PhD/PsyD Article on AA

[erg923]

http://www.theatlantic.com/magazine/archive/2015/04/the-irrationality-of-alcoholics-anonymous/386255/

Thoughts?

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[WisNeuro]

I think the problem is that it has fueled a zeitgeist that their methods are the only "tried and true" ways to get people to deal with their alcoholism. That, in addition to the notion that there are other options with better success rates and better data supporting them, are available and under utilized due to a reliance on AA. Also, it does seem that AA just makes up numbers to justify its existence, while denying people access to any real data to evaluate those numbers. It's kind of cultish.

When it comes to funding, I'd want to see other options emphasized. I wouldn't actively discourage patients from going this way, but I never advocate it either. Same reason I don't advocate other non-empirically supported interventions.

 

[Ardor]

Part of the author's point was that yes, AA can be helpful for some individuals, but it has also historically eclipsed and limited the development of viable evidence-based treatment alternatives.

 

[PsyDr]

As with any supposed "intervention", the efficacy can be a mystery until properly studied.

AA claimed a bunch of things, got a wide variety of people and legal institutions to believe them, derided other interventions that were supported by the literature, and tactitly violated some peoples' rights without ever having produced an evidence base.

There is another group that did the exact same thing but used niacin and steam baths.

 

[everythingbutcurling]

http://www.theatlantic.com/magazine/archive/2015/04/the-irrationality-of-alcoholics-anonymous/386255/

Very disappointing piece, IMHO. Rather than focusing on the potential benefits of newer “evidence-based” treatments (which I wish were more widely disseminated and integrated into treatment settings), the author really just airs out all of her grievances with AA.

As far as I’m aware, AA does not claim to be a scientific treatment model. AA doesn’t claim to be led by professionals nor do they attempt to compare themselves to other treatment approaches. My understanding of AA is that of a self-help program led by alcoholics, for alcoholics.

True, AA is not a good fit for everyone and clearly everyone who attends doesn’t necessarily benefit. But, many have benefitted, are benefitting and will continue to benefit from participation in AA. I know many patients and (and some friends) who have testified to the benefits of participation AA. Participation in AA is voluntary and it is financially self-supporting. Those who don’t agree with AA’s philosophy nor the references to a higher power are not obligated to attend and are free to explore other treatment approaches, including those referenced in the article.

I believe that AA can play a very important role in helping many people suffering from alcohol use disorder to live healthier and more successful lives. I see no benefit from discouraging patients from considering AA to support achieving their desired goals.

Thoughts?

I would offer that there's potentially some danger in a "disease-based" model of addiction when models of addiction based on principles of learning and behavioral-based discounting have been so well supported. I always feel like that point is worth a discussion with my clients who like or attend AA. In the same way that people are less likely to lose weight if they believe it has a strongly genetic component, an individual's self-efficacy can be taken away by a disease model of alcoholism.

At the same time, AA offers a lot of social support that can be really valuable, so I usually don't discourage my clients from attending AA, either.

 

[Therapist4Chnge]

The data aren't there, but that doesn't stop the propaganda. I guess if it works for ppl then it can be helpful, but I'm not a big supporter bc of the lack of data, lack of professional involvement, and risk of swapping one addiction for another. The fact that courts mandate it...ugh.

ps. As an adjunct (for social support) seems like a good compromise, but I've only really seen this with ppl well into recovery.

 

[smalltownpsych]

I have had numerous patients over the years who benefit greatly from their involvement in community-based support groups. There is research evidence that involvement in these groups is beneficial. The resistance of the scientific community sounds like bias to me. Sure there are people who are involved in these programs who think that because it works for them, then it will work for everybody, so what? I see that dynamic with gluten-free diets, exercise regimens, religious practices, politics. It doesn't negate the fact that it works for many individuals. I have mixed feelings about court mandated involvement in 12 step groups and 12 step groups often have mixed feelings about this as well. When I ran an addiction program, I was pretty clear that social support and involvement in groups that promote activities without alcohol or drugs is predictive of recovery whether it is a church, volunteer groups, or 12 step group. Chemical dependency hijacks the reward system and for humans, the social/attachment rewards system is probably the most significant for functioning.

 

[WisNeuro]

I have had numerous patients over the years who benefit greatly from their involvement in community-based support groups. There is research evidence that involvement in these groups is beneficial. The resistance of the scientific community sounds like bias to me. Sure there are people who are involved in these programs who think that because it works for them, then it will work for everybody, so what? I see that dynamic with gluten-free diets, exercise regimens, religious practices, politics. It doesn't negate the fact that it works for many individuals. I have mixed feelings about court mandated involvement in 12 step groups and 12 step groups often have mixed feelings about this as well. When I ran an addiction program, I was pretty clear that social support and involvement in groups that promote activities without alcohol or drugs is predictive of recovery whether it is a church, volunteer groups, or 12 step group. Chemical dependency hijacks the reward system and for humans, the social/attachment rewards system is probably the most significant for functioning.

Where is this research for AA, and how does it compare to other treatments, or a wait-list control?

