Discipleship - An Exploration

The Problem

My hypothesis is that addiction, treatment and recovery can be described in terms of transitions between states on this three dimensional grid. I also believe that recovery is an example of the process of discipleship. My goal in this paper is to explore these ideas and learn from that exploration. This model continues to evolve and I expect it will evolve again as I write this paper. Thus, this paper is a tool to focus my attention on the topic. This paper is also an example of the discipline of exploring a problem until the problem changes my way of thinking.

Stages of Change

• Inertia - we prefer not to change and will work hard to avoid doing so.
• Assimilation - this term was adopted by Piaget to describe the way we fit new information into our current thought processes. Trivia, for example, fits nicely into our brains and seldom disturbs our sleep.
• Constructionism - my understanding of this term is that we form mental patterns that behave like habits. I know how to find my way home without putting much effort into it. I know people instantly if I see them where I expect to see them doing what I expect them to be doing. I might walk right by someone that I know well if that person is not where I expect and not doing something I would expect them to do. My mental image of this person is linked to locations, ways of being and patterns of doing.
• Stages of change - the types of change that are of interest in addiction counseling are bigger than constructs but smaller than a developmental stage. These are the types of changes that I will describe in the remainder of this section of this paper.
• Developmental stages - a developmental stage change is a profound change. I include this concept in my model as the third dimension - the dimension of depth. Piaget noted that big changes often occur in small increments. One mental concept might shift from stage 4 to stage 5 while other parts of our life stay at stage 4 or possibly stage 3. These increments of change are called accommodation. When enough accommodations accumulate we might experience a radical change because several subsequent accommodations occur almost simultaneously. Thus some people experience developmental change in small increments and some experience it as a major upheaval - which might be called a spiritual transformation.

Prochaska and DiClemente's model has either five or six stages:

• Pre-contemplation is the state of inertia. In addiction this is the time when life is falling apart and yet we deny our responsibility for the situation.
• Contemplation is the stage when we believe that change could be beneficial but are not yet prepared to commit.
• Preparation is the stage when we begin evaluating alternatives. This is the time for bargaining. Maybe we can give up one drug, but keep another. Maybe we can stop drinking during business hours but continue drinking nights and weekends. Or maybe we start talking to friends about some of the treatment programs they know about.
• Action is the stage when we do something. For example, this is the time when a loved one might change the locks to force the addict out of the house. Or this might be the time when the addict works their program to break the cycle of addiction.
• Maintenance is the stable life that we all desire. We wishfully think that our problems are in our past and will not bother us again as long as we take some simple precautions. Maintenance is equilibrium - it gives us the illusion of tranquility.
• Relapse is sometimes added onto Prochaska's model as one more stage. We will come back to relapse in a latter section in this paper.

This model is called the Transtheoretical model (TTM) because it was devised to explain behaviors seen in a wide variety of circumstances. Gorski's model was derived from his observations of patients in treatment for addiction. Gorski's model has six stages.

• Transition is the stage when the patient realizes that they have a problem that they cannot control.
• Stabilization is the time in treatment when the patient is detoxified and physically and emotionally stabilized. Physical stabilization might occur in a few days, while mental stabilization can take one or more months.
• Early recovery is the stage when the patient learns new ways of coping with stress. Gorski believes this stage typically lasts one or two years.
• Middle recovery is the time when new life skills are solidified. Gorski believes this stage typically begins after one or two years and lasts between one to three years. All of those estimates are based on typical patterns for people who work their program and recover.
• Late recovery is when the person is ready to begin addressing their deep seated problems. Late recovery is when patients are finally ready to explore their childhood.
• Maintenance comes later - maybe five or more years after stabilization.

In my opinion these two models overlap. Without getting into a lot of depth on this I think that TTM stages are focused on the actions leading up to the decision to change while Gorski was focused on treatment. My attempt to merge these models is illustrated in the following table.

TTM Stage	Gorski Stage	Zimmerman on Treatment	Gorski on Treatment
Pre-contemplation		Motivational interviewing
Contemplation		Motivational interviewing
Preparation	Transition	Cognitive behavioral therapy	Accept abstinence
Action     Maintenance	Stabilization	Cognitive behavioral therapy   12 step programs	Learn to manage stress
	Early		Learn new value system
	Middle		Find a life balance
	Late		Work family of origin issues
	Maintenance		Work a program
Relapse		Motivational interviewing 12 step programs

One term that might be new to you is "motivational interviewing". Miller and Rollnick state: "We define motivational interviewing as a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence" (Miller and Rollnick, p 25). They credit Carl Rogers for their emphasis on the client. They reference Truax and Carkhuff - who were among the first to document the harm that therapists sometimes do to patients. And they describe a more directional approach that seems to me to lean towards the cognitive behavioral approach. When I found motivational interviewing I felt very much at home.

These same stages apply to life beyond addiction. For example, it is my goal to share what I have found. However, I had conflicting ideas about how to do that. I was content with the direction I was going and thus, I was in pre-contemplation regarding whether or not to divert from that path and spend time writing this paper. Slowly the idea of this paper became more appealing and I began contemplating what I could say in this paper. I next began preparations by tracking down a few journal articles and ordering a few more books. Once I started stacking up those articles and books in an orderly pile I was in action. The pile became an outline and the outline is my roadmap for writing this paper. Thus this paper illustrates my use of the stages of change.

