model psychiatry offers is a relief of the painful symptoms resulting from something that happened or is happening to them totally outside of their control and certainly not in any way their fault or responsibility. But personal responsibility and a sense of agency is precisely what 12 step recovery focuses on. Participants are taught how to identify what is under their control and will be their personal responsibility to address in the future during the fearless moral inventory in steps 4 through 7. Quoted directly from the EA handbook: "We keep ourselves from becoming well; no one else does. It is our own responsibility to become well. Only when we choose to act on this responsibility will we gain the ability to recover our emotional health". I am sure that some psychiatrists and therapists would heartily endorse this perspective but often meet strong resistance to it from their patients. So how does a 12 step program accomplish this? By preparing the way in steps 1 to 3.
Rational recovery and other alternatives to 12 step addiction treatment are extremely critical of step one which they believe espouses a disempowering, helplessness model of recovery. This is because in step 1 the addict is asked to acknowledge being powerless over drugs, alcohol, food, sex, gambling or in EA, their emotions. In steps two and three they are asked, in essence, to surrender to a higher power to solve their problems. (So far, it sounds a lot like making an appointment with a psychiatrist). But the goal and purpose of the first three steps is not to teach people that they are truly powerless, it is to begin the process of what humanistic psychologist Mike Aarons taught me many years ago as the primary goal of psychotherapy, displacing the patient from the center of the universe. Because step1 is not saying that you are now and forever will be powerless over your behaviors and emotions, it is just asking for an admission that whatever you’ve tried up to now, whatever you think is the nature of and solution to your problems hasn’t worked! So stop trying to figure it all out by yourself because, after all, they say "your best thinking got you here". The purpose of this ‘surrendering’ step is obvious in drug and alcohol addiction. Addicts have often already tried many, many times to conquer their addiction prior to finally seeking help from AA or NA. Statements such as "I’m a cocaine addict, I don’t see why I can’t drink" is a common example of what is called ‘stinking thinking’. So what is surrendered in steps 1 to 3 is your stubborn willfulness, your narcissistic defenses and unwillingness to listen to others. In early recovery it is not unusual for a chatty, overconfident novice to be advised to "take the cotton out of your ears and stick it in your mouth". But what about God; why does that need to figure into the equation?
The 12 steps of recovery were first formulated by an alcoholic doctor and his friend in the 1930’s when the use of the term God was not quite the touchy political subject that it is today. Many people report a very difficult time dealing with any concept of God playing a central role in the 12 step program. That is why 12 step programs go to great lengths to emphasize that the actual concept is, as stated in step 3, God as we understood him. The EA handbook says that this higher power can be "the group, nature, the universe, a Higher Power, the God of our understanding, or any entity a member may choose". In his book On Religion theologian and post-modern philosopher John Caputo suggests that perhaps a more meaningful and attractive concept of God for our postmodern times is "the force" as described in the Star War movies. In a compelling autobiographical account of her Al-Anon recovery, Letting Go With Love, author Julia H. devotes an entire chapter to her struggle with the higher power issue. The chapter’s title is "A Trip to the Ocean". In it the author’s sponsor asks Julia: "Are you willing to act as if you believed there is a higher power? Julia responds: "I’m willing to believe that the ocean is a power greater than I am". So her sponsor tells her: "Then go to the ocean and take your defects with you. Close your eyes, and feel them drifting off to sea, one at a time". It is true that religion can invade some 12 step meetings, but if that is a problem there are plenty of other (at least AA) meetings to choose from. The point here for the psychiatric community is that discomfort with the God concept is not a legitimate reason for patients to refuse trying 12 step programs. Look for other sources for resistance if this occurs.
Finally there are the advanced steps 8 through 12. I say "advanced" because there has to be some legitimate progress made in the first 6 steps before being ready to tackle the final 6. I can recall when I was working in an inpatient rehab how nearly all of the patients had this powerful instinctual urge to skip right to step 9, making amends. In particular they wanted to get on the phone to their families or bosses and apologize for all the harm their years of addiction had done. The only problem was they were forbidden to use the phone for their first two weeks of treatment. As we helped them through the first 6 steps most realized that that desire to apologize was not a genuine desire to make amends, it was a genuine desire to get themselves out of trouble with their support systems as soon as possible. Kind of like the way athletes and politicians have taken to making public televised apologies today.
