Tips For Dating a Person in 12 Step Recovery

Would you let your daughter go out with an addict?

In the title of her book, Girlfriend of Bill, author Karen Nagy riffs on the time-honored public code for mutual AA recognition: “Are you a friend of [AA co-founder] Bill?” Nagy says she was unable to find any material written “specifically for someone who is new to such a relationship or who is thinking about dating someone in recovery.” So she wrote one, and the publishing arm of Hazelden brought it out. People in Hazelden-style recovery (Nagy calls them “PIRs”) can present challenges, since, as Nagy learned by dating several of them, stopping drinking or using is not necessarily the end of the matter.

Readers should know that the book is written from the perspective of a member of Al-Anon, who is also a firm believer in the 12 Steps. But if dating people who participate in AA or NA is not your thing, than Nagy suggests dating people from SMART recovery, Secular Organizations for Sobriety, church, mental health peer support programs, therapy groups, and so on. Her own experience, however, appears mainly limited to men in and out of 12-Step recovery programs.

While the controversial disease model of addiction continues to provoke heated debate, Nagy discovered that “knowing addiction is a disease has helped me to confront and get over my past prejudices about alcoholics and drug addicts, and to better understand why they might think, act, and react the way they do.”

“Change is tough for all of us,” says Nagy, “but it can be especially hard for an addict” because of the strong tendency to rationalize and resist needed change. Addicts, she adds, “are also known for ‘wanting it now,’ a trait that could be related to their brain chemistry and addictive cravings.” (Or, as non-practicing addict Carrie Fisher memorably put it, “instant gratification takes too long.”)

Her summation of the notion behind the AA/NA concept of a higher power is a common one these days: “Some might call their Higher Power God; others might define it as nature, the positive energy of their group, or an unnamed sense of spirit.” While that may sound naïve to some, what the addict must grasp is that white-knuckle notions of triumph through personal will may have to be abandoned along the way, if we are talking about chronic, active addiction. And she correctly points out that the AA Big Book is “written in an old-fashioned style that hearkens back to the 1930s,” when the amateur self-help group known as AA was founded.

It’s easy to forget that there are common experiences that most recovering addicts are heir to. “We who care about a Person in Recovery are also powerless over alcohol and drugs,” Nagy writes. “Try as we might—we can’t control whether or not the PIR uses them.” And non-addicts who are dating them might usefully be forewarned about such things, Nagy believes. In addition, “It can take months for an addict’s body to adjust to abstinence,” she writes. “Aches and pains are common in withdrawal, and so are digestive problems that can include constipation, diarrhea, and loss of appetite… sleep disorders can be a huge problem….”

Nagy also tips boyfriends and girlfriends to the widening and primarily generational dispute over the use of medications for craving or associated mental health disorders. “Believing ‘a drug is a drug is a drug,’ many old-timers in recovery resist taking medications, whereas younger People in Recovery are more open to taking them if they need them.”

Addicts new to recovery may be coming off a period of social isolation, and a sense of being cut off from others. Nagy advises that a summary knowledge of the 12 Steps can be helpful, in particular the business about “making amends” to people one has harmed. Forgiveness is a touchy and ongoing bit of business. It never hurts to say you’re sorry, if in fact you are. Or to say it again.

Perhaps the single most common complaint takes the form of jealousy or irritation: Why is the Person in Recovery spending so much time with those other people, rather than with me? Aren’t I “supportive” enough? Nagy views the essence of AA/NA as a “spirituality of companionship—friends accompanying friends, helping, sharing, daring, celebrating, or grieving.” In the end, Nagy believes, “it’s not about religion; it’s about connection.”

Hazelden Offers Companion to the “Big Book”

New guide attempts a modest AA update.

The founders of AA published their book, Alcoholics Anonymous (The Big Book) back in 1939. The world has changed a great deal since then, so it’s not surprising that there have been periodic calls for an update. Barring an official revision, which is unlikely, Hazelden, the Minnesota treatment organization, has published an updated companion volume to the Big Book. (Narcotics Anonymous published their version of the basic text in 1962). “The core principles and practices offered in these basic texts hold strong today,” says Hazelden, “but addiction science and societal norms have changed dramatically since these books were first published decades ago.”

Hazelden’s book, Recovery Now, billed as an easy-to-follow guide to the teachings of Alcoholics Anonymous and Narcotics Anonymous, dispenses with the divisive question of medications for withdrawal straightaway. In a foreword by Dr. Marvin D. Seppala, chief medical officer at Hazelden, the doctor makes it clear: “I agree with the majority of treatment professionals who support using these meds to help with cravings when it is appropriate to do so. Addiction is a disease that calls for the best that science has to offer.” The unnamed authors of the “little green book” agree, stating that “for some mental health disorders, medications such as antidepressants are needed. These aren’t addictive chemicals and so professionals, as well as AA and NA, accept that we can take them and still be considered clean and sober (abstinent).” There are now, as well, specific Twelve Step groups for those with both addiction disorders and mental health disorders: Dual Diagnosis Anonymous and Dual Recovery Anonymous among them.

