Alcoholics Anonymous (AA), the biggest self-help group for alcoholics not only in the United States but in the world, was founded in 1935 by Bill Wilson. Wilson—known as Bill W in keeping with the AA tradition of Anonymity—was a successful stockbroker who was also an alcoholic. He sought treatment in a New York City hospital twice. The second time, Wilson’s treatment was successful, but only because he had what he referred to as a spiritual experience.
And spirituality pervades the literature of AA. With its many references to God and prayer, it seems far removed from evidence-based treatment. In fact, AA, like other self-help groups, is not treatment, per se, a fact that has confounded studies comparing AA with cognitive behavioral therapy (CBT) and other treatments for alcoholism. But studies have shown that in many people, AA does have a positive effect.
The American Psychiatric Association in 1995 recognized the importance of 12-step groups as an adjunct to treatment in its clinical practice guidelines for substance abuse disorders. The practice directorate of the American Psychological Association in 1999 called these groups “a crucial part of any recovery program” in its recommendations concerning the role of psychologists in treating patients during therapy and after therapy ends (Laudet AB, Int J Self Help Self Care 2000;1(3):213–225).
What the Research Says
Researchers note that it’s important not to confuse AA with treatment such as CBT or motivational interviewing, a problem that has kept many studies from producing clear results.
In fact, the biggest study ever funded by the National Institutes of Health on alcoholism treatments, Project MATCH, actually looked at “12-step facilitation,” which is not exactly the same as AA. In its Principles of Drug Addiction Treatment: A Research-Based Guide, the National Institute on Drug Abuse defines 12-step facilitation therapy as an active engagement strategy designed to promote abstinence by increasing the likelihood of a substance abuser becoming affiliated with and actively involved in 12-step self-help groups.
Overall, the $20-million study funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) did not find clinically significant differences in effectiveness between 12-step facilitation therapy and the two standard treatments it was pitted against: CBT and motivational enhancement therapy (which uses motivational interviewing) (http://1.usa.gov/16iHxX).
For Project MATCH, NIAAA focused on a specific group—people who have sought treatment for alcoholism and participated in AA (whether during treatment, after treatment, or both). “For this group, the bottom line is there is a positive association between AA attendance and recovery for short- and long-term outcomes,” says Robert Huebner, PhD, director of the Division of Treatment and Recovery at NIAAA.
What isn’t clear is what kind of clients do best in mutual self-help groups such as AA, says Huebner. For example, someone who is socially anxious might not like AA’s format. NIAAA recently funded an application from J. Scott Tonigan, PhD, for a meta-analysis of the literature on AA, with the goal of trying to narrow down characteristics of patients who do well in AA.
The work of recovery researchers Alexandre B. Laudet, PhD, and William L. White, MA, has been particularly important in bringing the role of AA into the scientific literature. White, a senior research consultant with Chestnut Health Systems/Lighthouse Institute, and Laudet, director of the Center for the Study of Addictions and Recovery at the National Development and Research Institutes, Inc, have found that even among substance abuse treatment providers there is a “knowledge gap” when it comes to AA (Laudet AB and White WL, Alcohol Treat Q 2005 April 6;23(1):31–45).
How to Talk to Clients About AA
When considering whether AA will help your clients, you have an important benefit: you know them. The best way to learn about your clients’ views on AA is to ask them, says Mark Willenbring, MD, a St. Paul, Minnesota-based psychiatrist who held Huebner’s position at NIAAA before retiring. Now in private practice, Willenbring suggests asking your clients questions such as,
It’s also important to determine whether the client perceives or has been told by AA members that psychotherapy conflicts with AA. Your client may balk at stimulant treatment for ADHD, or taking zolpidem (Ambien) to help with insomnia, and in some cases, may be advised by AA members to stop taking antidepressants or mood stabilizers, says Willenbring. And if clients are on an anti-relapse medication like naltrexone (eg, ReVia, Vivitrol) they may be put under particular pressure by a sponsor or other AA members to stop taking it. Some AA meetings are specifically for alcoholics with a co-occurring mental disorder; medication use is likely to be accepted at these meetings.
In fact, the American Psychiatric Association, in its practice guidelines for treating substance use disorders, notes that people on psychoactive medications should be directed to groups supportive of pharmacological treatment. However, finding such groups isn’t easy—there isn’t a published listing, because each meeting of AA determines its own rules. Nevertheless, participation in AA “can be an important adjunct to treatment for some but not all patients,” the American Psychiatric Association guidelines say. You can find the guidelines Treating Substance Use Disorders: A Quick Reference Guide at http://bit.ly/NFfRNl.
If your alcoholic client isn’t in AA already, you should at least bring up the subject, not necessarily as a recommendation, but as a question, says Willenbring. Usually, clients have an opinion about it, and it’s important for you to know what they think. Only 20% to 30% of clients in recovery from alcoholism will affiliate with AA, so not doing so doesn’t mean they don’t want to be abstinent. “AA simply is not for everyone, and so the psychiatrist needs to have other options, such as either doing CBT or referring someone to a CBT therapist familiar with addictions,” he says, adding that AA can actually impede recovery in some clients.
About AA Meetings
At AA meetings, your clients will have a chance to identify with peers who are seeking a solution for the same problem they have. For alcoholics, every day has the potential to bring cravings and temptations, so it’s important for them to know that whether they are home, on vacation, or on a business trip, there is going to be an AA meeting going on every day that they can attend.
Meetings usually start with 12-step readings. AA “work” includes having a sponsor, “working the steps,” and not drinking. “Don’t use [alcohol] no matter what” is a basic tenet, as is going to meetings and asking for help. The AA acronym HOW stands for honesty, open-mindedness, and willingness to change—all attributes that can be helpful to the work you do in therapy. The only requirement for people to participate in AA is that they want to stop drinking—they don’t need to have quit already. There are no membership records, and a key principle is anonymity. And it’s free.
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