 

[smalltownpsych]

I think the problem is that it has fueled a zeitgeist that their methods are the only "tried and true" ways to get people to deal with their alcoholism. That, in addition to the notion that there are other options with better success rates and better data supporting them, are available and under utilized due to a reliance on AA. Also, it does seem that AA just makes up numbers to justify its existence, while denying people access to any real data to evaluate those numbers. It's kind of cultish.

When it comes to funding, I'd want to see other options emphasized. I wouldn't actively discourage patients from going this way, but I never advocate it either. Same reason I don't advocate other non-empirically supported interventions.

AA refuses funding from outside sources so that is a non-issue. Also, it probably should not be characterized as an intervention as opposed to a support system to support maintenance of a change that has already been made. I don't see why you would not recommend it as a potential source for support for patients.

Where is this research for AA, and how does it compare to other treatments, or a wait-list control?

I guess I could drudge up my references from my dissertation which is where i saw some of that evidence. Obviously, most of it was correlational and the biggest confound is that people who find it helpful are going to be the people who go there, but does that really negate that it is helpful? Also, the underlying premise of my dissertation is that AA should not be conceptualized as a treatment so no sense comparing it to other treatments.

 

[WisNeuro]

AA refuses funding from outside sources so that is a non-issue. Also, it probably should not be characterized as an intervention as opposed to a support system to support maintenance of a change that has already been made. I don't see why you would not recommend it as a potential source for support for patients.

I guess I could drudge up my references from my dissertation which is where i saw some of that evidence. Obviously, most of it was correlational and the biggest confound is that people who find it helpful are going to be the people who go there, but does that really negate that it is helpful? Also, the underlying premise of my dissertation is that AA should not be conceptualized as a treatment so no sense comparing it to other treatments.

It shouldn't be, but they, and others present it as such. I wouldn't recommend it as a possible source for the same reason I don't recommend other things without an evidence base, we don't know that it actually works. As for the references, the research is weak, at best, and open to so many biases and confounds that it's hard to actually say that it's helpful. Conceptualize how you want, but most people see it as a treatment,not a support group, and many forgo actual treatment for it.

 

[smalltownpsych]

It shouldn't be, but they, and others present it as such. I wouldn't recommend it as a possible source for the same reason I don't recommend other things without an evidence base, we don't know that it actually works. As for the references, the research is weak, at best, and open to so many biases and confounds that it's hard to actually say that it's helpful. Conceptualize how you want, but most people see it as a treatment,not a support group, and many forgo actual treatment for it.

There was a time when AA was the only real option for treatment. In fact, hydrotherapy was one of the popular medical treatments at that time. The early members would often detox people themselves if they couldn't get them into a hospital. Eventually some of those sober members started developing their own "treatment programs". Initially, these were often considered part of AA, but in 1950, AA decided that it should not be professional and treatment programs would need to be separate entities. Since that time, AA as a whole, has communicated very clearly that they want to cooperate with the professionals. AA members as individuals often get in the way of that cooperation and will often act as though they speak for AA as a whole when they do not. This can cause significant problems because these individuals when they are involved in treatment programs begin proclaiming their own personal bastardization of the AA program. In the actual AA meeting rooms, these types have little real power or influence which is why they tend to be so loud in other venues. Part of working a good program is being humble, tolerant, and seeking to contribute and collaborate as opposed to being combative. The individuals with these traits don't get noticed as much as the loudmouths (kind of like our current debates ) so often professionals have a skewed view of what AA really is.

 

[WisNeuro]

Ok, for a second, let's accept that it's a support system, not a treatment. Where is the data showing that it adds any beneficial value when it is added to an empirically supported treatment?

 

[WisNeuro]

Additionally, my patients are increasingly agnostic/atheist/non-spiritual, and have problems with such language as "Remember that we deal with alcohol - cunning, baffling, powerful! Without help it is too much for us.But there is One who has all power—that One is God. May you find Him now."

Bottom line, no good evidence of support, especially with other efficacious treatments somewhat well established, and many of its central tenets actually refuted by the best data available.

 

[smalltownpsych]

Ok, for a second, let's accept that it's a support system, not a treatment. Where is the data showing that it adds any beneficial value when it is added to an empirically supported treatment?

http://www.mentalhealth.va.gov/providers/sud/selfhelp/docs/6_mckellar_stewart_humphreys_2003.pdf
Here is one article. I don't have access to other articles here at work. It is true that there is not much data and as I said the correlations show that the people who are more involved maintain abstinence at a higher rates, but directionality cannot be determined. Apparently, it does provide some benefit for the two million people who are purported to be members. So it works for the people it works for. Some of my patients it helps tremendously and they identify it as a significant source of social and emotional support and guidance. Others don't. AA itself does not purport to be the only means to maintain abstinence, although at the time it was written there were very few other means. I agree that more research needs to be done and I also feel that it needs to be conceptualized more accurately.

 

[WisNeuro]

We can't really say that it benefits the purported 2 million because of the lack of any semblance of rigorous data. I don't doubt that some people do well in AA, but my guess is that those are people who would do well in any treatment setting. AA just benefits from some individuals' intrinsic motivation and cherry-picking certain data. I'd rather advocate for supported interventions that will help more patients, not merely those that would have likely had improved outcomes with any intervention.