Two Perspectives

You also have a perspective. You, as a reader, were not expecting this article, contemplated something and took some action that led you here. Why did you choose those actions?

When two people are in a relationship there are two perspectives. I am the writer and you are the reader. You might be a therapist and I could be your client. You might be a meeting leader and I am a newcomer. Or, one of us might be an addict and the other is a supporter.

Brickman, et al suggest there are four patterns of helping that can be arranged on a two-by-two grid.

Responsibility for the problem

Responsibility for the solution   High Low High Moral model Enlightenment model Compensatory model Medical model Low

The moral model implies that the problem is a lack of will power. Sentencing a woman to death because she was raped is an extreme illustration of morality. Sentencing drug addicts to prison is an example that our culture readily accepts. And shunning Christians who sin is a practice that seems widely accepted in many churches. Now if you ask me to turn the stove off and I choose to continue watching TV while the house burns down then there is merit to the moral model. But if addiction or sexual preference or a weakness to a temptation is genetic or environmentally determined, then the moral model results in a lot of needless suffering.

Brickman mentions AA as an example of the enlightenment model. The first step in AA asks that we admit that we have a problem and that we cannot solve the problem. This is a very common model, so we will come back to it again later.

The medical model leads us to the disease concept for addiction. Some people have an allergy and if they are exposed to alcohol then they have a near fatal reaction called alcoholism. The cause might be genetic or environmental - but the person is not responsible for the originating cause. Nor can the patient cure themselves. An advantage of the medical model is that diseases bring the person under protection of various regulations designed to protect the ill. Another advantage is that it stops the blaming and lets the person get on with treatment. One risk, however, is that some people fail in treatment. And when a person fails in treatment the easiest explanation is to go back to the moral model and blame the person. So if someone has a difficult time with a particular therapist the simplest solution is to put the patient into prison. My fear is that the medical model is going to backfire in the near future. My expectation is that someone is going to invent a pill or drug - like methadone or suboxone - and everyone who has that illness is going to be ordered to take their medicine. Then, when someone who has been ordered to take the pill that is known to solve the problem should happen to relapse that someone will fall out from the medical model and land in prison looking at the moral model. Society, after all, likes simple solutions to simple problems.

The compensatory model is a bit more difficult to explain. We see it all the time in a behavior called enabling. I feel obligated to help even though I did not create the problem. Enabling is considered wrong, but if we look at the hero who pulls a baby from a burning building do we see an enabling villain? We see a hero and think that the obligation to help is a social good. As I pondered this situation I found the linkage that connects this model with my model. That link is the word is "obligation". I care enough to act even though I am detached from the problem.

If you turn back to the diagram I have at the start of this paper you should find the "Obligated state" in the lower left corner of the diagram. Notice the phrase "Shown in enabling". When I feel obligated I think I am acting with love and I am willing to tune out the dissonance. The addict and the supporter both expect the same actions when the supporter is obligated.

The medical model is also there. As the patient, I am detached from the cause and thus removed from the dissonance. As a patient I am in conflict with the disease. So from the patient's point of view the medical model is one of subjugation. I am held captive by a disease that I do not deserve. But where is the doctor - which frame of reference does he or she have about this situation? The answer to that question will tell us a lot about the outcome.

If the doctor is obligated to treat the patient, then no one claims responsibility for the problem. So if I go to the doctor and say I have a problem and the doctor tells me that I must take this specific little pill every morning then no one needs to be concerned about how the problem arose or what I suffered because of the disease or what benefits I get from holding onto the disease.

If instead the doctor is motivated by power, then the doctor is going to reside in the state of conflict. People in conflict love having people they can subjugate. And thus the addiction counseling profession is overflowing with people who want to be in charge. From what I have seen many of these professionals work hard to keep their clients subjugated.

There are other states where a therapist could center themselves, but before exploring those options I want to explore the AA model. If you look on that diagram I mentioned earlier you will see words in the upper right that say "Typical in addiction". When the addiction is raging the addict is in conflict with the disease - and quite often with everyone who knows him or her. When the addict is pre-contemplative, then they ignore the dissonance and stay in conflict. As he becomes more aware of the problem he transitions into chaos. And when the addict admits that he or she is powerless, then he or she accepts defeat and ends the conflict. Without conflict the addict shifts to the left. And by admitting their powerlessness, the addicts shifts downward into tranquility. In AA terms this is "hitting bottom". Finally, then, the addict is ready to be transformed and then to align with their program.

I first found this pattern when I explored John 8: 1-11 - the story about the woman caught in adultery. She was in conflict with the elders, found herself in chaos with a small mob, reached tranquility with Jesus, turned away from her sins and aligned with Jesus. This pattern is a common human pattern. Bill W and Dr. Bob packaged this model into AA and made a program that works.

Thus we see that "helping" is not static. We enter into a relationship when we help. There are two perspectives on that relationship. Both participants are in motion - they are not static. And helping fits into my model.

But then I ask why is it that I see this action so clearly demonstrated in twelve step programs while it seems so lacking in contemporary Christian life? Putting it bluntly, AA seems to do a better job of making disciples than the churches do. It seems to me that understanding how treatment for addiction leads to a disciplined life might help us understand the disciplined life that religions espouse and possibly help us understand how to enhance discipleship in churches.

