PhD/PsyD Article on AA

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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.

How do you know this is so? And, how do you know that this wasn't maladaptive to some? Especially if they were a drop out? Why are we willing to operate almost purely on anecdote here, but disparage it in other areas?
 
How do you know this is so? And, how do you know that this wasn't maladaptive to some? Especially if they were a drop out? Why are we willing to operate almost purely on anecdote here, but disparage it in other areas?

This was not operational and not in a vacuum. Sobriety is challenging for some...and AA, NA, ALANON, etc. does help. Sorry to say. Being a friend of Bill, is a good thing.

What was maladaptive? Sobriety? Attendance to a group? Forging a sense of community with like others? Regular attendance and accountability to the self and other? ...Please specify your thought here.

WisNeuro, Have you worked in addictions? Drop out, 'Falling off the wagon,' is part of recovery and expected...NOT FOR ALL, but some.

And we're not willing to operate on an anecdote. We are willing to let someone find their spiritual, self-help support group and not judge them for it. If you are judging on the basis of science, let's write a paper on the social theory behind it...and you can critique it. :poke:
 
What was maladaptive? Sobriety? Attendance to a group? Forging a sense of community with like others? Regular attendance and accountability to the self and other? ...Please specify your thought here.
I didn't say it was maladaptive, I said, how do you know it isn't to some? And, beyond anecdotes, how do you know that it's actually helping? We can throw nice words out here and there, but without anything of substance behind it, it's fairly empty. When it comes to AA, it is anecdote for the most part. The dearth of data that exists, is not exactly what I would call a glowing review, either. I am not an addictions person, although it is a presentation of a not insignificant portion of my patients, especially in the VA, where I have no problem recommending empirically supported interventions.
 
I agree there is a lack of hard data. However, I will continue to encourage (not disparage) it as a spiritually-based support group that, again, does not claim to be an empirically supported intervention. I also would not substitute an addictions-focused group in place of a self-help support group alone - the psychoeducation delivered by a professional is important, as well as the clinical check-ins. And I also work in the VA, which supports AA meeting - although it may not run the meetings, but may house them instead.

But, hell, if a patient said their Sickle Cell Support Group or Testicular Cancer Support Group worked for them I would not disparage those efforts, especially if the patient's 'operational data' were improving or stable.

I didn't say it was maladaptive, I said, how do you know it isn't to some? And, beyond anecdotes, how do you know that it's actually helping? We can throw nice words out here and there, but without anything of substance behind it, it's fairly empty. When it comes to AA, it is anecdote for the most part. The dearth of data that exists, is not exactly what I would call a glowing review, either. I am not an addictions person, although it is a presentation of a not insignificant portion of my patients, especially in the VA, where I have no problem recommending empirically supported interventions.

OK. Fair enough.
 
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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!
Just a note - AA does not think AA is the only way. They support outside treatments.
 
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.
Agreed on the court issue.

Your first argument is weak. Now you need to get beyond anecdotes because that's all you are citing. There is also a literature on people who recover with no treatment. Treatment isn't always necessary and the population is heterogenous with other comirbidities.

The entire addiction treatment landscape is undergoing huge changes with the ACA. Lots of emphasis on EBTs and pharmacological interventions.
 
Your first argument is weak. Now you need to get beyond anecdotes because that's all you are citing. There is also a literature on people who recover with no treatment. Treatment isn't always necessary and the population is heterogenous with other comirbidities.


I will wholeheartedly admit that it is part anecdote. But, the fact that it is court mandated in many areas actually is a pretty strong piece of evidence that it's thought of as a treatment by many, and that is not an anecdote. There are numbers on this. And, I am ecstatic that the treatment landscape is undergoing changes with emphasis on EBTs and pharma interventions.
 
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...).

Interesting; thanks. I've read a few lay articles that cite research studies that say they have substantial carcinogens, but admittedly haven't read the primary literature.

I think the discussion of AA as treatment or not is interesting--although we might not consider it as treatment (v. a support group model), I think a lot of people do, hence the court-mandated AA meetings, etc. I also think a lot of addiction counselors tend to be involved in 12 step groups and to consider it to be a very important piece of their own recovery, which leads to it being heavily emphasized as an important treatment component in a lot of treatment settings.
 
Interesting; thanks. I've read a few lay articles that cite research studies that say they have substantial carcinogens, but admittedly haven't read the primary literature.