As Seppala points out in the foreword, when some alcoholics and other drug addicts hear about the research showing that addiction is similar to many other mental and physical disorders we call diseases, it reorients their thinking amid the shame, stigma, and negative emotional states associated with active addiction. For some, it opens the door to treatment.

Okay. Hazelden, Betty Ford, and many other major treatment providers are no longer fighting a rear-guard action against a host of medications, from buprenorphine to Zoloft. But two-thirds of the Big Book consists of stories of how people recognized and dealt with their sundry addictions. That’s really about it, which tracks well with AA’s core operating principle: one drunk helping another. AA believes that much of its success stems from the fact that the program is run by the members, without direct rule setting and intervention from organizations, including their own. (All statements hold for NA as well).

What else? Recovery Now takes on another sticking point for many: the fact that “the AA Big Book and other writings include traditional male-focused and religious language, like discussing God as a ‘he.’” And there is the matter of “the realities and stereotypes of the 1930s, which is why it contains a chapter titled ‘To the Wives.’” Hazelden continues the recent tradition of broadening acceptable interpretations of “higher power.” One example given is from Samantha, a young cocaine and alcohol addict: “My higher power is the energy of this group. I call her Zelda.”

The book presents some of the psychological aspects of the AA program as a sort of reverse cognitive behavioral therapy. CBT attempts to teach people how to unkink their thinking and turn harmful thoughts into helpful ones. AA attempts to convince people to first change their behavior—“fake it until you make it”—and helpful thoughts will follow.

Perhaps the genuine sea change lies in this passage, which can be contrasted with the faith and certainty with which the Big Book proclaims that AA will work for all but the most stubbornly self-centered. Even with the myriad of choices of AA groups now available, Hazelden acknowledges that “a group based on the Twelve Steps doesn’t work for all of us. Some of us have found help in recovery groups that offer alternatives to the Twelve Steps, such as SMART Recovery, Women for Sobriety, and Secular Organizations for Sobriety.”  This is a change of heart, given that groups like SMART Recovery don’t necessarily buy the idea of total abstinence, and often structure recovery as an exercise in controlled drinking. Hazelden also suggests that many of “us” have found the necessary ongoing support for recovery at churches, mental health centers, and nonreligious peer support groups.

As for anonymity, Recovery Now states: “While Twelve Step members do not reveal anything about another member of the group, any one of us may choose to go public with our own story.” Another promising development is the proliferation of Twelve Step meetings catering to specific populations—AA meetings for African Americans, Latinos, Native Americans, women, seniors, gays, and drug-specific (Cocaine Anonymous).

In the end, one of the best arguments for attendance at the AA program (free of charge) is that many addicts have “worn out our welcome” with families and friends, “and they have a hard time putting all that behind them and supporting us completely. But at most Twelve Step recovery meetings we can find the support we need.”

Looking For the Science Behind the Twelve Steps

Transcendence, or nonsense?

What is it with the Twelve Steps? How, in the age of neuromedicine, do we account for the enduring concept of spiritual awakening available through “working the steps?” In Hijacking the Brain, Dr. Louis Teresi, former chief of neuroradiology at Long Beach Memorial Medical Center, along with Dr. Harry Haroutunian of the Betty Ford Center, sets themselves a formidable goal: “The sole intention of Hijacking the Brain is to connect the dots between an ‘organic brain disease’ and a ‘spiritual solution’ with sound physical, scientific evidence.” (For those who have grown weary of the overuse of “hijacked” brains in science writing, Teresi notes that an earlier term for the same idea was “commandeered.”)

Twelve Step programs remain popular, work for some addicts, and have their very vocal advocates in the recovery community. Outsiders are sometimes surprised to learn, writes Keith Humphreys, research scientist with the Veterans Health Administration and a professor at Stanford, that many of the people most profoundly and successfully affected by the 12-Step Program had “little or no interest in spirituality.”

The primary manifestation of this is the Twelve-Step Facilitation model (TSF), or Minnesota model, in honor of the Hazelden treatment facility in that state. Put simply, how do we go about explaining, in scientific terms, how a program like AA can have direct effects on a disease of the brain?

According to one strongly held view, we can’t. If there is something spiritual about recovery, it’s not anything that a medical doctor, who should have oversight of drug recovery and treatment programs, ought to be directly concerned with. Since the Twelve Step principles are explicitly spiritual in nature, how they apply to an organic brain disease is not at all clear. If you have cancer, your oncologists first line of thought is not usually, “why don’t you join a self-help group?” Writing for The Fix, health journalist Maia Szalavitz notes that “for no other medical disorder is meeting and praying considered reimbursable treatment: if a doctor recommended these religious or spiritual practices for the primary treatment of cancer or depression, you would be able to sue successfully for malpractice.” 

