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What Makes Twelve-Step Programs Therapeutic?

There is a special synergy between psychological theory & twelve-step programs.

Treatment providers regularly express the wish for an easily accessible and affordable community-based resource that can supplement professional treatment by providing social and emotional support, as well as a good enough “holding environment.” Such a resource could provide clients with opportunities to consolidate and sustain the gains they’ve made, both between counseling sessions and after the conclusion of treatment.

No matter how high quality the behavioral health/addiction treatment services provided to clients might be; no matter how impressive the improvements people present in session are, it can be difficult at best to maintain those gains in the face of the stresses and challenges embedded in many family, social, neighborhood, and work environments. The reality is that people naturally and appropriately spend much more of their daily lives in these environments than they ever will in treatment. The functional improvements clients make are mitigated if not undone through contact with these frequently countertherapeutic influences. This gooses the potential risk for a relapse of symptoms, or unhealthy behaviors—which for anyone struggling to recover from active addiction includes drug use.

The concept of the “holding environment” comes from D. W. Winnicott, a British pediatrician turned psychoanalyst. Winnicott viewed relationships and interactions with other people, along with how individuals saw themselves vis-à-vis their most important relationships, as the key factor in healthy development. He extrapolated his original holding environment—the physical and psychological relationship and interactions between primary caregiver (usually the mother) and infant child—to the relationship and interactions between therapist and client. Part of the therapist’s task is to create a holding environment that assists the client’s growth and development.

A quality holding environment promotes feelings of physical safety and emotional security, of being understood and unconditionally accepted. It brings about such supremely humane and salubrious effects through consistency, reliability, attunement to one’s needs, and by responding to those needs compassionately and empathically. By generating the experience of being emotionally “held” in these ways, the environment facilitates healthy physical, mental, emotional, and spiritual development.

For people seeking recovery from addiction, twelve-step programs can provide a holding environment that gives shelter from the heavy weather of life, especially in early recovery, and supplies the support needed to withstand its most extreme storms. The public stigma associated with addiction taints its sufferers, magnifying existing feelings of inadequacy. The longer and harder someone uses mind- and mood-altering drugs, the more of his or her true self goes into hiding and remains hidden. Active addiction takes people further and further away from who they really are. The injuries addicts inflict upon themselves and others multiply, and deep down they fear inherently undeserving of the acceptance of others.

Consequently, for most, the genuinely warm welcome, empathic understanding, and unconditional positive regard experienced in twelve-step programs of recovery is emotionally corrective. It offers a sanctuary that encourages addicts to take the healthy risks intrinsic to learning new and different ways of relating to oneself and others, and grow beyond the limitations of that which is familiar. It changes how they see themselves, opening the door to self-acceptance. If others can accept us for who we are, even after baring the most carefully concealed parts of our personas and the worst things we’ve ever done (with a sponsor and in twelve-step meetings), then maybe, just maybe, we are worthy of acceptance and can begin to practice self-acceptance. Self-acceptance is essential in order to heal from the ravages of addiction.

There are many individual differences among the people at any given twelve-step meeting, including all the colors of the racial and ethnic rainbow and the entire socioeconomic spectrum: from the homeless and desperately indigent to service workers and blue-collar tradespeople to physicians, attorneys, and other affluent white-collar folks.

Addiction is a great equalizer, and a shared interest in recovery brings together an extraordinary assortment of people who would otherwise come in contact with one another only in passing. Somehow, the commonalities that connect this diverse group of individuals usually overwhelm the vast differences between them. What people did during active addiction—to themselves, to loved ones, and to others; the depths they plumbed en route to finding the motivation to attempt a new approach to life; the desire to remain free from active addiction one day at a time and learn how to live a meaningful and value-directed life—generate a connection that translates to empathic understanding and mutual support at depth.

A healthy holding environment gifts its occupants with what Carl Rogers, the founder of Client-Centered Therapy, referred to as “unconditional positive regard”—the absolute, unequivocal respect for and appreciation of others, encompassing such qualities as acceptance, nurturance, compassion, equanimity, empathy, and love. Being on the receiving end of unconditional positive regard, of feeling accepted for who one truly is, is powerfully cathartic. For those afflicted with addiction, it is a profoundly therapeutic experience.

Copyright 2013 Dan Mager, MSW