Unmanageability: A.A.’s Greatest Contribution to Addiction Treatment
I find unmanageability to be of paramount importance to recovery. It’s a concept that has had continued relevance in all forms of addiction treatment to this day.
In this article, I will show its importance and the implications that it has had, and will continue to have, on the field of addiction treatment. Then, your questions, comments, or feedback are welcomed at the end.
The First Step as described in the Big Book of A.A.
Ask almost anyone who is not in a twelve step program what the first step is and they will say that it is admitting that there is a problem. That is a good summary, but lacks the true complexity of Step 1. The First Step of Alcoholics Anonymous reads:
“We admitted that we were powerless over alcohol––that our lives had become unmanageable.”
Basically there are two halves to this step, separated by the dash, consisting of two important terms––powerlessness and unmanageability. The powerlessness portion of the step is well covered in the first few chapters of the basic text for Alcoholic Anonymous, but when we see the steps listed for the first time, without much warning, the author throws in this new term (unmanageable) into the mix.
The closest the text comes to explain the significance of unmanageability comes in the first writing of the book which was written by a nonalcoholic doctor who states that “once having lost their self-confidence, their reliance upon things human, their problems pile up on them and become astonishingly difficult to solve (emphasis added)” (xxviii).
Why it’s Clinically Important
The Big Book – A.A.’s nickname for its self-titled book- does hint at unmanageability when it makes a distinction between a heavy drinker and an alcoholic. Although both are described as physically and mentally dependent (powerless), the heavy drinker is able to stop or moderate if he has sufficient reason (an unmanageable life) to do so; as opposed to the alcoholic who continues to drink regardless of social obstacles. The relevance to the field of addiction is that only the latter group of drinkers will seek help from clinicians.
Unmanageability is important simply because it explains why people seek to change their relationship with substances. This is often overlooked because it is so obvious. If a person’s relationship with substances didn’t interfere with their life then they would never stop.
On the other hand, when a person is able to use substances and live their life to their standard, they will not consider changing that relationship. Those individuals who are able to stop once their substance use interferes with their life goals do just that––they stop. And they stop without any notice from the professional community.
Social problems and diagnosing addiction
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental health issues used by mental health professionals in the U.S. It contains a listing of diagnostic criteria for every psychiatric disorder recognized by the U.S. healthcare system. Although I can’t speak to the influence that the First Step had on constructing the diagnostic criteria of addiction, it’s clear that the authors of the DSM had agreed on the importance of social problems in substance use. Both the DSM V and IV include social problems as necessary to have a Substance Use Disorder (SUD, the clinical name for addiction).
For Substance Use Disorder, there are eleven total symptoms; including the four social symptoms (listed below). Social criteria alone make up over 1/3 of the total diagnostic criteria.
Here is a list of the social criteria for substance use disorder as written in the most current DSM V.
- A great deal of time is spent in activities necessary to obtain drugs, use drugs, or recover from its effects
- Recurrent use resulting in a failure to fulfil major role obligations at work, school or home
- Continued drug use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of drug use.
- Important social occupational or recreational activities are given up or reduced because of drug use.
** The DSM IV listed reoccurring legal problems as a result of use but it was removed in the newest addition.
To be diagnosed with a severe disorder a person must have at least six of the eleven criteria. Two criteria must be met for a mild diagnosis and four criteria for a moderate disorder. A person who meets all of, and only, the four social criteria would be diagnosed with a moderate substance use disorder without having any physical dependence or health issues. I think this is a pretty good argument for addiction not being a disease, since social functioning and ability to control one’s life is socially constructed: meaning that the definition of manageability changes from place to place, and over time within the same location.
Unmanageably is subjective
Let’s say that I only drink two beers and smoke one cigar every Friday night. Would you say that I have a substance abuse issue? Probably not. But what if I am in a community where alcohol and tobacco use are prohibited: like I’m a Mormon, a Muslim, in prison, or on parole? Although I don’t meet the physiological diagnosis for dependence, my social life may become complicated because of the two beers and cigar.
Now let’s say I come home every Friday night smelling of beer and smoke. My devout Mormon wife is upset and we get in a fight. Our children are crying because their parents are fighting. I am sent to the church leader for counseling about my substance use. Maybe this habit leads to divorce or infidelity with a woman “who understands.” Although not powerless, my life has become unmanageable because of my substance use. These two beers put my marriage, social standing, and possibly even my eternal spiritual condition at risk.
I don’t know much about Mormonism, so I apologize if I made inaccurate assumptions, but my point is that high-risk behavior is socially constructed within the context of the community that moderates it. One culture may view a behavior as dangerous and another could celebrate it.
Our behaviors affect the people around us, and the society around us informs us of what behaviors are conducive to the values of that particular community. When members do not conform to the values of a given community, they will have difficulty managing their life within the context of that community’s culture.
Outside Influences on Unmanageability
My biggest issue with the disease model of addiction is that it completely lets society off the hook by squarely placing the disorder on the individual.
…these are real things that are conveniently put to the side when it comes to addiction.
Anyone who pays attention to the political climate knows that people of color and other marginalized groups have nowhere near the opportunities that come with being white and middle class. So when looking at marginalized people who use substances, it becomes a chicken or the egg question when considering how easily someone can manage their own life. Racism alone makes millions of people’s lives unmanageable stemming from:
- less access to medical care
- lack of education
- mass incarceration
…regardless of whether people use drugs or not.