 

[FadedC]

The 12 step program model gets applied to many more things then just alcoholism. I had an ex girlfriend who was part of AA, overeaters anonymous (which claimed to be equally effective at treating anorexia and obesity), business debtors anonymous, and a 4th group having something to do with finances. They all used the same 12 step model, even when it didn't seem appropriate. People who went to AA or any of the other groups were often strongly encouraged to attend other 12 step groups that were related to perceived short comings in their life. My ex spent most days in some form of group.

Obviously that whole experience left me somewhat biased against the system, but it wouldn't necesarily stop me from referring someone to AA for help as one of many options. I imagine it's just a risk inherent in any system without much in the way of central leadership.

 

[calimich]

It shouldn't be, but they, and others present it as such. I wouldn't recommend it as a possible source for the same reason I don't recommend other things without an evidence base, we don't know that it actually works.

"They" - AA - don't present it as anything other than a fellowship of people who are concerned about their drinking and want to stop. A key tradition of AA is gaining members through attraction rather than promotion. As far as an evidence base, there are many people (thousands, millions?) who have stopped drinking with support of AA.

Also important is that meetings are free, local, and often available around the clock. Especially for those people who lack means to see a professional, AA is a stable alternative and good starting point.

Is there evidence that attending AA meetings harms people or reduces efficacy of more standardized treatments?

 

[futureapppsy2]

Whereas AA teaches that alcoholism is a progressive disease that follows an inevitable trajectory, data from a federally funded survey called the National Epidemiological Survey on Alcohol and Related Conditions show that nearly one-fifth of those who have had alcohol dependence go on to drink at low-risk levels with no symptoms of abuse. And a recent survey of nearly 140,000 adults by the Centers for Disease Control and Prevention found that nine out of 10 heavy drinkers are not dependent on alcohol and, with the help of a medical professional’s brief intervention, can change unhealthy habits.

What is the evidence for people with clinical alcohol dependence being able to return to drinking moderately? The above quotes cites 20%, which to me seems to say that a vast majority of people with alcohol dependence can't return to drinking moderately, not that they can.

 

[WisNeuro]

Is there evidence that attending AA meetings harms people or reduces efficacy of more standardized treatments?

Nope, similar lack of evidence for or against. But there is no evidence that crystal therapy harms patients either, and I wouldn't recommend that as an addition to CBT. I wouldn't actively discourage it to patients if they are doing it and like it, but I will never personally advocate it.

 

[WisNeuro]

Speaking to the harm issue, though. In those who do not do well in AA, I can imagine being told that AA didn't work for you because you are flawed, could be a very invalidating thing and lead to a distrust of other interventions.

 

[cara susanna]

AA seems to be helpful as a social support. I'm not sure how helpful it is as a treatment. I agree that AA has eclipsed other treatment approaches, which I think is a shame. I also think that AA's philosophy doesn't really leave room for controlled drinking or risk reduction approaches, which may be more realistic and sometimes appropriate goals (depending on the client).

Edit: Reading that article. Holy abstinence violation effect, Batman.

 

[deleted343839]

Additionally, my patients are increasingly agnostic/atheist/non-spiritual, and have problems with such language as "Remember that we deal with alcohol - cunning, baffling, powerful! Without help it is too much for us.But there is One who has all power—that One is God. May you find Him now."

Yeah, people have to do some mental gymnastics to find their Higher Power if they're not spiritual in the conventional sense.

I don't present AA as a treatment at all. It's usually patients who bring up AA in the first place, often because they are wondering whether there is some alternative. Which is a great way to kick off discussion about the necessity, risks, and benefits of participating in a peer-led social support group. I neither encourage AA nor discourage it, though if there is some value conflict (eg, the spiritual component or the total abstinence philosophy) I think it's useful subject matter for therapy.

 

[Peacemaker36]

Yeah, people have to do some mental gymnastics to find their Higher Power if they're not spiritual in the conventional sense.

I don't present AA as a treatment at all. It's usually patients who bring up AA in the first place, often because they are wondering whether there is some alternative. Which is a great way to kick off discussion about the necessity, risks, and benefits of participating in a peer-led social support group. I neither encourage AA nor discourage it, though if there is some value conflict (eg, the spiritual component or the total abstinence philosophy) I think it's useful subject matter for therapy.

I highly recommend "The Sober Truth" by Lance Dodes for an explication of the pros and cons of AA and the rehab industry.

The data is pretty clear that the vast majority of people sent to AA either get no benefit, or actually have worse outcomes. About 5% of people who achieve and maintain abstinence cite AA as the reason.

I think the biggest problem with AA is that mainstream society assumes as medical fact much of AA's doctrine, nearly all of which has no basis in objective reality. On the flip side, AA's spirituality can become a prosocial, humanistic organizing philosophy for people who adopt it.

 

[WisNeuro]

I actually find it interesting that people have no problem shaming things like EMDR here, but will stand up and fight for AA. I highlight the downfalls of each, but EMDR actually has much better data to support it than does AA. If we're going to consider ourselves people who evaluate the clinical science of our interventions, I would hope that we're relatively consistent in that belief, but it would not seem so.