I think the discussion of AA as treatment or not is interesting--although we might not consider it as treatment (v. a support group model), I think a lot of people do, hence the court-mandated AA meetings, etc. I also think a lot of addiction counselors tend to be involved in 12 step groups and to consider it to be a very important piece of their own recovery, which leads to it being heavily emphasized as an important treatment component in a lot of treatment settings.
The professional counselors who promote AA do tend to be a problem. I have had the opportunity to work with them and help them temper their enthusiasm and biases, and practice more tolerance of other paths. Since I am very familiar with the AA program, it has been relatively easy to redirect them using culturally congruent language and principles. Psychologists and people in recovery tend to live in two different worlds and our job is to bridge that gap to be most helpful. Surprisingly, many of the principles from CBT and from MI can easily be translated into AA terms. We aren't really as far apart as it seems at first glance.
 
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People need to stop assuming and start talking to professionals in this arena. Addictions was very separate from other mental health for a long time and many folks were trained in an apprenticeship model. Things don't change overnight- it has been changing gradually for awhile. Are some counselors stuck in their ways and reluctant to embrace ebts? Sure. You can say the same about psychologists in general. Addictions counselors historically have not been as well trained but that is also changing.

12 step has plenty of correlational support. Its a group of unprofessionals that are not supposed to play doctor but occasionally some do. That's a problem that is more than mitigated by the positives. Go to a few open meetings. If one is full of jerks it will seem useless. If one has a lot of thoughtful people, you might be amazed. Tonigan had a study out awhile back showing how social support from peers is of better quality than from people in general. There is something to the model that works for people - check out some Rudy Moos articles to operationalize this. Or John Kelly's work at Harvard.

This thread is a bunch of opinions. Read the stuff out there about this. You might be surprised. As far as AA goes it is just one nontreatment tool. Works for some. Just like MI and CBT RP only work for some as treatment - in fact the evidence for these approaches is not as great as people assume. Same with integrated tx for dual diagnosis. There is no one size fits all. The research is not to the point that we can optimally match people to a treatment that works best for them, but we do the best with what we have. And even treatment varies like crazy in terms of fidelity of implementation, so my referrals vary a lot depending on the client.

Finally don't forget that this is an insanely heterogeneous population. Most psychologists I know apply a very simple heuristic and make a lot of assumptions about this group, and their lack of understanding probably has its own iatrogenic effects.
 
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One other interesting compilation of resources from Project Match. They did 12 step facilitation, not 12 step.

http://pubs.niaaa.nih.gov/publications/ProjectMatch/matchIntro.htm

I'd encourage people to check out the Division 50 stuff that is out there in PAB. Lots of great studies on various treatment modalities, support services like AA, etc. Don't just assume until you have a sense for the data.

AA is an unregulated group of lay people that follow a set of guidelines but allow for organic group discussions to emerge. The value of professional involvement is lacking in AA, but if you read the literature broadly enough, the lack of professional involvement can be a good thing sometimes. Addiction is a more complicated and diverse issue relative to many other disorders. We are a long way from nailing down the best treatments for certain clients, but in most cases what works best is a combination of services that are tailored to the variety of problems that most clients with AUD have. To suggest one thing is best is irresponsible - that goes for those individuals suggesting AA is the only way as well those psychologists that are fixated on specific interventions that may not be a good fit for everyone without being realistic.
 
Holy abstinence violation effect, Batman.
I'm totally procrastinating and this had made me chuckle yesterday.

The AVE is one part of RP that I find the be a little weaker. I think it applies to a subset of people who use but not everyone. Some don't have this issue at all.

Before Marlatt died I enjoyed watching an interview of his where he said abstinence really should be the goal of RP, but that it is applicable to just reducing use as well. That is part of why I like it.

There was a good review about RP a few years ago. See below. I think it does a nice job and explains revisions to the model and the pivot to mindfulness.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3163190/pdf/1747-597X-6-17.pdf

The review notes some of the limitations in the data out there, and even notes how TSF was better for some clients than CBT/RP in Project Match. We need to get more comparative studies of these interventions, because often the natural question for the front lines folks is does this work better than what I'm doing now? We can't always answer that definitively. Disseminating findings and then getting them implemented appropriately is another challenge. I havent check the NIDA CTN lately but will have to see what's new.

I think my view could be summarized as that the population is heterogeneous, and we need different treatment approaches for different people (and different comorbidities). Results have suggested efficacy of some interventions relative to no treatment, but there are also people who recover without treatment and we know little about them. AA has a place for some people, and not for others. Other alternatives (Smart, SoS, etc) are also available but less widely. We're going to have to look at mechanisms within interventions that work to really tease apart comparative treatment studies. I discuss all of this stuff when I am recommending treatment to a client-I'd prefer not to cherrypick.

When I see people gang up on AA I question their objectivity. You can't ignore the data out there that do suggest it is associated with good outcomes - even if they are correlational findings they are all over the place.

Back to work...
 
The review notes some of the limitations in the data out there, and even notes how TSF was better for some clients than CBT/RP in Project Match. We need to get more comparative studies of these interventions, because often the natural question for the front lines folks is does this work better than what I'm doing now? We can't always answer that definitively. Disseminating findings and then getting them implemented appropriately is another challenge. I havent check the NIDA CTN lately but will have to see what's new.

