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Sunday 21 September 2014

"Review of the effectiveness of treatment for alcohol problems"


Review of the effectiveness of treatment for alcohol problems, Raistrick D, Heather M and Godfrey C. National Treatment Agency for Substance Misuse (NHS), 2006

Extract (pp. 139-142):

12.4 Collective mutual aid

12.4.1 Alcoholics Anonymous

12.4.1.1 Context

In modern times, the first mutual aid group to be formed in the alcohol field was the Fellowship of Alcoholics Anonymous (AA), which was founded in 1935 in the USA when medical and scientific interest in alcohol problems was low. Since then, AA has been enormously successful in reaching alcohol misusers around the world and has helped many hundreds of thousands of people.

There are estimated to be two million active members of AA worldwide in nearly 99,000 groups in over 140 countries (Emrick, 2004), although the demographics of AA membership vary widely across different countries. AA have established a website in the UK: www.alcoholics-anonymous.org.uk.

It would be more accurate to describe AA as a way of life than a form of treatment. In the early days of AA, professional involvement was eschewed; later, links with the helping professions were more welcomed (Slattery et al., 2003). This topic will be returned to later.

From the treatment policy point of view, AA is an extremely cost-effective means of combating alcohol-related harm (Humphreys and Moos, 1996) and is entirely self-financing. From the individual’s point of view, it is highly accessible and offers help on a continuous, 24-hour basis. No formal treatment service can match AA for the continuity of support it offers to its new adherents.

Members of AA believe they suffer from a disease, which is present before they ever come into contact with alcohol and that results in a permanent inability to control drinking. The “disease of alcoholism” model espoused by AA is said to afflict a small minority of drinkers and cannot be cured, but only arrested by total and lifelong abstinence. Adherents believe that without such a commitment to abstinence, further drinking leads invariably to progressive deterioration, insanity or death.

The code of AA principles and practice finds expression in the Twelve Steps, supported by the Twelve Traditions (Alcoholics Anonymous World Services, 1980) (see figure 12a). The references to “a higher power” in these codes reveal the strong spiritual element in AA teaching.

A crucial feature of the AA recovery programme is the practice known as “12-Stepping” in which an established member takes responsibility for helping and advising a new recruit. This is regarded as essential to beginning the recovery of the new recruit and to maintaining the recovery of the older member. This activity is supported by regular meetings at which “recovering alcoholics” tell their personal stories and AA recruits are urged to attend these meetings almost every night at first and then on a regular basis for the rest of their lives.

In addition to its spiritual content, the social organisation of AA provides support for a new life without alcohol, together with a new self-concept and social identity. Further description and comment on AA can be found in McCrady and Delaney (1995) and Emrick (2004).

There are two organisations that provide help for families of alcohol misusers: Al-Anon for spouses and Alateen for teenage children.

12.4.2 Evidence

It has proved difficult to conduct research on the effectiveness of AA, mainly because of the anonymity upon which it properly insists and because of the
problems in forming randomised control groups.

The Fellowship of Alcoholics Anonymous claims a success rate of 65 per cent sobriety at one year or more (Alcoholics Anonymous, 1990), but this only applies to those who persevere with regular AA attendance [viz: “Of alcoholics who came to A.A. and really tried, 50 % got sober at once and remained that way; 25% sobered up after some relapses, and among the remainder, those who stayed on with A.A. showed improvement.” Alcoholics Anonymous, Foreword to Second Edition, p. xx]; as a general statement of outcome among all those who attend or are referred to AA, it must be regarded with caution.

Several studies have shown either that alcohol misusers who attend AA are more likely to recover than those who do not (Humphreys, Moos and Cohen, 1997; Ouimette, Moos and Finney, 1998) or that frequency of AA participation is positively correlated with good outcome (Connors, Tonigan and Miller, 2001). However, these studies are subject to the problem of selection bias; those who attend AA meetings, or do so more frequently, may be more motivated to solve their alcohol problem than others, while those who do not attend or drop out from AA may already have relapsed.