 

[Peacemaker36]

I actually find it interesting that people have no problem shaming things like EMDR here, but will stand up and fight for AA. I highlight the downfalls of each, but EMDR actually has much better data to support it than does AA. If we're going to consider ourselves people who evaluate the clinical science of our interventions, I would hope that we're relatively consistent in that belief, but it would not seem so.

This is a good point. I think our inclination to tacitly approve of AA is a consequence of the subtle influence AA has over our society. Hollywood has played a huge role in "convincing" society that AA is the only path. Wasn't Denzel terrific in "Flight"? Speaking against AA can feel like heresy.

 

[deleted343839]

I actually find it interesting that people have no problem shaming things like EMDR here, but will stand up and fight for AA. I highlight the downfalls of each, but EMDR actually has much better data to support it than does AA.

It's hard to really compare the two in this way. EMDR is a structured treatment that can be tested and dismantled empirically, whereas I would not even elevate AA to "treatment" status. You could try and manualize a 12-step group program for a clinical trial, and maybe that's a good idea, but you still wouldn't be able to generalize to AA. If I'm treating someone who tells me that AA is really helping them to meet and maintain their sobriety goals, I'm not going to discourage them, nor will that convince me that something unique or specific about AA is responsible for it. The same is true with any peer support group, for that matter. Some people find cancer support groups uplifting, and others find them depressing. I am very deliberate in how I frame peer support with patients. The belief that one has to do these things to be "good" at recovery, etc. is a clear problem.

 

[WisNeuro]

It's hard to really compare the two in this way. EMDR is a structured treatment that can be tested and dismantled empirically, whereas I would not even elevate AA to "treatment" status. You could try and manualize a 12-step group program for a clinical trial, and maybe that's a good idea, but you still wouldn't be able to generalize to AA. If I'm treating someone who tells me that AA is really helping them to meet and maintain their sobriety goals, I'm not going to discourage them, nor will that convince me that something unique or specific about AA is responsible for it. The same is true with any peer support group, for that matter. Some people find cancer support groups uplifting, and others find them depressing. I am very deliberate in how I frame peer support with patients. The belief that one has to do these things to be "good" at recovery, etc. is a clear problem.

Exactly, but yet, AA as it is portrayed is thought of as a treatment. And, it is thought to contribute something unique and specific regarding recovery. I wouldn't compare them in an apples to apples way either from a technical standpoint, but from a public (and professional standpoint, it seems) people do compare it to other treatments for substance abuse. Even legally, where it can be a mandated condition of parole. My main problem is that AA is usually emphasized, when there are many more effective and efficient options. It's not simply that AA exists and people use it, it's that AA has become a de facto "treatment" to the exclusion of other methods.

 

[Ollie123]

Few points. We really don't know if it helps or not. We don't know if it hurts or not. We can conceptualize it as treatment or support or anything else, but that is really secondary to the question of whether or not it helps with recovery. I liken this to Medications vs. Supplements...just because something is a vitamin or supplement doesn't excuse the need for good evidence before I'd recommend it. Personally, I do think the support can be helpful for most people. I also think there is some risk. Building a peer group of individuals who are not active substance users can be important and helpful. However, relapse rates are high. Is an AA group the best avenue to build that network, recognizing they may be building a network of individuals of whom many are likely to relapse at some point? I'm not saying yes or no, but that is exactly the sort of question that we need an answer to and don't have. It could be helpful or harmful. The answer is likely a little of both, but maybe more of one than the other.

Almost all of that seems besides the point though. Even if we take it for granted that AA is effective, that doesn't invalidate some of the other points raised. It is very much a culture endemic to treatment facilities, dependent individuals and the general population. I think THAT is the real focus of the article (even if they don't do a great job making that clear) and the bigger issue at hand. We have all sorts of unproven treatments around that are used regularly because it seems unlikely to harm and likely to help...until we show that it does harm. I agree its a problem, but I'm past the point where I can get worked up over it because I'd never get anything else done. The bigger issue is that its become a cultural phenomenon that extends far beyond what you see in treatment for virtually any other presenting problem. Some of its views are problematic. We actually recently had a discussion on the problems with an abstinence-only framework and this article highlights some of those concerns. At an individual level, I may still recommend it. When it becomes part of the culture the way AA has, it may deter individuals from pursuing treatment because they don't think abstinence is realistic or appropriate. That worries me from a public health standpoint. Significantly. Even if it helps boost abstinence rates by 10%, if it reduces reach by the same amount, I'm not sure that tradeoff is worthwhile. There are other similar problems with the culture that also create challenges that I won't bother getting into.

We deal with these sorts of issues all the time in the substance use field and our messaging has hurt us in the past. Demonization of nicotine is an ENORMOUS problem and has had horrible consequences for public health (attended a conference plenary on that very topic this morning). The war on drugs has relied on tremendously flawed evidence about the neurobiological effects of drugs of abuse, which are remarkably less robust than public health messaging would have you believe. The popularity and strength of belief in the messages AA conveys are far bigger concerns to me than whatever intervention effects might actually be present.