Patterns in Treatment The treatment programs that I am most familiar with are the programs that help the families. Nar-Anon, for example, has a twelve step program for those who care about an addict. From my personal experience, from the readings I have done and from conversations with people in twelve step meetings I have learned something about these patterns. Its seems that most of us come into these programs feeling obligated to care for an addict who does not seem interested in caring for him- or herself. The program helps us find peace and acceptance so that we can then begin to change ourselves. The program only works, however, if we discipline ourselves to make it a priority and align our lives with the program guidelines.
Many of us seek out CODA - the twelve step program for people who suffer from a co-dependent relationship. Many of the people I have met in CODA have been subjected to mental, physical and spiritual abuse from others. They join the CODA program and strive to find peace in their lives. They work the program to change their behaviors. We realize that we cannot do this alone and need others to help us. Together we align ourselves with the program and discipline our lives to work the steps.
I have friends who were compelled to go to treatment. Their families forced them to go. The court ordered them to go. They believe they were setup and deceived by their friends, the police, their lawyer, the judge, their probation officer and / or lots of people. They enter treatment in the pre-contemplative stage unready and unwilling. They enter treatment ready to do battle with any and all. But, ready or not, in they go. Those who succeed find a way to accept where they are, achieve an inner peace and then begin the difficult work of change. They succeed when they align themselves with a goal.

Relapse

"Despite methodological limitations, the available research evidence indicates that any treatment of alcoholism is better than no treatment. Calculations of average success rates across studies indicate that about two-thirds of those treated improve. Reported success rates depend partially on whether the outcome indicator is abstinence, controlled drinking, or some other index of improvement. However, there is little definitive evidence that any one treatment or treatment setting is better than any other. Furthermore, controlled studies have typically found few differences in outcome according to intensity or duration of treatment."

That is an optimistic assessment. For example, Simpson, et al report that 23.5% of the patients studied for cocaine addiction were using again in the year following treatment and an additional 18.0% returned to treatment. In that study 41.5% of those treated had relapsed within one year after treatment. Xie, et al evaluated a ten year longitudinal study of clients diagnosed with both a mental disorder and an addiction and found the persistent downward trend shown below.

Year % in Remission Number in Remission 0 100% 169 1 69% 117 2 53% 89 3 44% 74 4 36% 61 5 34% 57 6 29% 49 7 23% 39 8 20% 34 9 14% 23

This same trend is found throughout the studies on addiction treatment. As Miller and Hester put it: "The outcome of alcoholism treatment is more likely to be influenced by the content of interventions than by the settings in which they are offered."

Miller with Rollnick restates this concept: "In controlled trials, people typically show about the same level of benefit, whether they are assigned at random to longer or shorter treatment or to inpatient versus outpatient care for alcohol use disorders, for example. On average brief interventions yield outcomes that are similar to those with longer treatment." (And yet) "most people with alcohol, drug, or gambling problems ultimately escape them and go on to lead reasonably normal lives, often without formal treatment."

And thus we can see the significance of the title used by Miller and Hester - "Inpatient Alcoholism Treatment: Who Benefits?" The studies imply it is not the patient. My conclusion is that these programs are designed to benefit the program and patients are a means to an end.

And then, patients relapse anyway. Explanations for relapse focus on stress. One explanation is that using the addictive substance offers quick relief while the adverse consequences are remote. The goal for effective programs is to help clients learn coping skills so they have a choice. If you have an argument with your spouse, you can block out the pain by getting drunk. Or you can call your sponsor and have someone express sympathy and discussion solutions. Or you can learn how to argue without causing damage. Or you can work on anger management so that there is less need to argue. All of these strategies are learned behaviors.

Learning, as any teacher or student can tell you, is not always retained. In popular terminology, knowledge has a half-life. Knowledge deteriorates and is lost over time. When I look at the curve from Xie, et al, I see a half-life curve. People go into treatment. The treatment puts the disease into remission, but does little to solve the underlying stressors that hamper the person's life. Learned skills are put to use, but the new skills deteriorate. Then the person falls back on old skills and old habits. The way to solve this problem is with skill refresher courses.

The addicts that are the most successful at recovery are the people who work their program for five years or longer. By then the new skills have taken over most of their life and the old skills are deteriorating. The key is to keep refreshing the knowledge. And that takes discipline. The original treatment method, technique and setting quickly become irrelevant. What matters is the follow-up and follow-through.

Discipline

In this paper I have wandered about beginning with the vague goal of exploring the problem of addiction and recovery. I briefly outlined the models of change most popular in addiction treatment with the intent of showing that the Transtheoretical model applies to other aspects of life. I then explored treatment both as a relationship and as a dynamic sequence of transitions. I finally got around to the concept of relapse and linked that concept to the problem with knowledge and skills retention. I realize these linkages are tenuous. And I realize that the breadth of this paper seems unwieldy. Even so, I am now going to expand the scope of this paper even further by trying to link addiction treatment to a common life pattern known as discipline.

Some of the common disciplines that I am familiar with are: family, church, school, social clubs, work, exercise, certifications and higher education. My hypothesis is that all of these disciplines follow one common pattern. I illustrated portions of this pattern earlier when I described the patterns I see in treatment. What all of these patterns have in common is that we first center ourselves in tranquility and then begin a transformation. The result of that transformation is that we align with an ideal of some sort.

