The Curious Friendship Between 12-Step Programs and Psychodynamic Psychotherapy

Guest Post by Caroline Adkins

Caroline X. Adkins is a community mental health psychotherapist. She obtained her MSW from the University of Maryland Baltimore with a concentration in clinical behavioral-health, and is completing her post-graduate training at the New Washington School of Psychiatry. She is based in Washington D.C., and works with adolescents and adults.

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Introduction

For as long as I’ve watched TV, I’ve been well-acquainted with the imagery of Alcoholics Anonymous. With the circle of folding chairs, the church basement, the big book, and the awkward process of making amends, AA is just as much a cultural symbol of sobriety as it is a recovery program. As a psychotherapist in community mental health, I’ve heard a variety of perspectives from people whose lives have been touched by this unique support group.

Certainly, there are many ways to recover from alcoholism and to build a life full of meaning. Many are wary of AA for a variety of reasons, not least of which are the elements of patriarchy and Christian overtones found in its literature. Nevertheless, Alcoholics Anonymous reaches across class lines and cultural backgrounds, forming its circles in religious institutions, community centers, private homes, and prisons. Rarely do I meet a patient in recovery who hasn’t at least crossed paths with it. With each passing session, it has become increasingly difficult for me to ignore both the tension and mutuality that the world of AA shares with the institution of psychotherapy.

A brief history

Prior to psychoanalysis, hypnosis was commonly used to treat what was once called hysteria. Freud finished up his studies in Paris and returned to Vienna, Austria where he started to see patients in his practice in 1886.¹ Although the methodology of psychotherapy has evolved considerably over the past 100 years, Freud’s concepts—namely, the interpretation of defense mechanisms and the role of transference and resistance in the consulting room—remain paramount for psychoanalytically-inclined therapists working to develop an understanding of our patients and their suffering.

AA started in 1935 after a meeting between Bill. W, stockbroker from New York, and Bob S., a surgeon from Akron Ohio. Through Bill’s mentorship, Dr. Bob quickly started to recover, and the two set out to carry the message of sobriety to others.² As of AA’s 2021 report, there are almost 2 million members worldwide.³ Several groups with the same twelve steps and twelve traditions have since emerged–Narcotics Anonymous, Crystal Meth Anonymous, Eating Disorders Anonymous, are a few examples. Al-anon and Nar-anon–groups centered around supporting those with addicts in their lives–maintain the same principles, recognizing the vicarious effects of addiction require a sort of recovery as well.

AA and its related groups have twelve steps and twelve traditions. The twelve steps embody the characterological and interpersonal changes that the program recommends its participants go through with the help of a sponsor. The twelve traditions describe the group norms to keep the rooms unified and focused, regardless of the varying ideological orientations or life experiences of its members.

Like psychotherapy, AA maintains that personal change is integral to meaningful recovery. Unlike the exploratory work that can be done with a clinician, however, AA prescribes a basic framework for self-improvement centered around principles of service, responsibility, and interpersonal repair. 

The methods of Alcoholics Anonymous stand in stark contrast to those of depth-oriented psychotherapy. If either were a religion with instilling values as its primary purpose, then they would be completely at odds… With that said, I have yet to meet a single psychotherapist who is anything but supportive of their patients attending AA.

Clinical implications

In my clinical experience, there are as many ways of being impacted by AA as there are people in recovery. Sometimes, it shows up in a story about a sponsor or an interaction at a meeting. Other times, it shows up in a truism from the Big Book that struck a chord for someone. The sheer ubiquity of the program means that its presence is often palpable in the therapy room when the client is in recovery. 

What are psychotherapists to make of this presence? I find myself most interested in how it brings to light the ways of thinking and understanding oneself that a person already carries. 

Undoubtedly, the program has proven itself to serve an important containing function for alcoholics. Those who follow the steps religiously and those who simply view it as a way of making sober friends have this in common. Studies have confirmed the salience of social support to sustaining sobriety.⁴ “AA gives people a lot of structure with the sponsor and with the stepwork that isn’t available in therapy,” notes Doug Eifert, a D.C.-area psychotherapist specializing in addictions and recovery at an outpatient clinic (personal correspondence). Unlike AA, formalized group psychotherapy generally restricts clients from outside contact for the duration that it meets. Because its purpose is to work towards a common goal rather than exploring one’s interpersonal patterns in the context of a group, AA has ample room for people to socialize outside of its meetings.