Steps 10 and 11 are reminders that a 12 step program isn’t curative therapy but something that needs to be continually worked and reworked throughout life. That is why alcoholics and addicts are taught to use the term recovering, not recovered. Step 12 emphasizes that recovery work is relevant to all aspects of life, not just the maintenance of sobriety. Finally the concept of altruism is introduced in suggesting carrying this message to others. In 12 step programs there is a mentoring process where more experienced members will sponsor newer members and assist them in understanding the program and working the steps. Sponsors are aware that they should not and cannot attach to the success or failure of their sponsees and that the true reward of being a sponsor (which is often emotionally draining work) is found in the act of sponsoring, not in the outcome. In other words, detach from what is not and never has been under your control, the actions of another person.
This idea of detachment from what is not under your control is the central theme of what I see as the unifying statement in 12 step philosophy, a mantra of sorts recited at the end of most meetings: the serenity prayer.
"God grant me the serenity to accept the things I cannot change, the courage to change the things I can and the wisdom to know the difference". The dictionary defines wisdom as "experience and knowledge together with the power of applying them critically and practically". In that sense I believe that mainstream psychiatry and psychology are not displaying much in the way of wisdom. Information (falsely labeled as knowledge) is being generated by the boatload in our scientific publications. Yet I see patient after patient presenting to me with histories of multiple past diagnoses and failed trials of medications who insist on clinging to the medical narrative we’ve taught them. I believe that the mental health system has failed these patients and their families and loved ones. We are not displaying wisdom in our treatment of these people, we are displaying a dogged idealism and tenacious clinging to a singular model of understanding even when it fails time after time. We owe more to the patients who trust us. That is why I am advocating for our profession to get behind an effort to revitalize Emotions Anonymous. We need to stop complaining about a lack of resources and money for mental healthcare because it won’t do us or our patients any good if we succeed in getting more money if it is simply spent or resources devoted and subservient to the medical model. Do we really want to see millions of dollars spent on programs such as the mental illness screening of all schoolchildren our government has proposed?
As a clinician I would describe myself as a pluralist and pragmatist. I am an advocate of a social constructionist model of truth and a narrative therapy model of treatment. The 12 step program is easily compatible with my clinical philosophy. But if I am advocating that the psychiatric profession support Emotions Anonymous as an adjunct and/or alternative treatment then we need to look at its compatibility with other schools of thought. Let’s start with the most obvious and problematic- the medical model. Officially, EA is careful to not represent itself as being in the position to judge or critique what goes on between their participants and their doctors or therapists. In the handbook it explicitly states that "EA has no position on therapy, medication or mental health issues". In their pamphlet "Introducing Emotions Anonymous to the Health Care Professional" it states "We neither endorse nor oppose use of any medication or therapy but encourage each member to adhere to the advice of their physician". EA’s position therefore is stated clearly. However, some doctors may recall instances in which AA seemed to oppose the use of any psychiatric medications, pejoratively labeling them to be ‘mood altering’ drugs. That extreme a position is rare to encounter today. I do believe however that being in a 12 step program might lead to patients taking a more decisive role in their relationship with medical model psychiatric theory and practice by presenting an alternative understanding of dysphoric moods to them because, as stated in the handbook" "In the Emotions Anonymous program, we do not analyze emotional illness. We do not label and categorize everything". I believe that psychiatry’s problem with EA would not be that it is openly critical of or incompatible with the medical model, but that it may introduce some doubt in patients about the certainty with which mainstream psychiatry utilizes it. I think this would also be rue with the most dominant school of thought in psychology, cognitive therapy.
In the EA handbook it says: "Along with habits of action, we also develop habits of thought. Our thought patterns help form our attitudes toward life. These attitudes have the potential to make us well or sick, happy or miserable. It all depends on how we choose to think".