I think my view could be summarized as that the population is heterogeneous, and we need different treatment approaches for different people (and different comorbidities). Results have suggested efficacy of some interventions relative to no treatment, but there are also people who recover without treatment and we know little about them. AA has a place for some people, and not for others. Other alternatives (Smart, SoS, etc) are also available but less widely. We're going to have to look at mechanisms within interventions that work to really tease apart comparative treatment studies. I discuss all of this stuff when I am recommending treatment to a client-I'd prefer not to cherrypick.

When I see people gang up on AA I question their objectivity. You can't ignore the data out there that do suggest it is associated with good outcomes - even if they are correlational findings they are all over the place.

Now this post I would agree with fully. I certainly hope my posts didn't come across as ganging up on AA. My stance is simply that we need a more nuanced view than "AA is great" and "AA is garbage." The original article definitely had some problems. It also had some incredibly valid points that seem to have been ignored because of emotional reactions to questioning AA (which ironically...is one of their points!). Related to that is the notion that something can be beneficial for an individual and still potentially damaging at the population level (or at least also have significant negative consequences even if they are outweighed by the positive). At the doctoral level, I expect people to be able to take more nuanced views and hold/assimilate competing notions in their head. It seems a core skill that one should develop in graduate school at the very least (if not present at the outset). I too question whether several of the posts on both sides of the argument come from people with substantive familiarity with the addiction literature or significant clinical experience working in addiction. I agree slamming AA is not objective. Touting it as something unequivocally great is equally not objective. I can't fathom how a solid read of the literature or significant clinical experience in the field could lead anyone to either of those conclusions. As with most everything, the reality lies somewhere in the middle.
 
Now this post I would agree with fully. I certainly hope my posts didn't come across as ganging up on AA. My stance is simply that we need a more nuanced view than "AA is great" and "AA is garbage." The original article definitely had some problems. It also had some incredibly valid points that seem to have been ignored because of emotional reactions to questioning AA (which ironically...is one of their points!). Related to that is the notion that something can be beneficial for an individual and still potentially damaging at the population level (or at least also have significant negative consequences even if they are outweighed by the positive). At the doctoral level, I expect people to be able to take more nuanced views and hold/assimilate competing notions in their head. It seems a core skill that one should develop in graduate school at the very least (if not present at the outset). I too question whether several of the posts on both sides of the argument come from people with substantive familiarity with the addiction literature or significant clinical experience working in addiction. I agree slamming AA is not objective. Touting it as something unequivocally great is equally not objective. I can't fathom how a solid read of the literature or significant clinical experience in the field could lead anyone to either of those conclusions. As with most everything, the reality lies somewhere in the middle.
I'm familiar with the recovery literature so I see the bias people are referring to come out often, particularly in AMC settings. But it reflects a lack of understanding.

There are three observations I have and some of it is self-directed.

1) Regardless of the treatment topic, we are limited to what we have read. I learned this the hard way when I did a big review article. I learned so much from the journals I don't normally read that contradicted sometimes what I assumed. In practice we are all busy and read probably the journals we like most of the time. I bet even Wisneuro would admit to that. If I'm going to invoke the literature then I in theory have a comprehensive understanding of it, but it depends on the topic and how much time I put into it. Confirmation bias etc is all relevant here. I don't assume for a second that other psychologists have read everything out there about AA. Hence the bias. But that goes for other conditions too. I haven't read everything about depression but feel like I have a general understanding of where things are at - but then I look more and realize I missed studies. I am sure a strategy I and others use is to find good metaanalyses or review articles to be a quick study.

2) Inherent in #1 are things like publication bias, poor conceptualization of methods, and the inherent lack of external validity in a lot of fed-funded work. We ignore the limits of the studies we read sometimes, and ignore others that may be less rigorous but more externally valid.

3) In addictions I feel like immersing yourself in the culture here and there (e.g. Go to a meeting here and there to see what it is like) helps to inform clinical practice well - you can discuss it better with clients that way. But at the same time I ought to hold that standard to other problems. I've never observed EMDR or gone to a support group for sexual assault victims. Access is part of the issue and AA as unique as it is (as others have mentioned it in this thread) allows it much more relative to other conditions. But I do think psychologists are generally unprepared to deal with addiction, and there is training literature to support that. I've seen people refer to AA without preparing people for what to expect. I've seen people advise against AA but not advise well on alternatives. I've seen people perform MI when they were never properly trained - and if you check out the Miller 2006 article I posted you may realize why this is a problem.

My point? We can't understand everything all the time. We have to acknowledge when we haven't reviewed the literature thoroughly and when we need to either do that or refer out.
 