 

[futureapppsy2]

Demonization of nicotine is an ENORMOUS problem and has had horrible consequences for public health (attended a conference plenary on that very topic this morning).

I'd be curious to hear more about this.

 

[smalltownpsych]

Wow! I am really shocked at some of the strong negative reactions to AA that I am hearing. How do you guys feel about recovery groups that are part of churches? Do we really need to prove that social support is helpful? Most of the people that I have known who are active in a 12 step recovery group seem to do a whole lot better than my patients who aren't. I just had a patient who stated that he stayed sober for a year after a treatment program but that he struggled with socializing with people and became more and more isolated and alone. He relapsed and attributed that directly to his lack of ability to find a supportive sober network. He has 30 days clean now and wants to do things differently. Should I not tell him to try 12 step meetings? Is there really a better option?

 

[WisNeuro]

Is there really a better option?

According to the data, yes. Yes there is.

 

[deleted343839]

Demonization of nicotine is an ENORMOUS problem and has had horrible consequences for public health (attended a conference plenary on that very topic this morning).

I'm also curious to hear more about this. When I think about nicotine and public health, I think about tobacco control, which has been an unequivocal victory for public health. Are you referring to nicotine itself (ie, in the "pure" form)?

 

[463951]

AA is definitely not for everybody. But it works for so many individuals. I have seen many patients, friends, and relatives struggle with substance abuse, and a majority of them cite AA (or NA) as an integral part of their recovery. Sure, cross addiction can happen. For many of these people, cross addiction is an inevitable part of their lives.

The author of this article talks about drinking in moderation. It depends. For a person who notices that they are drinking a little bit too much lately because of increased stress in their life, sure, try drinking in moderation.

Patients have told me that they initially had trouble with AA's belief that they find a "higher power," because they are not religious. A lot of them eventually brought this up in meetings, and were encouraged by other members to think of their "higher power" as whatever worked for them, it did not have to be a religious entity. It could be whatever (e.g., their cat, the meetings themselves, a relative).

Also, AA does not have to be a life long commitment for an addict. For some people, they absolutely need these meetings every week to stay sober, even after years of sobriety, and they will attend these meetings indefinitely. For others, AA provided them with a solid foundation when they were first trying to get sober.

Recovering addicts cite the social support as a huge component in these meetings. The fact that addicts can go to these meetings and talk with other addicts who can relate to them on a level that others can't (even trained professionals) is something that is difficult to quantify I think.

Again, AA is not for everybody, and I certainly would never tell a patient to go back if it wasn't working for them. And obviously AA is not perfect. There will be overzealous members telling newcomers that they will fail unless they believe in God and that they must go to a meeting every day for the rest of their lives in order to be successful. But overall, I think AA is a good thing. Also, I don't automatically advocate going to AA as the first thing a patient should do when trying to get sober, it depends on the patient. But I would never discourage a patient attempting to get sober from attending AA meetings.

 

[Ollie123]

RE: Nicotine, its actually quite straightforward and pretty much what MamaPhD hinted at. Nicotine alone is quite innocuous. Yet because of how it has been portrayed, an enormous number of people think its the dangerous part of smoking (per the talk this morning, as many as 80% of smokers depending on how you word the question). The result is fear of (and resistance to using) NRT, implications for how we can even go about reducing the nicotine in cigarettes now that FDA has the authority (will smokers think they are now safe? Some will...), and disproportionate fears about e-cigarettes as a treatment/harm-reduction method. So basically, we overplayed our hand trying to scare people out of smoking and may end up having done more harm than good in the long-run - that obviously has yet to be determined.

RE: AA, let me be clear. I rarely discourage someone from attending and can and do encourage some patients to attend. I just think its important to recognize exactly where that falls on the art/science spectrum and the risks inherent to doing so. Smalltown, I'm sorry but absolutely yes we need studies demonstrating that. We can perhaps make the leap that social support is beneficial, but social support in the context of large groups of addicts meeting to discuss addiction and form social connections with individuals at significant risk for relapse....yeah. It might be fine. It might not. Reasons like what I posted above (which is one of many concerns I have) are what concern me...we just flat out have no idea what downstream implications it will have and it can create a big mess to clean up.

I'm seeing anecdotal evidence from a number of posters "So-and-so said it helped, addicts cite social support as a huge component, harm reduction is 'crap' for real addicts." Baloney. Back it up with good science or you are no better than the moonbeam therapists out there. That is the junk we chew people out for saying when it comes to treating many other disorders, but as a field we tremendously lower the bar when it comes to treating addiction (which I think is the real point of the article). I think that is a shame. I'm not saying don't refer to AA (like I said above - I can and do). I am saying to do so recognizing that there are risks. Recognize that there is the potential for harm to the individual and potentially detrimental effects for the population at large. Part of being a good provider is recognizing those risks and making determinations when referring for care.

 

[futureapppsy2]

disproportionate fears about e-cigarettes as a treatment/harm-reduction method. So basically, we overplayed our hand trying to scare people out of smoking and may end up having done more harm than good in the long-run - that obviously has yet to be determined.

