April Newsletter: Step One

By John Steinberg, MD, FASAM
Medical Director, The Bergand Group

Every journey begins with the first step and the journey of recovery is no exception. Step One, from AA/NA is as follows: “We admitted that we were powerless over alcohol/our addiction, and that our lives had become unmanageable.” Recovery is a process of change. In human experience, change rarely begins until the current state becomes intolerably uncomfortable. In medicine, we physicians have observed that “people rarely comply with treatments for diseases they do not believe they have.” Why on earth would an alcoholic give up alcohol or a drug addict give up getting high unless he or she truly believed that addiction was the disease that needed treatment; that addiction was the root cause of his or her life’s problems?

The first step is one of three that I refer to as identity steps. These three steps clearly establish the identity of having the disease that predicates the need for treatment. They are the three steps by which the concept of one’s self as having a substance dependency disorder is internalized and they form the foundation for a commitment to a fundamentally and radically new approach to living. The first step begins this process by naming the problem and recognizing the damage done.

In naming the problem, the essential aspect is loss of control. While expressed in the 12 Step programs as “powerlessness” which sets the stage for a spiritual/religious approach to resolution, the concept is equally applicable to a therapeutic/secular interpretation. At its heart, addicts’ and alcoholics’ core problem is the displacement of efforts to control feelings to the ingestion of substances which they subsequently become equally unable to co

ntrol. For others, the primary displacement of efforts at control relates to behaviors and is manifested in “process” addictions such as compulsive gambling, spending, or sexual behaviors. But the core issue remains the same: The addict/alcoholic is unable to control his internal emotional and mental milieu, his feelings. The control is then displaced by ingesting substances that, for many, actually work for a period of time and enable the addict/alcoholic to control her feelings. This is then followed by an inability to control the use of the substance at hand, referred to as “the drug of choice.” More importantly, what is actually lost is the ability to control or to predict what will happen when the drug of choice is consumed.

Many alcoholics reject acceptance of the diagnosis of substance dependency by pointing out that most times when they drink or use drugs, nothing bad happens. The therapeutic rebuttal takes several forms useful to pierce this denial:

  • Most of your problems relate to alcohol being consumed. When the alcoholic says, “If you had my life, you’d drink, too.” the rebuttal is to illustrate the cart has been placed before the horse by turning this around: “If I drank they way you drink, I’d have your life.”
  • The addict may only have intermittent problems, but, he is utterly unable to predict or anticipate when those problems will occur.
  • The alcoholic may state that he or she has been able to “quit any time I want.” The therapeutic response, with a nod to Mark Twain*, is to note that any alcoholic can stop drinking, but, seems to be unable to STAY stopped.

My two personal favorite definitions of alcoholism relate directly to this loss of control:

  1. It’s not what you drink, why you drink, when you drink, how much you drink, where you drink, or with whom you drink. It’s what happens when you drink. Bad things happen- intermittently but unpredictably- when you drink and, despite knowledge that bad things happen to you that are related to drinking, you keep drinking.
  2. More simply, with thanks to John C., a friend from AA, “An alcoholic is that person who will drink when common sense, past experience, and prudence all suggest doing otherwise.”

Clearly, we have the first of the clauses of Step One in hand: powerlessness or loss of control has become manifestly self-evident. Control, the ability to reliably predict the consequences of one’s actions and behaviors, is gone. We have, as well, touched on the second clause of “unmanageability.”

Unmanageability is highly subjective. It can be referred to as “high bottom” or “low bottom.” The consequences may be trivial to outsiders or explicitly awful to even the most neutral of observers. The self-recognition of unmanageability is the point at which some refer to as a “moment of clarity.” The alcoholic or addict is, often suddenly, confronted by a graphically revelatory flash of insight, “I’m an addict and I cannot go on like this.” Whether the unmanageability is the loss of self-esteem or the loss of home and family and employment and health together, as soon as the consequences of the addictive behavior are realized by the sufferer, Step One has been completed.

I will usually put this to patients as follows, using two questions:

  1. Do you understand that you can never predict what will happen when you use drugs or drink alcohol?
  2. Do you understand that when you drink or use drugs, randomly, intermittently, but assuredly, bad things directly related to your substance use are going to keep happening to you?

When the answer to both questions is an unreservedly affirmative answer, the client has completed the first of the self-identification process necessary to accept treatment for and to recover from an addiction to drugs or alcohol. The foundation is now laid to proceed with recovery. The problem has been recognized, defined, and accepted. We now proceed to Step Two, where hope for a successful resolution is introduced.

*Mark Twain noted wryly, “Quitting smoking is the easiest thing in the world. I’ve done it thousands of times.”

By John Steinberg, MD, FASAM
Medical Director, The Bergand Group