Children emulate their elders. Churches teach us to emulate the saints. Schools teach us about national heroes and the teachers offer themselves as role models. Social clubs, like the boy scouts, have ideals and mythical heroes. At work we are taught to align our wills with the goals of our supervisor, company executives and corporate guidelines.

When we follow a discipline of exercise we set goals for ourselves and look to find role models who prove that those goals are achievable. Certifications give us navigational aids to set our direction and measure our progress. And higher education teaches us new skills as each level requires mastery in new thinking processes.

These are disciplines. We practice discipleship when we follow a discipline. And the way we do that is by reaching acceptance, transforming ourselves and aligning ourselves with an ideal.

The ideals we choose depend upon our developmental stage.

Stage one in the developmental model describes the individual as focused on him- or herself. The desire is for immediate gratification. Most works on developmental psychology say that this stage is not very relevant to adult psychology. I think, however, that some addicts are trapped in stage one. What these people need is a substitute sibling. They need someone just a little ahead of where they are in life who can explain the next step in terms that they can understand.

I think that many addicts are trapped in stage two. These are the people most skilled in manipulation. In stage two our expectations are like those of a fifty year old, while our relational skills are like those of a ten year old. If one parental figure says no, then the simple solution is to keep asking other parental figures until you find one that says yes. In my opinion, people trapped in stage two want a parental authority where yes means yes and no means no.

In stage three people focus on their peer relationships. Many adults spend their lives in stage three. Twelve step programs, churches and other organizations work well for those of us in stage three when we think that everyone else in the program is like us. Otherwise we form cliques so that we have conformity. We want to be like those around us and we want those we know to be like we are. Addicts admire Bill W because he was an addict. Christians admire Jesus because he was human. I think that the understanding of stage three explains why addicts want counselors who have been addicts. They need a role model who is like them, only better.

In stage four we adopt roles and express ourselves differently in different settings. When I meet with project managers I am a project manager. When I go to church I am a Christian, and what I do as a project manager is not particularly relevant. If I was a business person and I sold a product for an exorbitant price then in stage three or stage four I can easily separate that role from the role of being a Christian asking others to give to a charitable cause. In stage four I want to emulate people who excel at a role. I admire great project accomplishments. I admire great Christian accomplishments. I admire those who run marathons or race bicycles. But in stage four I can separate those roles. In stage three a great bicyclist must also be a great Christian. In stage four I can admire a great bicyclist who is an atheist. And I can admire Carl Rogers' concept of unconditional positive regard even if I read that his religious views are different from mine.

In stage five I want to integrate all of myself into one consistent person. Thus I am a project manager who can help churches. I can be a Christian while greeting people on the running trail. And in stage five I admire collective efforts. For example I admire the way that Marlatt works with collaborative efforts. I admire the interwoven relations between Marlatt's works on relapse, Miller's work on motivational interviewing and Prochaska's work on stages of change. To me, that collaborative effort expresses one of the fundamentals of stage five - the ability to transcend limited roles and express a role related concept in differing arenas.

And when I look at stage six I admire virtualized concepts of ideals. I see Jesus, Paul the apostle, Gandhi, Martin Luther King, Jr. Carl Rogers, Bill W and a few others as examples of people who rose above all the boundaries and role expectations to care for humanity. In stage six I detest organizations that focus on profit rather than people.

When we enter into fellowship we bring our developmental expectations, our stage of change attitudes and our states of being framework. Then we judge whether or not this fellowship will meet our needs. Those needs are human needs. And every organization that fits into our society addresses those same needs, somewhere, somehow. For example, consider the following comparison between a twelve step program and the Christian sacraments.

Christian	12 Steps
Baptism: A public demonstration of commitment to this faith. Usually done once, but some people are baptized as an infant and then again as an adult.	Chips: New comers are given a small token and a public greeting to recognize their commitment to recovery. Chips are given again periodically and the chip celebration leads into the cake celebration.
Reconciliation: This is often thought of simply as confession, but the full process includes conversion, confession and celebration. I realize my sin, confess to a priest and then reconcile with my fellows.	Amends: The steps include an inventory of the wrongs we have done, confession of those wrongs to our sponsor and the amends to those who were wronged, where possible.
Communion: A ceremony where bread and wine are shared as a remembrance of the shedding of Jesus body and blood. Some congregations celebrate this in each service while others only celebrate monthly.	Cake: This is a celebration for all of those present who have completed an additional year of sobriety. Most meetings do this once a month but some meetings do this weekly.
Confirmation: A public ceremony in which the person joins into this congregation. When joining I pledge to serve and support this congregation.	Service to the Meeting: Anyone can attend, but you truly accept a meeting as a part of your life when you volunteer to serve the meeting. Service includes making coffee, leading meetings, or taking on an office such as secretary or treasurer.
Holy Orders: A person can choose to devote his or her life to the ministry and be ordained into service. This commitment is expected to last for a life time. Ordained leaders typically form a hierarchy. Although a few denominations set aside time for member sharing, most expect the ordained leaders to speak while the congregation listens.	Burning Desire: 12-step meetings differ significantly from most denominations in that the members are expected to speak frequently and thus share leadership in meetings. It is not uncommon for a meeting to require that every person share. It is not uncommon for one person to share in every meeting he or she attends.
Marriage: Marriage is a life-long commitment with a sharing of all. When two join in marriage their families are also joined through this union.	Sponsorship: A sponsor accepts a sponsee for life and each pledge to full honesty and a lifetime of trust. When a sponsee joins with a sponsor the sponsor's own network of sponsors also become available to the sponsee.
Anointing of the Sick: In some denominations this service is reserved for those who are dying. In other denominations this service is made available for those who are sick. The intent is to offer a blessing to the recipient and prayers for their protection.	Service to Others: Some people focus their service on the new comers. Others go out into the streets to search for those who have not yet heard the message and try to give them comfort.

