12 Step Treatment and Group Therapy for People with Addictions
Imagine a group of 12 recovering addicts/alcoholics, one peer supporter and two facilitators, sitting in a circle. Most of the clients have been in contact with the criminal justice system at some point, with convictions ranging from drink driving to GBH and attempted murder. Some have served time. About half have had a social services caseworker at some time in their lives. More than half are divorced. Most of the others are single. Some are also estranged from their children.
These are people who have exhibited extreme anti-social behaviour and seem unable to conform to the norms of society. Their self-destructive behaviours, their constant failure to face their responsibilities and the waste of their gifts and talents frustrate their loved ones. They have between them a number of failed suicide attempts, and half of them have another mental disorder as well as addiction. Professionals agree that as a client group, addicts/alcoholics are the least likely to respond to their advice, they are unpredictable, unreliable and uncooperative. A common description of the individuals in this group by people who know them is that they are ‘lost souls’.
This group has been together for 12 weeks, meeting 5 times a week for intensive drug and alcohol treatment and group psychotherapy. They have shared intimate details of their lives and built up a deep understanding and trust. They have learned how to give constructive feedback to each-other, and can recognise their own and each-other’s defensive patterns of behaviour. They know the difference between support and collusion, and challenge versus aggression. In short, during the last 3 months these group members have formed a cohesive social structure, supportive, accountable and responsive to each-other. And they have remained clean and sober.
It has not always been a comfortable group to attend. There have been stormy times. They have battled with each-other and the facilitators, and in the process learned how to manage conflict in a productive way. They have experienced deep tenderness and emotional support, and also been helpless with laughter. They would all agree that the last 12 weeks have been an emotional roller coaster. They are approaching the end of their time together, preparing for graduation.
This is an imaginary group based on many that I have had the privilege of working with in an addiction treatment setting. I was trained to deliver this type of group therapy while working for RAPt (Rehabilitation of Addicted Prisoners Trust) in Bullingdon Prison. RAPt have successfully rolled out 12 Step drug and alcohol treatment programmes in many UK prisons and their results are impressive.
The Roots of 12 Step
12 Step philosophy evolved from the inspiration of 100 alcoholics in America back in the 1940s who contributed to the book, ‘Alcoholics Anonymous’ 1. They developed a way of staying sober by meeting with others who also suffered from alcoholism, and sharing their experience strength and hope with each-other. They discovered that they had a higher success rate when they helped other people than when they tried to go it alone.
‘Alcoholics Anonymous’ sets out the principles of the 12 Step philosophy. This includes the belief that in order to recover, addicts and alcoholics must exchange their selfishness and self-centred behaviour for consideration and service to others. AA members believe that group involvement is essential for recovery from drug and alcohol addiction, and that group membership changes an individual’s perspective from being egocentric, isolationist, and introverted, to welcoming connections between individuals and understanding the significance of accountability to the group.
12 Step Treatment
Many UK drug and alcohol rehabilitation institutions use the 12 Step model which has proved consistently successful. 12 Step treatment is not to be confused with the self-help fellowships of Alcoholics Anonymous and Narcotics Anonymous etc.. These fellowships provide a constant and consistent support network for addicts to incorporate into their lives and maintain their recovery indefinitely.
12 Step Treatment on the other hand is typically 3 – 6 month intensive rehabilitation therapy at the beginning of the recovery process. Participants move quickly through the Stages of Change2from Contemplation to Action and Maintenance. It is a powerful combination of therapeutic interventions that allows the client to explore historical issues as well as working in the here and now to address problematic behaviours and relationships. It uses therapeutic devices such as homework assignments, role play (drama therapy) and group therapy. The group is an experimental space where clients can try out new ways of relating, new behaviours and attitudes before using them in the wider community and effecting fundamental change in their lives.
In my time as a group facilitator I have become convinced of the importance of a consistent structure. As long as the group knows the structure, the participants will feel safe to take risks and build trust with each-other. I generally work with 10-12 group members for 90 minute sessions. I find that with this number, group members get involved and receive support and identification from the others. Any fewer than 8 and people become less willing to take risks and give little feedback. In larger groups I have struggled to hold my awareness of all the participants’ process even with a co-facilitator present and I find that the majority of group members simply witness others’ performance.
Holding the time boundaries of warming up and concluding is vital to the safety of each session, so I avoid the temptation to run on for longer if the session becomes intense. It can be challenging to interrupt a client in the middle of some difficult work, but I calmly signpost the work as important to return to at the next session and complete the finishing ritual – the group routine takes priority.
Our groups all have ground rules which are kept in a visible place for each session and adhered to. We give the group time to discuss and understand the rules and agree the penalty of not abiding by them. In this way we help our clients to invest in the structure that keep the group secure.
