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'!)
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