Making Disciples

The same concept of matching applies to the larger stages of development as well. In stages one or two the relationship needs to be tangible - like a sibling or parent. In stages three or four the relationship can be idealized as long as it has tangible representation - like the ideals of Bill W expressed in the life of your sponsor. In stages five and beyond we seem capable of using concepts as an ideal for our discipleship.

Each of us who enter into a relationship brings our expectations about the discipleship. Each of us reads the other and the environment to assess whether or not we are safe. And only then will we begin to change. Coercion does not work. If you believe otherwise, then study history. The numerous persecutions, tortures and cruelties inflicted by governments and religions have not worked. You can compel people to do almost anything, but change. Prisoners read prepared statements they find repugnant, but renounce those statements when they are freed. Treatment that coerces compliance can elicit desired behaviors - and yet fail to change minds.

The goal for discipleship and for treatment is to change the person. Lawrence Kohlberg studied the way people change and sought to find a way to accelerate the moral development of high school students. What he found is that the students need to see the next stage of development demonstrated for them in meaningful activities. Stage two students learned from the stage three students. Stage three students learned from the stage four teachers.

Loevinger describes this as "pacer". People need someone just a little bit ahead of themselves.

We seek places where we fit. I, for example, am comfortable with change and have a strong sense of dissonance when things are not aligned. Knight gave me an insight into myself when I saw that my love for technology is not just because technology changes so frequently but because the continual evolution of technology attracts people who are comfortable with change. I like technology because many people who like technology also like change. My stage of change and my expectations align with my environment.

There are also mismatches in alignment.

Consider the stage five concept of a European Union. Most of the people voting for or against each step in the union are in stage three or four. The EU compels stage three people to associate with people who are not like themselves. The EU compels stage four people to rethink and relearn their roles. Thus people resist the EU.

Consider a Christian renewal effort called Renovare. This collaborative effort seeks to touch Christian churches across denominations - so it is stage five. It is not interested in renewing the religious faith in non-Christian religions. Now if it was, then it would express stage six. Interestingly, one of the criticisms regarding Renovare is an accusation that it is a universalist religion and universalism is repugnant to many Christians. But, in my opinion, the reason for making such an accusation is that people in stage three like people who look like themselves and act like they do. People in stage three do not understand the subtleties of stage five and can easily mistake it for something other than what it is.

Now the mismatch can also go the other direction. I occasionally attend silent meetings of the Society of Friends (Quakers). The key concepts of this faith are stage six concepts of the unity of all humanity. Most silent meeting Quakers that I know would find no offense in the title "universalist". And yet, I know many who live in stage three. While they can articulate all of the concepts of this stage six faith - they cannot grasp the subtle distinctions. There is a mismatch.

Therapy, discipleship and recruitment all rely on a match on the stage of development between the client and the therapist. They also need an alignment in understanding regarding where the client is in the stages of change.

And yet, as I mentioned earlier, I see discipleship working in AA far in excess of what I see in Christian churches. Both draw from a similar pool of people. Both exist in the same culture. So there is something that AA does that churches do not seem to be doing. Consider the following table describing some of the obvious comparisons between an AA meeting and a Christian small group fellowship.

Christian	12 Steps
Entry is typically through the congregation and then into a small group. A few churches encourage entry into a group as a path into the congregation. But membership in one is closely linked to membership in the other.	Each meeting is autonomous and each session for a meeting is distinct from the other sessions for this same meeting.
Membership in a group is by invitation. Membership in the congregation requires approval from authorities.	Membership is chosen by the individual and cannot be denied by the meeting. There is no formal enrollment of membership above the meeting.
Leadership is typically elected or appointed and generally lasts for a defined term such as a year.	Leaders are typically elected for a period of time such as six months or a year. But leadership is dynamic because anyone at any time might relapse.
Adding a new member disrupts continuity and is often discouraged until a time designated for new enrollments.	Every meeting expects to have new people attending every session and reminds the new comers that they are the reason the meeting exists.

If we check the raw statistics provided by AA on membership in the USA and compare those numbers to church membership - such as provided by demographia.com - AA ranks as a mid-sized "denomination". And rough estimates show that about 15% of those in need of treatment get treatment while, according to ReligiousTolerance.org about 20% of the USA population attend church. So in rough measures it seems like we should be able to compare AA to a mainstream Christian denomination. And, in making a very subjective comparison I see strong discipleship in AA, NA, Nar-Anon, CODA and other similar twelve step groups. I see weak discipleship in the Methodist, Presbyterian and Friends denominations.

