Interviews with AA participants illustrate effect on emotion regulation
Emotion regulation (ER) refers to the manner in which individuals express, subjectively experience and manage their feelings. Successful ER entails the capacity to self-soothe and endure stressful emotional occurrences in addition to the physiological arousal accompanying emotions. ER skills are essential in social interactions, stress management, and many aspects of daily living. Researchers have noted that poor ER is related to impulsivity, difficulty delaying gratification, and affective lability (rapid changes in emotion). In the absence of ER skills, people often use substances to manage their emotions. Logically, then, people with substance use problems often have limited ER skills.
Those in recovery from substance abuse often need to develop healthy ER skills so they are not tempted to use substances again to manage emotions. Alcoholics Anonymous (AA) and similar 12-Step support groups are foundational in the treatment of substance abuse. Appropriately, many of AA’s fundamental concepts involve ER. For example, the notion that one’s life is out of control includes one’s emotions being unregulated. Because of the intimate link between cognition and emotion, AA’s challenges to the ways addicts conceptualize reality likely promote the development of ER skills.
Nevertheless, a scientific investigation of AA’s effects on ER skills has not been attempted, to our knowledge. As such, we conducted in-depth interviews with nine long-term participants in AA groups in North Carolina to examine how AA participation has affected their ER skills.
Focus of research
We analyzed and coded the information obtained through participant interviews into five core categories of ER skills: situation selection, situation modification, attentional deployment, cognitive change, and response modulation.
In situation selection, people make predictive judgments of their emotional reactions in specific situations and estimate the likely emotional consequences of their actions within these situations; they then choose or avoid a situation based on their assessment. In situation modification, people attempt directly to adjust a situation to avert its subsequent emotional impact. In attentional deployment, individuals use distraction to divert their attention from negative aspects of their experiences to positive ones. In cognitive change, individuals evaluate an upcoming situation by altering the way they think about the situation. Finally, in response modulation, people directly influence their physiological, experiential, or behavioral responses through such techniques as meditation, prayer and exercise.
These five ER skills can be summed up as avoidance, assertiveness, distraction, reappraisal and suppression. In addition to these five primary ER skills, other skills exist.
During interviews, we asked AA members how AA has affected their ability to handle a variety of situations and specific emotions, including anxiety, fear, depression, sadness, anger, resentment, guilt, shame, loneliness and boredom. The ER categories they reported using were extracted from interview transcripts and were aggregated to determine which ER skills are learned through AA participation.
Cognitive change most prominent
Participants described 128 discrete instances of using ER skills. First, we tabulated interview results separately for men and women, but found no differences in the ER skills learned or used based on gender. Both men and women indicated that AA participation has taught them cognitive change more than any other ER skill, with 34% of ER reports falling into this category. The 12 promises of AA speak to this notion: “Our whole attitude and outlook on life will change. … We will intuitively know how to handle situations which used to baffle us.”1 It appears that this promise is being fulfilled in AA participants’ experiences, since they often report using cognitive change to manage emotions.
Many respondents also spoke of their journey through the 12 Steps as a spiritual awakening, beginning with surrender to a Higher Power as described in AA’s 2nd Step. “Sanity” is an inherently cognitive concept, and participants often elucidated their spiritual renewal in cognitive terms. “Charlie,” for example, stated that entering AA was a fresh start mentally: “You have to get rid of old attitudes and perceptions about addiction and drinking. … AA helps the recovering addict by somewhat of a reconditioning and unlearning of bad mental habits...”
As such, it appears that the spiritual dimension of AA may be acting in support of the ER method of cognitive change. Other AA adages, such as “Live life on life’s terms” and “One day at a time,” further teach recovering addicts to focus cognitively on today, reducing stressors that may arise from thinking about the past or future.
Response modulation was the second most commonly learned skill in AA, mentioned 26% of the time. Thus, AA members relied collectively on cognitive change and/or response modulation 60% of the time to regulate emotions. Along with cognitive change, response modulation was also noted as the most frequent ER skill that AA members discussed with their sponsors. All respondents reported that conversations with their sponsors have affected how they handle their emotions, with two-thirds discussing response modulation with their sponsors. It appears that the sponsor's role may be critical in the acquisition and effective application of this particular ER technique.