At the cornerstone of AA lies the notion of personal responsibility. At each turn, its members are reminded of their contributions to the challenges facing them and asked to examine their role in fixing them. In step 4, members are required to make “a searching and fearless moral inventory” in which they work with a sponsor to reflect on their personal shortcomings.⁵ For those who follow the program to fidelity, the moral inventory is not a one-time event but one to be revisited continually.

In practice, this means that I am rarely the first person to introduce them to the role they play in the events around them. Many have sat with a sponsor and filled out a chart detailing a situation they’re frustrated by, why it frustrated them, and the role they played in it. Nevertheless, externalization remains a strongly rooted defense, and for good reason. To remain unaware of one’s capacity to cause damage may serve to protect a person’s self-concept. Cognitive awareness of one’s own misstep here, or one’s bad decision there is a good start. But building a coherent sense of self that can non-judgmentally self-reflect and accept feedback from others while remaining sturdy is an arduous task. I’ve had several clients express resentment towards the responsibility-taking aspect of AA, feeling as though they’re being asked to assume fault in every situation. Fruitful conversations have arisen from this. Sometimes, people struggle with neatly delineating their contribution to a situation from that of the other person. Other times, people wonder what it means to assume responsibility when the people in their lives refuse to do the same. Successful treatment requires that the clinician know how to take responsibility too. Therapists of all theoretical orientations are taught and repeatedly reminded that we bring our entire selves into our daily work. Personal therapy and supervision have been indispensable in providing me space to reflect on what it is that I’m bringing to the room, and how I can manage and make use of my experiences. 

Making amends is another hallmark of the Alcoholics Anonymous program. The program’s focus on the interpersonal realm makes sense—addiction is known for eroding one’s decision-making capabilities, leading to strains or destruction in both personal and professional relationships. The eighth step of AA requires people to make a list of people that the alcoholic has wronged; the ninth step requires the alcoholic to attempt to make things right with each of them. This process brings up another set of difficult questions. What does it mean to apologize—and what does it mean to do so when the impetus is one’s own recovery? I generally hold back from taking a position as to whether a client of mine should reach out to someone from their past, or whether it was the right decision if they already have. But repair itself provides fertile ground for discussing how one understands their relationships and the ways in which one seeks closeness.

Most people seeking therapy are somewhat aware of what they ought to be striving for—stability, self-sufficiency, and a meaningful role in their families and communities. In AA, an individual’s contribution to the group is commonly straightforward and oriented to a goal shared by the entire group—maintaining sobriety, and all of the emotional and behavioral changes that ought to come with it. These are all good objectives for therapy as well. Nevertheless, some of our wishes are buried. Some of them are tangled up in contradictions. It has been my experience on both sides of the couch that the question of individual desire reaches far beyond shoulds and should-nots.

Addictions and psychoanalytic thought

There is hesitance towards psychoanalytic thought from both professionals and non-professionals in the recovery world.  Much of the disconnect makes sense on a practical level. Although there are psychoanalytically-oriented therapists with expertise in addictions, many will refer to more intensive treatment until the patient has achieved and maintained sobriety. But as manualized interventions have gained traction in recent decades, long-term depth-oriented therapy has often been caricatured as an endless, aimless quest to figure out why a person acts the way they do. “Change is hard,” says Darren Haber, a psychoanalyst in private practice with a specialty in addictions and recovery. “Sometimes the psychoanalytic blind spot is that a change in behavior first really can lead to bigger things. The AA blind spot is that feelings don’t matter, just do the action.” (personal correspondence)

The truth is that psychoanalytic tradition has always recognized that insight alone is insufficient. “There is no ultimate answer or final explanation why one is a certain way or did a certain thing,” writes Bruce Fink, a renowned Lacanian analyst and translator. “The emphasis goes on bringing about a change in ‘subjective position,’ a change in the way the analysand gets enjoyment in life, a change that puts an end to the attempt to endlessly try to explain what is ultimately unexplainable.”⁶ 