Of the formally organized small group programs I have participated in within Christian denominations many form strong relationships and stay cohesive for several years. In the twelve step meetings that I have attended most experience a continual turn over in leadership - partially by intent and partially through attrition. Team formation theory suggests that turn over hinders progress - so it would seem that a stable set of Christian small groups should traverse the team formation stages from forming, through the storming transition and into normal teamwork fairly effectively. And yet many of the Christian small groups that I have visited seemed stagnant. My thought is that AA meetings thrive because the core leadership form a group within a group - and that group within a group is able to traverse forming, storming and enter into norming.

Now groups within groups can be called cliques. Christian small groups seem to have a tendency towards closure while the constant influx of new members prevents the AA groups from closing in on themselves. Christian small groups also tend to become islands of isolation. AA small groups are continually cross pollinated with members who interconnect across multiple meetings. Perhaps Christian small groups could benefit from more cross-group exchange.

Such ruminations caused me to probe in multiple directions searching for an explanation. I kept searching for some tangible reason that AA meetings seem better at making disciples than the Christian church seems to be in the USA today. I found one clue when I checked the AA statistics on member retention. Consider the data shown in the table below. When I do an even spread between years ten and thirty I get the subsequent data and graph. To me, this looks like a half-life curve. And it would probably have an even stronger resemblance if I had more accurate data.

Years %Membership 1 31% 1 - 5 24% 5 - 10 12% > 10 33%   Years %Membership 1 31% 1 - 5 24% 5 - 10 12% 10 - 15 8% 15 - 20 8% 20 - 25 8% 25 - 30 8%

Falcone found a study with more accurate data and concluded that the success rate for AA is about 3.7% after one year and about 2.5% after five years. He also notes that 20% to 30% of all users will eventually stop on their own, often without treatment. The numbers look bigger on membership because not all members are sober - but they are trying.

Discipleship

Christianity today seems to lack this level of dedication. It is not a new problem. One of the more prominent commentators on this was Dietrich Bonhoeffer. His point was that the church has so watered down the Christian faith that the adherents put little effort into their faith.

Perhaps, then, the difference between AA and Christianity is like the difference between a military academy and a public school. AA only selects the few that are the most dedicated. The Christians welcome all. Relapse quickly eliminates all but the hardiest from AA. Cheap grace keeps everyone fairly content in Christianity.

From these ruminations I next turned to Richard Foster's work on Discipline. Consider the following summary of the disciplines that Richard Foster describes and the counterparts that I find in twelve step programs.

Christian	12 Steps
Meditation - Foster separates prayer (conversation with God), Solitude (silence to focus oneself) and Meditation (seeking the inner peace). Meditation is turning inward to "fill the mind" with Godly thoughts (p20).	Personal Inventory - is the step of contemplating the wrongs that we have done and the life that we have lived. This starts in step four and then turns into a daily practice in step ten.
Prayer - is conversation with God. It is speaking with the faith that God will hear and it is listening with faith that God will respond. Prayer is in anticipation of a response and that response may well guide our direction.	Higher Power - in his first AA writings Bill W referred to God. Some, however, felt this was a hindrance so the phrase "Higher Power" came into place. Addicts call upon their Higher Power in times of need and give thanks to their Higher Power for each minute of sobriety.
Fasting - is to discipline the body so that it will submit to the personal will in order to help the will submit to God. Fasting is not conflict with the body, but a tool to help the body and mind align with the guidance of the spirit.	Abstinence - is a discipline of the body, mind and spirit to act in accordance with a life that is free from addiction.
Study - is the discipline of learning with the expectation that we will be changed in the process.	Working the Steps - is a continuous study effort to learn the concepts, write papers, communicate with others and learn.
Simplicity - is being content with what we have and having faith that what is needed will be provided.	Humility - step one emphasizes our powerlessness over addiction.
Solitude - is separating our self from the world to allow time to find our self. The result is that we are better able to attend to others.	Silence - some treatment programs use silence as a punishment or as a way of helping the addict focus. But most programs strive to avoid solitude because addicts are especially vulnerable when the "committee" within the mind starts to debate whether or not it is safe to try the addiction again. Meetings, however, use silence as a way to encourage people to speak without feeling misunderstood.
Submission - Foster's use of the concept of "submission" requires elaboration in the text that follows this table.	Alignment - twelve step programs emphasize working their specific program and ask that people not mention other disciplines during a twelve step meeting. We need to align our efforts with the steps and traditions for our program.
Service - is helping others in all aspects of our lives. Special types of service are working within the community or providing leadership within the fellowship.	Service - is helping others in all aspects of our lives. Special types of service are working within the community or providing leadership within the fellowship.
Confession - is assessing our life and admitting the wrongs we have done. Confession is to our self, to God and often to another person.	Amends - are the inventory of the wrongs we have done, confession of those wrongs to our self, to our Higher Power and to our Sponsor. Whenever possible an amend should also be given to the person who was wronged - unless doing so would cause more harm.
Worship - is both the formalized use of rituals and the informal gathering of two or more in the name of God.	Meetings - are both the formalized use of rituals and the informal gatherings of two or more seeking recovery.
Guidance - is the talent of offering guidance and the ability to accept and follow guidance.	Sponsorship - is a commitment to guide one or more sponsees. The relationship serves both the sponsee and the sponsor as this becomes a close bonding.
Celebration - are joyful occasions to be thankful. Typical celebrations are the religious holidays but each worship service can include elements of celebration.	Conferences - are celebrations where many twelve step meetings come together. Many celebrations also bring together separate programs. For example AA conferences typically include Al-Anon and Alateen sessions.