When working with a person of color who is homeless, undereducated, unemployed, and uses crack cocaine, a clinician must ask what the role of oppression has played in his addiction and inability to find a recovery plan that allows him to participate in conventional society. Is this person’s life unmanageable because he uses drugs or does he use drugs because his life is unmanageable?
The answer is both.
An ethical treatment plan must include case management in political arenas as well as direct services for addiction.
Life, convention, and compatibility with drug use
Gene Heymen, in his book Addiction: A Disorder of Choice, shows that the majority of people who have met the diagnostic criteria for substance dependence, as outlined in the DSM IV, have stopped using substances by the time they are 30 years old without any type of treatment. It is hypothesized, through conducting qualitative research, that these individuals who stop by age 30 do so because substances interfere with their conventional life goals such as family and career. It’s not so much that they grow out of drug use, but instead they grow into a life that is incompatible with drug use.
It is also hypothesized that people who suffer from mental illness have longer substance use histories because their mental illness prevents them from joining in on conventional life (Heyman, 2010). This raises an interesting question: What other groups of people have similar problems joining conventional society and how does that affect addiction and recovery rates?
In the United States, we live in a country that systematically bars people of color from conventional lives; not to mention it is the majority that has defined what it means to be conventional. Marginalized people who are unable to fulfill their life goals because of oppression, lack of educational opportunities, lack of career opportunities, mass incarceration, and segregation, will not be afforded those same incentives to stop using drugs once they reach middle adulthood. If opportunities lead to natural addiction recoveries, then it’s not much of a stretch to assume that lack of opportunities lead to prolonged drug use latter into life.
One can argue that addiction is an equal opportunity employer, but recovery has nowhere near the same equity. And since continued use is one definition of addiction, lack of recovery and addiction are one and the same.
Criminal “Justice” Gets in the Way of Recovery
The field of addiction has made at least one move in the right direction when concerning marginalized people and social justice. The DSM IV had a criterion about reoccurring legal problems as a result of use but was removed in the DSM V. Although I don’t know the reasoning behind this, it takes away a criterion that disproportionately affects minorities. Michelle Alexander in her book, The New Jim Crow: Mass Incarceration in the Age of Colorblindness, shows that people of color and other marginalized people have higher rates of drug arrests and incarcerations even know whites use substances at equal rates.
Although the criterion which specifically mentions criminal arrests has been removed, the legal system, which almost solely shapes what is deemed socially acceptable behavior, continues to legislate manageability. Those who are under legal supervision must live their lives to a different standard of accountability than those who don’t get swept into the system.
I’ve seen countless people referred to treatment because they failed a drug test while on parole. Failing a drug test tells us nothing about that person’s addiction; only that their drug use has prejudiced consequences based on their status in society.
Getting caught up in the court system, especially probation and parole, affects the probability of being able to manage one’s life. In fact, the government will manage people’s lives for them, via jail and prison, if it is believed that a person can’t do it on their own. Drug arrests are not isolated incidences, but instead create a compounding progression of social problems.
Acceptable behavior is not inherently imbedded in society, but rather changes over time. Marijuana is our latest example. This last election we, here in California, have legalized marijuana. This new law will, literally overnight, cure people of the diagnosable disease of addiction, based on the four social criteria in the DSM, by removing social obstacles that have obstructed people from controlling their own lives.
Harm Reduction: Redefining What it Means to be in Recovery
Because people seek treatment when their lives become unmanageable, I see harm reduction as the only ethical treatment for substances. If clients are seeking clinicians because their life is unmanageable, then the only standard of success must be whether their life becomes more manageable.
If a person came into my office when I first started working in addiction treatment and told me that they needed to find work, I would have told them that they had their priorities wrong and they must find sobriety first. They would have been told that employment is not why they were in treatment and would be labeled as noncompliant and resistant to treatment. This was wrong of me and ignorance is no excuse.
In harm reduction, a client is seen as a success when they make life improvements, regardless of whether or not they change their relationship with substances. This type of treatment is often written off as enabling––but who are we to judge? If a person is able to look at life in a different way, prioritize their life, and still use substances then they have achieved what they came into treatment for in the first place.
Methadone is an example of this. Heroin, and other opiates have created chaos in someone’s life and opiate substitution allows them to put some control back into their life and is a solution to their primary concern. It’s possible that marijuana is another way for people to find relief from narcotics that allows them to function without abstinence.
Some people, however, have shown repeated inability to manage their lives with the use of any substance. In these most severe cases, abstinence may be the only way to live life without disaster. The point is that all people are different and fall in the addiction spectrum uniquely. Clinicians should use techniques such as motivational interviewing to allow clients to explore the best way to manage their situation.
The simplest definition of addiction is “continued use despite negative consequences.” This sums up the two halves of the first step, powerlessness and unmanageability, in one succinct sentence. This sentence, however, doesn’t make sense in reverse order nor is it complete when one is removed; they are both necessary.
From a practical standpoint, it is the negative consequences that are the critical factor because they can stand alone as clinically treatable. Continued use alone may or may not require intervention but there is always a need for intervening on an unmanageable life.
Treat people where they are at. They want help with their presenting problems and if they use drugs it is really out of our control. It’s our job as clinicians to look at the larger picture because often our clients are unable to.
It is said that addicts have tunnel vision and I, for one, don’t want to fall into that same trap.