Isn't it fairly well-documented that vaping/e-cigarettes contain a fairly substantial level of the same--or equally as dangerous--carcinogens as cigarettes, though?

I've worked with subclinical substance misuse (mandated clients who minor legal violations related to substance use) before, and I really loved the combination of risk reduction and motivational interviewing for that population. It worked well, addressed what probably 90-95% of our client base needed, and as a bonus, was great initial clinical training.

I think one issue that AA and other 12 step programs can have is that many people who swear by them really do credit them with being life-saving and elevate them to an almost cultish status in their minds and conversations. I've seen the same thing happened with EMDR, including my favorite line of "don't get psychotherapy for PTSD; get EMDR! Only EMDR will work! It's all about eye movements!" In general, laypeople aren't going to dismantle treatments or look at their effectiveness beyond personal experience and the reinforcement of finding relief from considerable psychological and physical distress is incredibly reinforcing.

 

[smalltownpsych]

According to the data, yes. Yes there is.

So what is this better option for social support that the data points to? I hope it exists in this rural community with an extremely high alcohol abuse rate. Because about the only non-drinkers I know around here are either in AA or LDS.

I think one issue that AA and other 12 step programs can have is that many people who swear by them really do credit them with being life-saving and elevate them to an almost cultish status in their minds and conversations.

After decades of living with the hell that addiction is, I can see why they take it so seriously. I really wish that we as psychologists would be more open to their experiences and perspectives.

I don't really have the time or inclination to challenge all of the mistaken views and premises that I see occurring in this thread or to delve into all the research to challenge it. I just want to say that one of the most important aspects of being a psychologist is to have an awareness of your biases. I am acutely aware of my own bias in favor of AA and where that comes from and some of the ways it shapes my views. Trust me, I have thought a lot about it as I have gone through my own training and professional development. Seeing an opposite bias from my colleagues and how far from the truth this often led them mystified me as I was going through this process which is why I chose (actually my mentor suggested it) to conceptualize AA using a cultural framework. I guess if you deny that the million or so Americans who are in these groups are part of a culture, then that absolves you from the ethical obligation to view these individuals within their own cultural context as opposed to your own. Just asking you all to think about this alternative perspective.

 

[smalltownpsych]

I also wanted to add that our community has no substance abuse treatment program other than a few licensed addiction counselors. I met with the state a couple of weeks ago and they stated that the only inpatient option is for people who cannot stay sober for a day or have a comorbid disorder. My patients will see the addictiom counselors and they usually encourage them to go to AA or NA. as well. It seems awfully hard to criticize the nonprofessionals when they have two to three 12 step meetings a day going on and the professionals offer almost nothing. Every week we have people admitted to our hospital in liver failure, DTs, pancreatitis, SI with intoxication. Sometimes the nurses will call the AA folk to visit these poor souls of the patient wants. These patients always seem pretty grateful that someone cares about them at that point in their life or end of their life.

 

[futureapppsy2]

After decades of living with the hell that addiction is, I can see why they take it so seriously. I really wish that we as psychologists would be more open to their experiences and perspectives.

I think I worded that poorly--my bad! I think AA can be a legitimately incredibly helpful--and yes, even life-saving--tool for many people with addiction issues. I'd never deny that or deny their own experiences. What I start to get wary about is people who claim that AA is the only way to successfully treat addiction or substance abuse, when the literature doesn't show that. I'm 100% in favor of it being offered as an option, just not in favor of it being protrayed as the only or necessarily best evidence-based option.

Sorry if my post read otherwise!

 

[Ollie123]

Isn't it fairly well-documented that vaping/e-cigarettes contain a fairly substantial level of the same--or equally as dangerous--carcinogens as cigarettes, though?

This one is easy...no. Not sure where you heard that, but I'm currently at the annual meeting of the Society for Research on Nicotine and Tobacco and no. They certainly aren't perfectly healthy and even nicotine alone does carry SOME risk (primarily to subpopulations - pregnant women, folks with heart disease, etc.), but there is little reason to believe they will be anywhere near as dangerous as cigarettes. As always though...it will take some time to sort out exactly what that looks like (toxicology studies in particular can take years/decades...).

I guess if you deny that the million or so Americans who are in these groups are part of a culture, then that absolves you from the ethical obligation to view these individuals within their own cultural context as opposed to your own.

Well, I'm very interested and hope you will have time/be open to discussion on it in the future, since I think it is important. Feel free to PM if its something you'd prefer not to have on the main board. I feel like you still have some major blindspots in this area (I'm sure I do too), so I hope the discussion would be informative for both of us. I don't know that anyone is saying they aren't a culture...most of us are saying they are. And that like any culture...parts of that culture can be problematic and thus we need to think carefully about what implications that holds for them and society at large. That is particularly true if "referring" people to a cultural group with the idea that it will help them with mental health concerns...which happens frequently, for better or worse. Access to care in rural areas is a serious problem, but I'm not sure how that is relevant to the point most of us seem to be making. AA can perhaps help fill that gap. That seems a separate issue from its impact. My approach is not one of "AA is evil" but what I consider an appropriate amount of skepticism regarding what we do and do not know about AA.