One item in Foster's disciplines that needs clarification is the discipline of "Submission". Foster, on page 122, quotes Thomas a Kempis. "As thou wilt; what thou wilt; when thou wilt." That simple statement reveals two aspects of "submission". It is either the surrender of one who has been utterly defeated or it is the expression of total devotion of one who has been saved. In my opinion, what Foster describes regarding "submission" are loving acts of alignment. I suggest that Foster should consider renaming this chapter "The Discipline of Alignment" or "The Discipline of Agreement".

Consider, for example, the dilemma faced by Dietrich Bonhoeffer. He was aligned with God and could not submit to Hitler. The Christian epistles and traditions call for obedience to the state but Bonhoeffer found no way to submit to the Nazis without losing his alignment with God. Thus he chose a path of discipleship that led to martyrdom.

Aside from that one minor point of semantics, I find a reasonable correspondence between Foster's list of disciplines and the behaviors I see in twelve step programs. I think we could easily map almost any discipline into this grid and find a strong correlation. So the gem of knowledge that I find here is in what is missing. Nothing in the list of disciplines offered by Foster and nothing that I see in twelve step programs involves passivity. All of the disciplines named by Foster are disciplines of action.

AA calls alcoholics into a disciplined life. Daily life means working the steps. And when an addict says that he or she has stopped working their program everyone knows that relapse is imminent.

And yet, most Christians that I know have become quite passive about their religion. Some time is set aside for a worship service, but for many that might be all they do during that week. And then when we examine what transpires in those services we find that most people are spectators. Few twelve step meetings use the speaker format that most churches use. Instead, like the silent Quakers, a twelve step meeting expects everyone to be an active participant. And the old timers remind the newcomers that you get out of a meeting what you put into it.

People leave a Christian worship service and talk about what the choir should have done or what the preacher really should have said. People leave a twelve step meeting and ask each other what they really meant but did not say. People leave a twelve step meeting and confront and challenge each other pointing out the hypocrisy in their program or asking one another to share their wisdom. Twelve step meetings are opportunities to participate. How many do you know that truly work at worship?

Treatment Revisited

Action	Typical Response	Medical Model	Will Power Model	Social Model
Resistance	The addict will be confronted and their resistance will be put down.	Resistance is a temporary irrational behavior. Once the disease is in remission the patient will become rational again.	Sanctions and punishments will bring the addict into compliance.	Resistance originates in the therapist. Reassess the treatment because the therapist is probably getting ahead of the client.
Dirty Test or a Lapse	The addict will be punished for non-compliance.	The addict cannot cure them self. Dirty tests imply that the person providing the treatment is not being successful.	A dirty test implies that the addict did not master the skills that are available.	The underlying causes have not been mitigated and the stress exceeded the client's ability to cope.
Relapse	The addict will be moved to a stricter program from outpatient to inpatient and on to prison.	The disease is no longer in remission and must be treated again. As with cancer, if one treatment is insufficient then a more aggressive treatment is required.	Punishment will teach the addict that there are consequences to their behaviors.	Use motivational interviewing to bring the addict back into treatment. Then focus on additional training in relapse prevention.

In my opinion, we are doing the following:

1. We use the disease model to justify funding for treatment.
2. Then we use the will power model to compel the addict to comply.

I find it understandable that most addicts relapse. After all, the professionals that are supposed to be experts in this field seem confused. The experts say one thing and do another. So why then should we expect the addicts to be more capable than the experts at solving this problem?

Or perhaps it should be the other way around. As Ryan and Deci point out, the treatment that is best received by the addict is the treatment that the addict desires. The approach they recommend is called the Self-Determination Theory. "The application of self-determination theory (SDT) to psychology is particularly relevant because a central task of therapy is to support the client to autonomously explore, identify, initiate and sustain a process of change."

Ryan and Deci also note that there is a correlation between punishments in treatment and goals or quotas set for the therapists. If the therapist is in a coercive environment then that therapist is more likely to create a coercive environment for their clients.

The problem that I see is called "profits". A business lives or dies based on profits.

And the result that I see is that addicts are treated like property rather than like people.

If you have not done so lately spend some time in a drug court. Listen to the cases and see whether or not the addicts are allowed to testify and then assess whether or not anyone listens. I can tell you that I have watched program representatives lie to the judge and watched addicts protest that what was being said were lies. In all of the cases where I knew the facts and knew that the addict was telling the truth I have never yet seen the judge rule in favor of the addict.

But it is not just the courts. Families quickly learn that addicts lie and thereafter everything that an addict says is presumed to be a lie. Yes, the addict earned that reputation. And yet, our system of justice is based on the presumption that we are innocent. And our ability to get the addict into treatment is based on our ability to maintain sufficient relationship to motivate the addict. When the addict is in pre-contemplation, contemplation or even preparation, then the correct treatment is motivational interviewing. And to use that technique, we need to hold onto a loving, trusting relationship.