For this type of group therapy it is most effective to have two facilitators, one leading and one supporting. These are trained professionals with an awareness of their own as well as group process. They are responsible for the safety of the group as a whole, including the facilitators. They work together to hold the boundaries. Having two minimises the chances of a facilitator being unconsciously drawn into the dynamic of one or more members. Working as a team is considerably less stressful and creates a more holding environment for the group.
To do this work, the facilitators must have a thorough understanding of group dynamics. They need to recognise what stage the group is at, to play a supportive role. For example, at the start, when participants are developing their relationships and understanding of each-other, the group leaders will do much of the work, inviting individuals to take their space and modelling effective feedback techniques. As the group matures there will be some jostling for power and control. This is normal and the group leaders must allow the safe expression of conflict, again modelling how to express emotion in a way that is not abusive to others or damaging or overwhelming for themselves. There will also be conflict from some of the group members towards the leaders, as they begin to rebel and stretch their own muscles of responsibility. Although alarming for the novice, this is often a sign that the group is working effectively and the members can now conceive of challenging the status quo and being responsible participants. Towards the end of the group’s life, the facilitators will be playing much more of a witnessing role. They will still hold the boundaries, but the group will largely organise itself.
The Facilitators Perspective
Working in this way it is impossible not to become emotionally involved. I am also a member of the group, and while I have my professional boundaries and understanding, I am also a human being and witness the struggles and triumphs of my fellow humans. I form relationships. I feel my soul respond to a group member exploring his fear, guilt or anger. I am touched to tears by someone expressing their vulnerability to others for the first time. I am frustrated beyond belief by the obtuseness of an individual, or scared when she lashes out at me. Without supervision it would be too much for me and I would burn out and retire to my potting shed – or worse, I would act out my frustrations within the group. But with the support of my peers and a supervisor to challenge, encourage and direct me, I can continue to be a useful part of the process. It is important for me to constantly remind myself that I am one small part of the process – far from the all-knowing, all-seeing professional. I am a facilitator, and what I facilitate is the natural curative effect of working in a group.
12 Step Treatment Works
Three factors are intrinsic to the success of this type of treatment:
The nature of the work allows the participants to become vulnerable to each-other quickly and so to trust one another with very personal material. They learn how to give constructive feedback to each-other and so learn in an experiential way how their behaviour impacts people around them.
- Peer Support
A peer supporter is a vital component of the group. This is a person who has graduated from a previous programme, has the T-shirt and is living proof that recovery is achievable. A peer supporter can model recovery, identify with the participants and disclose their own experience in a way that the facilitators cannot.
The 12 Step method strips denial away by encouraging clients to look at their own process and witness the other group members’. They are encouraged to look for aspects of each-other’s story that they can identify with. The mantra of “you can’t kid a kidder” is central to 12 Step Treatment, discouraging the habitual manipulation and dishonesty that can characterise addictive behaviours.
When individuals go into 12 Step Treatment they are quickly introduced to a culture of recovery. While using drugs and alcohol, many became isolated, or if they were part of a group, their peers reinforced their addictive behaviours. During treatment, clients are introduced to a new language, a new philosophy and a new set of values. Peer pressure becomes a positive factor in encouraging individuals to conform to recovery. Meaningful relationships are developed which nurture the individuals, sometimes in ways that they have never before experienced. This culture extends to their lives in the community as they attend 12 Step Fellowship meetings where they encounter the same language and recovery culture. Slogans that emphasise the importance of social cohesion can frequently be found in AA and NA meetings:
“Give it away to keep it”, “Stick with the winners”, “12 step programs are a school in which we are all learners and all teachers”, “If I serve, I will be served”, “You are not alone” 3
This treatment works. In a recent study RAPt analysed data for almost 400 prisoners who had completed an intensive abstinence-based programme between November 2004 and April 20094and compared the results with a control group of prisoners identified as having substance misuse problems but who had undergone shorter, less intensive programmes. According to their research, the percentage of people who received custodial sentences after release was 26% for the RAPt group, compared with 49% for the control group. Fewer than half of prisoners (44%) with substance misuse problems who completed a RAPt intensive 12-step long-term programme went on to reoffend on release. This compares with a reoffending rate of two-thirds (73%) for other drug-addicted prisoners who did not go through the programme.
12 Step group therapy treatment kick starts the recovery process by introducing clients to the dynamics of working in groups and learning how to inter- relate in new and rewarding ways. Working within groups as experimental spaces, individuals can effect lasting change in their lives. We wish our new graduates luck as they go into the world to try out their brand new strategies and behaviours. Without this treatment the odds of premature death or ending up in prison are extremely high. With the treatment they have a fighting chance of building a new life.
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