Consistent with its highest endorsement, cognitive change was also the number one method used by participants to manage most of the specific emotions we asked about. When it was not the most common method, it was second. Response modulation was right behind it, noted as the first, second, or third most common method of managing the various emotions. In fact, every respondent made direct mention of the daily practice of prayer and/or meditation, which are forms of response modulation. All respondents cited a direct correlation between these spiritual practices learned in AA and their ongoing sobriety. Clearly, AA appears most often to teach its members either to change their thoughts about difficult situations or to rely on response modulation techniques such as meditation or prayer to manage problematic emotions.
In contrast, the AA members we interviewed reported using the other three ER techniques much less often. Situation selection was mentioned 16% of the time, attentional deployment was cited 14% of the time, and situation modification was used only 9% of the time. These three infrequently endorsed ER strategies may be less emphasized in AA because AA provides guidance on how to deal with emotions and life situations directly, while these three techniques involve a certain degree of indirectness. For instance, “Delta” stated that participation in AA has helped her to “walk through problems” instead of running away from them.
Although these three less-used ER techniques are clearly valuable, persons with substance use problems may have a more urgent need to respond directly to ensure not only their emotional well-being but also to maintain sobriety. One might therefore conclude that AA emphasizes the methods of cognitive change and response modulation more in comparison to other ER techniques because of AA’s primary focus on providing participants with direct methods to live soberly and sanely.
Nevertheless, AA members did report using situation selection and attentional deployment often during one particular emotional experience—stress, anxiety and fear. Attentional deployment was also used often when participants felt lonely or bored. These exceptions illustrate that although these ER methods are perhaps not emphasized in AA, participants are still acquiring these skills through AA participation. That is an important point, as it suggests AA’s sensitivity to teaching the right ER skill at the right time in each person’s life.
Of note is that one form of response modulation, spirituality, was mentioned 44% of the time as the tool used when participants felt guilty or ashamed. It is possible that because guilt and shame are emotions with a clear moral dimension, they naturally lead to spiritual responses more often than other emotions, such as loneliness or sadness, which do not necessarily imply failure in relation to a personally held moral code.
Conclusions from research
Overall, results from the interviews suggest that the 12-Step model effectively provides AA members with a foundation to acquire and employ all five core ER techniques. However, due to the fact that the number one goal of membership in AA is to maintain sobriety, AA’s efforts are likely focused on achieving that goal as directly and intentionally as possible. Thus, one could argue that cognitive change and response modulation are the most compatible ER skill matches with AA’s principles and practices, and, as such, the most commonly taught ER methods during AA participation.
This study has several limitations. First, its findings derive from interviews with a relatively small number of participants. Although small sample sizes are common in qualitative research such as this, findings should be confirmed by follow-up quantitative studies with larger samples. Second, the interview questions used for the study were developed specifically for the present investigation, meaning that limited reliability and validity data exist for these questions. Third, the study relies on only one categorization of ER techniques; other ER categorizations exist and might be productively explored in future research. Last, we did not collect information about subjects’ co-occurring disorders. There may be differences in how persons with various co-occurring disorders experience AA and in how they acquire specific ER skills. Differences based on age, ethnicity and other demographic characteristics may also exist, and should be explored in future studies.
Miranda D. Teel, MS, is currently attending the American School of Professional Psychology at Argosy University in Washington, D.C., pursing a clinical psychology doctoral degree. Teel works with the DC Superior Court Child Guidance Clinic, providing therapy to female youth offenders. Edward J. Cumella, PhD, is retired from private practice and hospital administration and now teaches students pursuing the MS in psychology at Kaplan University online.
References
1. Alcoholics Anonymous World Service. Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered From Alcoholism (4th ed.). Center City, Minn.: Hazelden Publishing; 2001.