In the Mesa Grande (see page 44), Alcoholics Anonymous obtains a fairly high negative rating, indicating ineffectiveness. However, the studies on which this rating is based used court-referred alcohol misusers who had been mandated to attend for treatment. This is likely to underestimate the effectiveness of AA because:

Such individuals are poor prospects for success from any form of treatment [Note: consider implications for chit-system]
The involuntary nature of referral to a voluntary organisation like AA limits any conclusions that can be reached.

Kownacki and Shadish (1999) carried out a review and meta-analysis of 21 controlled studies of AA and residential treatment based on 12-Step principles, with a particular focus on their methodological quality. With regard to AA itself, there were three randomised trials and nine quasi-experimental (non-randomised) studies. They concluded:

Randomised studies yielded worse results for AA than non-randomised studies, but were biased by the selection of coerced participants
Attending conventional AA was no worse than no treatment or alternative treatment
Several components of AA seemed supported (recovering alcoholics as therapists, peer-led self-help therapy groups, teaching the 12-Step process, doing an “honest inventory”).

Although the only requirement for membership of AA is a desire to stop drinking, there are good reasons to believe it is helpful to particular kinds of individual. Of all those who initially attend AA or are referred to it by a professional worker, it is likely that only a small proportion will attend regularly (McCrady and Delaney, 1995) – the rest either attend on a spasmodic basis or drop out completely. Since those who attend regularly are likely to have a good outcome, it is important to know what kind of people they are.

In a meta-analytic review of the literature on AA, Emrick et al. (1993) found that those most likely to affiliate successfully:
Had a history of external supports to stop drinking
Were more likely to have experienced loss of control over drinking
Were more anxious about their drinking
Were obsessively involved with their drinking
Believed alcohol improved mental functioning.

It is important to note that these findings on successful AA affiliation were confined to US alcohol misusers.

Mankowski, Humphreys and Moos (2001) showed that greater involvement in 12-Step groups after discharge from formal treatment is related to the degree of compatibility between the alcohol misuser’s personal belief system and that of the mutual aid group. Tonigan, Miller and Schermer (2002) reported that atheists and agnostics were less likely to initiate and sustain AA attendance than spiritual and religious individuals and recommended that this be taken into account when encouraging AA participation.

In a survey of service users carried out in conjunction with the Scottish Health Technology Assessment Report (Slattery et al., 2003), it was found that most respondents had attended at least one meeting of AA. While all said they recognised that AA works well for many people, most felt it was not suitable for them. Those who found it beneficial, although in a minority, seemed to gain considerable support.

The results of this survey confirm the view that AA is not suited to all alcohol misusers. Some may be put off by the spiritual aspects of AA teaching and others may have difficulty in revealing the details of their personal lives to others. This argues for a range of mutual aid approaches to be made available.

There have been no controlled trials of the effectiveness of Al-Anon, but there is evidence that members show improvements in emotional adjustment through participation in the organisation (Humphreys, 2004).

Members of AA tend to do better if their spouses are affiliated to Al-Anon – however, affiliation to Al-Anon by the spouse does not appear to make alcohol misusers more likely to attend AA or to initiate formal treatment.

Hughes (1977) showed that, among teenage children of alcohol misusers, Alateen members had significantly fewer emotional problems that those in matched comparison groups.

12.4.3 Conclusions

AA appears to be effective for those alcohol misusers who are suited to it and who attend meetings regularly (IIA)
AA is a highly cost-effective means of reducing alcohol-related harm (II)
Not all alcohol misusers find the AA approach acceptable (II)
Coercive referral to AA is ineffective (IA) [see above]
Al-Anon and Alateen are effective in providing emotional support to families of AA members (IIB).”

(our emphases) (comments in red)

Cheers

The Fellas (Friends of Alcoholics Anonymous … but no friends of the 'chit-system'!)


PS For AA Minority Report 2013 click here

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