My Recommendations

1. Ensure that treatment uses evidence based methods.
2. Shorten the mandatory treatment interval.
3. Increase the length of after-care.
4. Empower the person.

Evidenced based treatment techniques are methods that have been tested and proven to work. A little over one hundred years ago anyone who wanted to could mix up a batch of chemicals and sell it for whatever purpose they chose. Laws were passed and today foods must be pure and medicines must be tested. Today, however, anyone who gets a job as a treatment counselor can use whatever techniques they like. In California you do not need any training or certification to work as an addiction counselor - as long as others in the same program do have some certification. In California you are free to use whatever techniques you want. The end result is that people who might have been sober for as few as four weeks can be put in charge of a group of patients. Would you take your baby to a doctor who never went to medical school? And yet, when our babies turn twenty or thirty we gladly give them over to people whose primary qualification is that they got there first.

The studies show that there is little or no benefit to inpatient treatment. The studies show there is benefit to maintaining a social support network. When courts order people into six month, twelve month or eighteen month inpatient treatment they do so in order to coerce the person. In other words, the courts endorse the medical model of treatment instead of punishment and then punish the addicts by sentencing them to coercive treatment. It really should be one or the other. If the medical or social model is right, then addicts need treatment. And if those models are wrong, then I suggest that we should stop using those models as excuses to sell people to treatment centers.

After-care is critical to success because of the half-life curve. The types of programs offered to airline pilots achieve 90% success. The types of programs used in court ordered treatment tends towards a 90% failure rate. My suggestion is to set up a telephone system like used for jury duty. Each addict in after-care would telephone the court perhaps three times a week - on pre-assigned days. The telephone call indicates that the person has not completely relapsed. Then on a random basis this telephone system will tell the addict that they have twenty-four hours to report for a drug test. Addicts today often know the schedule of the "random" tests and plan their binges so that they can be clean in time for the test. And many programs tend to not actually do the tests because the tests cost money. The telephone system will make the schedule more unpredictable and the mandatory test will force the treatment center to either do their job or be liable. Then require that each person in court ordered treatment work this system for enough years for the new life skills to become habit. Perhaps three years is sufficient.

Twelve step programs work because those programs give people tools so that they can change their life. This does not mean that twelve step programs are the only way to do after-care. Many organizations offer excellent programs that are not twelve step programs and thus do not count for court ordered programs. But if the goal is to change lives then colleges have been doing that far longer than twelve step programs have. And religions have been changing lives far longer than even colleges have. Give the person the responsibility to comply with the program and give the person the right to choose their own path. And if the addict chooses a path that does not work, then they will learn from that. And even if an addict does a twenty-eight day treatment three times in three years it will still be more effective for the state and for the addict than doing a six month treatment once, spending a few months clean and then living two years in relapse.

Follow Up

• On the diagram that describes my model I had the word "enabling" under the category of obligation and it belongs with smothering.
• I learned that the concept I had called "disability" in the paper before this is known as the "social model" and I now see how it fits into my diagram.
• I identified the nine helping models and placed them on the diagram.
• I learned more about the perspectives that define a helping relationship. For example, I might support my friends by acting as if the social model is the right model. At the same time those friends might live their lives as if the disease model explains the problem. Neither model is right and neither is wrong. Both are just perspectives - points of view.
• The key to treatment is discipleship. No matter where people are mentally, then must first let go and surrender into tranquility. Once there we are ready to learn and begin transforming ourselves. But we need a role model to follow. The role model can be a pacer - a person just a little ahead of us - like a sponsor. The role model can be guiding principles - like the Big Book or the Bible. Or the role model can be conceptual - like asking "What would Jesus do?"
• I raised a question earlier about which state a therapist should be in while counseling. My understanding now is to come back to Carl Rogers' approach. The therapist should be centered, should demonstrate transformation of them self and should be committed to a discipline.
• I have a better comprehension now regarding the cohesiveness of the works on motivational interviewing, relapse prevention and stages of change. I see how well these parts mesh with each other.
• I also now see broader implications from this model than I did before. I first created this model to integrate several theories about organizational efficiency. I then pulled in thoughts about addiction treatment. And now I see that these same patterns apply to my relationships with people in general. I now understand that someone who is homosexual can feel subjugated or conflictual or chaotic all the while struggling to find their identity. I now understand why Kohlberg stopped working in prisons once he determined that the culture was trapped in stage one and I see that until we change that we are going to continue to be displeased with their failure to rehabilitate.
• I learned that I endorse universalism and understand it better and appreciate it more.

When I write one of these papers I give myself homework assignments so that the learning process will continue. Here are the assignments I am giving myself.

• Continue the discipline of study. This is my discipleship. I will help everyone I can with twelve step programs but twelve step programs are not my discipleship path.
• Adjust my life based on what I learned from this exercise.
• Share what I learned in three ways:
  • Post this paper onto the internet.
  • Write a more focused paper to share with people I know in churches.
  • Work with my addict friends to write a book to tell people about what these treatment programs are doing to people - both the good and the bad.
• Do what I can to try to reform these treatment programs.

And from there I might finally have a hypothesis that I can test. I prefer evidence based methods over subjective methods and fault myself for being so subjective in these papers. For now, however, this is the technique that I have available so I need to use it. Later I hope to formulate a testable hypothesis and verify my model.