Those who have recovered from addiction—and those who have borne witness—know that the process is not one of mere abstention. “Getting sober means having to figure out how to spend twenty four hours a day… It means learning how to eat, how to speak among people and walk and love and more than any of that, learning how to just sit still,” writes Kaveh Akbar in the introductory passage of Another Last Call, a poetry anthology centered on addiction and recovery.⁷

The task of learning how to feel is excruciating. Early sobriety feels like a loss for many; a defense against the suffering of daily life has suddenly vanished. In AA, it’s the group custom to introduce oneself as an alcoholic. But emotional growth means developing a sense of identity beyond that. The type of self-examination that can help one come to understand their agony instead of jettisoning it takes years. Patients come to see unconscious conflicts, relational patterns, and coping mechanisms unfold within the context of their relationship with their therapist. The psychoanalytic tradition maintains that this work is best done by a professional who has gone through an arduous psychological journey in therapy of their own. 

Conclusion

The methods of Alcoholics Anonymous stand in stark contrast to those of depth-oriented psychotherapy. If either were a religion with instilling values as its primary purpose, then they would be completely at odds—AA’s ideology would be overpowering to the sense of open-ended psychological flexibility that patients in psychotherapy are seeking to develop.

With that said, I have yet to meet a single psychotherapist who is anything but supportive of their patients attending AA during the week. AA itself instructs its members to “take what you want, and leave the rest,” deprioritizing its own ideology in service of creating a wide tent. In my day-to-day practice, people tend to look at both therapy and AA primarily as settings to assist them in recovery. The frame is the technical term for this. Psychotherapy has a contained, limited frame, with a focus on working through one’s conflicts and desires. AA has a more casual, peer-oriented frame with a focus on supporting each other through the challenges of sober life. They are both institutions. But from the standpoint of the individual, they are soft places to land, consistent and sturdy amidst the chaos of the week. 

I am not in recovery myself, but I am familiar with the world of 12-step programs because I love people who are. Al-anon—AA’s sister group—as well as my therapist’s office are my own settings for finding peace. I’ve become familiar with many of the aphorisms associated with the 12-step world, hearing them both directly in meetings, and repeated to me by some of my patients. “It’s not about bad people becoming good,” dictates the program, “it’s about sick people becoming well.”

I don’t know whether a bad person can become good, or what goodness really means at all. Imparting morality is beyond my scope of practice as a psychotherapist. Ego-strength and integration, like sobriety, are not moral virtues unto themselves.

But it’s these elements of self-efficacy that grant a person the sturdiness they need to make a decision about the sort of life they’ll lead. No psychotherapist—and no sponsor, for that matter—can tell a person who they’ll be. People seek that out for themselves when they realize they have no other choice. Over each 50 minute hour, or meeting, or late night phone call, or table full of laughter, or journal entry. We are always coming back. And we are always finding our footing.

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See also:

The Conceptual Muddle of Addiction and Recovery: A Discussion with Carl Erik Fisher

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1. Saul McLeod. “Sigmund Freud’s Theories & Contribution To Psychology.” Simple Psychology, May 22, 2024.

2. “History of A.A.” Alcoholics Anonymous. Accessed August 25, 2024. https://www.aa.org/aa-history.

3. “Estimates of A.A. Groups and Members as of December 31, 2021.” Service Material from the General Service Office, December 31, 2021, 1–1.

4. Islam, Mohammed F., Mayra Guerrero, Rebecca L. Nguyen, Alexandra Porcaro, Camilla Cummings, Ed Stevens, Ann Kang, and Leonard A. Jason. “The Importance of Social Support in Recovery Populations: Toward a Multilevel Understanding.” Alcoholism Treatment Quarterly 41, no. 2 (February 28, 2023): 222–36. https://doi.org/10.1080/07347324.2023.2181119.

5. Alcoholics Anonymous World Services, Inc. (1989). Twelve steps and twelve traditions. Alcoholics Anonymous World Services.

6. Bruce Fink, Fundamentals of Psychoanalytic Technique: A Lacanian Approach for Practitioners (W. W. Norton & Company, 2011).

7. Kaveh Akbar & Paige Lewis. Another last call: Poems on addiction & deliverance. Louisville, KY: Sarabande Books, 2023.