 

[WisNeuro]

So what is this better option for social support that the data points to? I hope it exists in this rural community with an extremely high alcohol abuse rate. Because about the only non-drinkers I know around here are either in AA or LDS.

If it's the only option, sure. It may be better than nothing, but for some people, I'm not too sure. If this were my area, I'd rather advocate for other methods that have empirical support. Luckily, there are a few mouse clicks of a referral away for me. Use it if you want, just don't blow smoke up people's ass about it's benefits when they have never been proven, and are far too often refuted.

 

[Pragma]

Wow this is an interesting thread. Some posters here clearly are very rigid in their conceptualization of AA and what it actually is vs. their idea of it. It is large enough that there are assumptions made about it that aren't true. I'm actually baffled by how poorly a lot of psychologists understand AUD/SUD and the subculture. You can't say "yeah it isn't a treatment, but some people think it is so I'll treat it like a treatment anyways" in my opinion.

It's a support group. Some people find it helpful and some don't. It does not have great fidelity of implementation. A good example of this is the medication issue. AA itself has published a position that your medications are between you and your prescriber. They view that form of treatment as important for some and want to stay out of that discussion to just be a support group. However, there are rogue AA members that say otherwise and that can be to the detriment of some people, most definitely (anecdotally).

There are tons of correlational studies that find participation in AA to be associated with good outcomes. No rigorous studies sure, but we're not comparing this to CBT/MI here (which have mixed results by the way even though I'm a huge proponent).

What you see on TV is not AA (e.g., Johnson model interventions). If you've never tried a meeting you should go, if anything to inform a discussion about it with a patient. I tell mine that it is not a treatment, it's a support group, meetings vary a lot depending on the people there, and some people find it helpful and some don't. There aren't tightly controlled studies about it out there but it is a unique resource.

I dump on EMDR because it is a treatment people profit from and it is presented as a treatment. AA is completely different, not a treatment, not a money maker, etc. Just because some segments of the public misunderstand what it is does not mean you throw the baby out with the bathwater. Moreover, there are alternative support groups out there too, lots of them. If I had a cancer patient I wouldn't hesitate to refer them to a support group if they were interested in one. I also would tell them the support group isn't going to cure their cancer.

Vaillant has an interesting article discussing the cult concept: http://www.ncbi.nlm.nih.gov/m/pubmed/15943643/

 

[WisNeuro]

At its heart, no one hear is conceptualizing AA as a treatment program. But, in it's implementation, it is definitely being treated as such in many segments of substance abuse intervention world. And, in many segments, it is the only thing offered. Sure, in a perfect world, it would be a support group, and people would be in actual treatment. But, that's not how it plays out in the real world. I'd much rather see interventions receive more focus, which seems unlikely to happen due to laypeople seeing this as some sort of panacea.

Also, the libertarian/atheist/scientist in me has a huge problem with court mandating this support group as part of a legal proceeding due to its limited empirical base and focus on higher powers.

 

[erg923]

At its heart, no one hear is conceptualizing AA as a treatment program. But, in it's implementation, it is definitely being treated as such in many segments of substance abuse intervention world. And, in many segments, it is the only thing offered. Sure, in a perfect world, it would be a support group, and people would be in actual treatment. But, that's not how it plays out in the real world. I'd much rather see interventions receive more focus, which seems unlikely to happen due to laypeople seeing this as some sort of panacea.

Also, the libertarian/atheist/scientist in me has a huge problem with court mandating this support group as part of a legal proceeding due to its limited empirical base and focus on higher powers.

Yes, and the Catholic Christian AND the scientist in me agrees that religiosity and/or investment in higher power that facilitates accountability, humility, and a sense of comfort and forgiveness is a good thing for ones overall mental health.

Anyway, wow! This thread has turned into a great discussion and more than i anticipated. I agree AA is not a treatment unto itself. I agree some members distort what it is. I agree about the redonkulousness of court mandated treatment of any form, really. I don't agree with the disease model of addiction either (just as most psychologists I know don't), which is teleological at best. The symptoms and the disease can not be the same thing. I have a disease? Yea, what is the disease? I drink too much. What are the symptoms? I drink to much.

But I agree with Pragma. I refer patients to support groups relevant to their situation all the time. Not sure why this is considered any different? If a person chooses to do only AA, I would certainly inform them of the risk of this, and what I feel they would be missing out on by not engaging in empirically based treatments with professional staff. But if they say, no, that is there choice. And I would encourage social support and a development of a sober support network over, "No, that **** isn't studied very well. Just go home and sit on the couch if you aren't gonna see me."

 

[WisNeuro]

Yes, and the Catholic Christian AND the scientist in me agrees that religiosity and/or investment in higher power that facilitates accountability, humility, and a sense of comfort and forgiveness is a good thing for ones overall mental health.

Not much in those who considers themselves atheist/agnostic/non-religious people. Anyway, the life satisfaction/happiness in religiosity is almost all accounted for by social networks and social capital. Plenty of ways to foster positive social support networks outside of AA. If people are in it, and like it, more power to them. I have many options of places to send them that don't make me feel like I'm being disingenuous to my training, so I will continue to do so.