At an immediate level, the “power of the group,” which AA and other Twelve-Step Programs seems to tap into isn’t so hard to understand. Here are some of the obvious advantages of group work, as Teresi sees it:

--A reduction in the sense of isolation addicts feel.
--Useful information for addicts who are new to the processes of recovery.
--A way for people to see how others have dealt with similar problems.
--Additional structure and discipline for people whose living situations are often chaotic.

Teresi follows a common methodology, splitting the question into three dimensions: physical (an “allergy of the body driven by exaggerated limbic activity), mental (cognitive obsessions and compulsive drug use), and spiritual (an existential dilemma; a malady of the “soul”.) But the “spiritual awakening” that relieves this feeling and allows the addict to enter sobriety remains maddeningly ineffable: “The personality change sufficient to bring about recovery from alcoholism (addiction) has manifested itself among us in many different forms,” the Big Book cryptically affirms.

What makes it click for many addicts is what Teresi terms “empathic socialization,” defined as follows: “Positive socializing experiences received in support and therapeutic groups, such as praise, affection and empathic understanding, activate the brain’s reward centers as much as other natural rewards and similar to addictive substances. More importantly, belonging to an empathetic group reduces stress, a predominant cause and catalyst of addiction.”

Most people have only a hazy idea about what the Twelve Steps entail—something about admitting powerlessness over drugs, making amends for past wrongs, invoking a vague power higher than oneself. And the payoff? The reward for all the strenuous self-searching and personal honesty?

As Teresi sums it up: “inner peace, freedom, happiness, intuition, and alleviation of fear.” A heady package, indeed. All in return for achieving an emotional state called gratitude. Where are we to find the science in these claims?

Even though he doesn't solve the mystery, Dr. Teresi does offer  thoughts on some of the mechanisms in question, one of which is commonly referred to as an “attitude of gratitude” among Twelve-Step practitioners. “Gratitude for blessings received,” as it says the Big Book, is biochemically effective, Teresi argues. “In this regard,” Teresi writes, “grateful people show less negative coping strategies; that is, they are less likely to try to avoid the problem, deny there is a problem, blame themselves, or use mood-altering substances. Those with gratitude express more satisfaction with their lives and social relationships.”

And stress is where Dr. Teresi focuses his argument. More precisely, the working of the steps in Alcoholics Anonymous and kindred organizations involves “letting go” of high-stress states such as fear, guilt, self-loathing, and resentment. In Teresi’s thinking, the “power of the group” resides in its ability to reduce stress responses—and to raise levels of the “tend-and befriend” hormone, oxytocin. Oxytocin interacts with dopamine to increase maternal care, social attachments, and other affiliative behaviors and emotions. Thus, social rewards stir up a fair share of dopamine in reward centers of the brain, too. When alcoholics admit to powerlessness over alcohol, they are moving from a state of high autonomic nervous system tone to a more relaxed, “thank goodness that burden has been dropped” modality. This admission, when made as a conscious cognitive choice, and internalized through repetition and group motivation, lowers blood pressure and stress hormone levels, creating a more relaxed metabolic tone.

That is, in any event, how Teresi sees it. By confronting stress in this fashion, he believes that people with addictions can draw strength from group experience, even in the absence of personal religious belief.

Measures of Twelve-Step success will never be as precise as people would like. Not only does the national organization of AA generally avoid engaging in follow-ups, but the structure, or lack of it, works against precision measurements as well. As Teresi writes, “Anyone can start a Twelve-Step group by contacting the general service counsel of the organization of their interest, finding a meeting place (sometimes a person’s home) and adopting a readily available meeting protocol.” In fully monetized form, the Twelve Steps become Hazelden, or the Betty Ford Center. In supercharged upper income mode, it’s Passages and Promises. There is more going on here than simply a call to the pre-existing church-going addict. “AA,” says Keith Humphreys,  “is thus much more broad in its appeal than is commonly recognized.”

Teresi’s stated goal of connecting the dots isn’t an easy one. AA Twelve Steps and Twelve Traditions states unambiguously that the steps are “a group of principles, spiritual in their nature, which, if practiced as a way of life, can expel the obsession to drink and enable the sufferer to become happily and usefully whole.” In another passage, the Big Book refers to this as a personality change “sufficient to bring about recovery from alcoholism (addiction).” The explanations and definitions are maddeningly circular—unless you happen to be one of the people for whom the obsession to drink has been expelled through this practices.

Teresi believes it is possible to explore this terrain in a “belief neutral” manner, “with findings applicable to those who believe in a single God, multiple gods, or no God at all." Spiritual practices, Teresi believes, promote recovery in three ways. Meditation and some forms of prayer reduce stress levels. Techniques that lower stress have also been shown to stimulate limbic reward centers, “modulating emotion while strengthening attention and memory.” Finally, “spiritual practices, through improving morals and interpersonal behavior, foster closeness and a sense of community with one’s fellows and satisfy our instinctual need for social connection, also reducing stress.”