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(PSYCHIATRIC TIMES) - Until the last half of this century, there were few if any treatments that seemed consistently effective in responding to the clinical needs of individuals who were abusing or dependent upon alcohol. As a result, as is so often the case when professionals are unable to provide adequate solutions for such problems, support or self-help groups emerged (Caplan, 1974). Alcoholics Anonymous (AA) is an extraordinary example of these groups.

AA had its beginnings in 1935 when two alcoholics, Bill W and Dr. Bob S, met and began to work with alcoholics in Akron, Ohio. Together they recruited others who admitted an inability to control their use of alcohol, who supported each others' attempts to abstain, and who spread the word that alcoholism was a disease, which alcoholics could help each other to overcome. Public admission of vulnerability, spirituality, taking inventory of one's life, admitting to personal wrongs, and sharing with and committing to help others became crucial elements in transforming the lives of alcoholics.

In 1974, Gerald Caplan described how such self-help groups (he called them support systems) evolve, drawing attention to and providing legitimacy to understanding and remediating such problems. He observed that in doing so, the groups encourage professionals to become more aware of and involved with problems such as alcoholism. Caplan emphasized that self-help proponents and professionals do not need to, nor should they, compete.

In the first two decades of its existence, AA was slow to gain wide recognition or acceptance. Over the last half of this century, however, the program has grown to thousands of AA groups throughout the world, and an estimated 1.5 million to 2 million individuals are involved in AA (Emrick, 1994; Galanter et al., 1998). During this time, there have been an increasing number of medical and psychiatric practitioners and other health care professionals who have been more effectively responding to the medical and psychological problems associated with alcoholism. Early pioneers included William D. Silkworth, M.D. (Bill W's physician); Ruth Fox, M.D., the founder of the American Society of Addiction Medicine; and Stanley Gitlow, M.D., among other prominent physicians.

In conjunction with the successes of AA, the clinicians and investigators who have subsequently become involved have given increasing hope for prospects of treatment and successful recovery. Given the growing acceptance of both approaches, Caplan's original admonition that self-help programs and professionals need not compete has been replaced by a new challenge: how can AA work with and in psychotherapy-and why should it?

An increasing number of clinical investigators and scholars have studied the therapeutic elements of AA. (An extensive review of this literature goes beyond my scope here, but the interested reader is referred to recent reviews that examine these findings [Emrick, 1994; Galanter et al., 1998; Khantzian, 1994, 1995a; Khantzian and Mack, 1989]). There are, however, some investigators who have recently addressed more precisely how AA accesses and modifies alcoholics' vulnerabilities and what some of the psychotherapeutic implications might be for such patients in psychotherapy.

These authors identify crucial elements in AA that establish and maintain abstinence and, perhaps more significantly, draw attention to aspects of AA that are important in producing personality changes and modifying the distress and suffering associated with addictive behaviors. Bean's examination of how AA and psychotherapists can more effectively break through the denial of alcoholics (1975), and Brown's (1985) focus on the central problem of loss of control in alcoholics and the need to maintain their identity as alcoholics have been of singular importance. Bateson (1971) provided a scholarly description of alcoholics' proud and self-sufficient battle with alcohol and the need to relinquish this struggle and engage with others in meaningful contact. Kurtz (1982) focused on alcoholics' need to accept "essential limitation" and AA as a therapy for shame. I recently described how AA challenges alcoholics' problems with engagement and contact (Khantzian, 1995a). These perspectives all emphasize the importance of addressing characteristic (or characterologic) vulnerabilities in the personality organization of alcoholics, and their need for human connection and comfort.

Partly independent of and partly in conjunction with these recent views of AA, contemporary psychodynamic clinicians have focused on deficits in self-regulation and related defenses. These vulnerabilities and defenses involve feelings, self-esteem, relationships and self-care. Knowledge of these allows us to appreciate how and why alcoholics suffer in the ways they do, and what the psychotherapeutic implications might be for such vulnerabilities (Dodes, 1988, 1990; Khantzian, 1981, 1995a, 1995b; Khantzian et al., 1990; Krystal, 1989; Mack, 1981; Wurmser, 1974).

These findings and explanations of alcoholics' vulnerabilities and how and why AA works stimulated me to consider how psychotherapists need to function in evaluating, brokering, monitoring and directing roles to coordinate the clinical needs of patients with substance use disorders (SUDs) (Khantzian, 1988). I described the role of such a clinician as a primary care therapist (Khantzian, 1988, 1985) and emphasized that psychotherapists must not use their alliance only to foster exploration of patients' vulnerabilities, deficits and defenses. I suggested it might be even more important, at least initially, to use the treatment relationship to broker other interventions-especially self-help groups such as AA-to establish abstinence, and to provide the needed support and comfort for alcoholics derived from being with others who suffered and struggled as they did.

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