 

[erg923]

I have many options of places to send them.

But this is a luxury, no?

What would you do if you practiced in a rural area where I would guarantee there in AA, but no residential programs or EBT for SUDs for a hundred miles?

 

[CheetahGirl]

I have many options of places to send them that don't make me feel like I'm being disingenuous to my training, so I will continue to do so.

It is not a psychological intervention, certainly not evidence-based, nor claims to be so. We can theoretically discuss social learning theory to understand why it works. And it doesn't for some. But does for others.

It does not need to be either, or. And I'd hate to think you were discouraging your patients to attend if they spoke favorably about it (you know the look, like you smelled something stinky).

It can be both: Your intervention and the support that Alcoholics Anonymous, NA, ALON, etc. offer people, and people allow themselves to honor themselves within the paradigm of the given program ("This too shall pass. One day at time." All those mantras).

What's that saying: People making others seem ugly, end up looking ugly themselves... or some sort of colloquial saying I've heard along the way.

Happy Saturday.

Edit: I have not read all the past posts but probably will now.

 

[WisNeuro]

But this is a luxury, no?

What would you do if you practiced in a rural area where I would guarantee there in AA, but no residential programs or EBT for SUDs for a hundred miles?

Inform them of their options, and which I thought were best. Depends on the area and what is available. We can bring the rural option out all day long, but we all know that rural areas lack a great deal of treatment options. If all that were available in a rural area for PTSD treatment was someone who did a combination of crystal therapy and rhythmic tapping, would you send your patients there? No, you'd find out where the closest legitimate treatment is and inform that patient of that. I would do the same thing in this instance. If said hypothetical patient wanted to go to AA, that is there choice. If they asked me what I thought of it and it's efficacy, I would tell them what I know and the research behind it.

 

[WisNeuro]

It is not a psychological intervention, certainly not evidence-based, nor claims to be so. We can theoretically discuss social learning theory to understand why it works. And it doesn't for some. But does for others. It does not need to be either, or. And I'd hate to think you were discouraging your patients to attend if they spoke favorably about it (you know the look, like you smelled something stinky).

It can be both: Your intervention and the support that Alcoholics Anonymous, NA, ALON, etc. offer people, and people allow themselves to honor themselves within the paradigm of the given program ("This too shall pass. One day at time." All those mantras).

What's that saything: People making others seem ugly, end up looking ugly themselves or some sort of colloquial saying I've heard along the way.

Happy Saturday.

If they are in it, and happy, I let it be. If I'm referring out, I never mention it and instead send them to the appropriate referral sources at my disposal. As I said, I don't actively discourage it, but I will never endorse or mention it when I'm making my recommendations.

 

[smalltownpsych]

Yes, and the Catholic Christian AND the scientist in me agrees that religiosity and/or investment in higher power that facilitates accountability, humility, and a sense of comfort and forgiveness is a good thing for ones overall mental health.

Anyway, wow! This thread has turned into a great discussion and more than i anticipated. I agree AA is not a treatment unto itself. I agree some members distort what it is. I agree about the redonkulousness of court mandated treatment of any form, really. I don't agree with the disease model of addiction either (just as most psychologists I know don't), which is teleological at best. The symptoms and the disease can not be the same thing. I have a disease? Yea, what is the disease? I drink too much. What are the symptoms? I drink to much.

But I agree with Pragma. I refer patients to support groups relevant to their situation all the time. Not sure why this is considered any different? If a person chooses to do only AA, I would certainly inform them of the risk of this, and what I feel they would be missing out on by not engaging in empirically based treatments with professional staff. But if they say, no, that is there choice. And I would encourage social support and a development of a sober support network over, "No, that **** isn't studied very well. Just go home and sit on the couch if you aren't gonna see me."

The Catholic part brings up another issue with AA that I saw some very limited evidence on that could be worth exploring. It seems that some cultural or religious groups appear to mesh better to AA than others. One of my close friends used to say, "if it weren't for the Irish Catholics in AA, you could hold your meetings in a phone booth." There is also some evidence that individual personality characteristics affect how helpful patients find support groups. As a psychologist, I see my job as to help patients navigate what path is going to maximize their chances for success as they define it and help them sort through what others tell them they need to do. As part of that, I do often find myself telling patients that there are many ways of maintaining a healthy lifestyle without drugs and alcohol despite what the treatment center told them which is often "if you don't do this or that (go to meetings being a favorite, others being avoiding triggers or former friends), then you will relapse". So while I know that 12 step groups are beneficial for many people, I also recognize the frustrations many have with the dogmatic approaches that often surround it.

 

[CheetahGirl]

If they are in it, and happy, I let it be. If I'm referring out, I never mention it and instead send them to the appropriate referral sources at my disposal. As I said, I don't actively discourage it, but I will never endorse or mention it when I'm making my recommendations.

Hmmm. I don't know how I feel about that. That's fine that you let it be, then.

I ran groups that ran parallel and there was a sense of community towards sobriety that was protective. That is not unusual of the AA, self-support group models.