Just a note - AA does not think AA is the only way. They support outside treatments.
Yes, but a sizable chunk of members of 12 step programs think that AA/12 step programs are a critical and necessary part of any recovery program, and I don't think the literature is there to say that.
 
Yes, but a sizable chunk of members of 12 step programs think that AA/12 step programs are a critical and necessary part of any recovery program, and I don't think the literature is there to say that.
Which program are you referring to? The only AA program I know of explicitly does not do that. They make that clear.

Outside of your anecdotal ideas I can't see a real position that discusses real data.

ETA: When you say things like "a sizeable chunk" it just is an extrapolated anecdote. I'm guilty of the same thing I suppose when I think "a sizeable chunk" of psychologists have a lack of training and some inherent bias regarding addiction. But there actually is data to support the lack of training. I haven't seen you or others present data to support what your opinion is here.
 
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Which program are you referring to? The only AA program I know of explicitly does not do that. They make that clear.

Outside of your anecdotal ideas I can't see a real position that discusses real data.
Pragma, I think you are underselling the stranglehold AA has in this country. I understand that this may not be AA's fault, as they claim to be a program of attraction. But the stranglehold is real.

I've worked with physicians who were sentenced to long-term AA attendance by the physicians health service. I've worked with nurses similarly sentenced to AA. I've heard about airline pilots sentenced to AA. I've worked with people caught up in the court system who are sentenced to AA. And I've worked with many, many patients who have been strong-armed into AA meetings by well-meaning providers. I've also worked with many patients whose well-meaning families have strong-armed their loved into AA meetings which do not work for that patient. The biggest travesty, perhaps, is the rehab industry. The majority of outrageously expensive rehab programs offer primarily TSF. For $25K per month.

I mention AA as a resource to patients. When a patient is struggling and previously found AA helpful, I help the patient to explore whether going back makes sense. But as a psychologist I also feel responsible for commenting on the fact that society has oversold the beneficial effects of the AA program.
 
Pragma, I think you are underselling the stranglehold AA has in this country. I understand that this may not be AA's fault, as they claim to be a program of attraction. But the stranglehold is real.

Interesting language to describe this. It definitely provokes the idea that there is someone behind the curtain trying to manipulate society. Please forgive me for not taking the last sentence in this statement seriously.

I've worked with physicians who were sentenced to long-term AA attendance by the physicians health service. I've worked with nurses similarly sentenced to AA. I've heard about airline pilots sentenced to AA. I've worked with people caught up in the court system who are sentenced to AA. And I've worked with many, many patients who have been strong-armed into AA meetings by well-meaning providers. I've also worked with many patients whose well-meaning families have strong-armed their loved into AA meetings which do not work for that patient.

Again, numbers would be good here. I've already made it clear that I disagree with courts or other regulating bodies mandating AA specifically. That's an interesting political issue on its own - they can and have mandated things like CBT/MI too which also are not necessarily effective for everyone.

The biggest travesty, perhaps, is the rehab industry. The majority of outrageously expensive rehab programs offer primarily TSF. For $25K per month.

I'm assuming that you mean the Minnesota Model probably, because no one in their right mind would charge or pay that much for simply Twelve Step Facilitation, which by the way is not associated with AA formally at all - it's a way that psychologists and other providers can charge patients by trying to facilitate people getting involved in AA or other 12-step organizations.

I get the sense that you are equating things like Celebrity Rehab, etc with AA. The outlandish treatment costs you see out there have nothing to do with AA itself. Some programs work within a 12-step framework but they usually do a lot of other things too, and again, that's not AA (which is free). I also question the efficacy of those programs. However, for every 1 person in your anecdote that might pay that much money for some niche treatment, there are probably over 100 that are funded through block grants that go through a variety of different types of treatment. The whole concept of a 28-day program was just arbitrarily created by insurance companies back in the day too. There was no data to support it they just had to decide how much they were willing to pay for. A lot of what you see these days are just basically brief detoxes and then a transition to some outpatient form of care quickly.

With the ACA there is a greater emphasis on brief interventions and medication, including replacement therapies and better integration with primary care. We're already seeing an evolution here.

I mention AA as a resource to patients. When a patient is struggling and previously found AA helpful, I help the patient to explore whether going back makes sense.

Great! Seems reasonable.

But as a psychologist I also feel responsible for commenting on the fact that society has oversold the beneficial effects of the AA program.
Could you explain this more? It's a vague statement and I'm not sure what you mean. It would be helpful if you could be more specific here.

I'd like to note to anyone reading this thread that I actually do spend a fair amount of my time discussing some of the negative practices that have been conducted by individuals within the AA program that go against the principles of AA itself. But really, if we're being objective here, we could also point to the crappy training and implementation of actual treatment models too like MI - isn't that just as bad? And that is actual treatment, not just a support group like AA that doesn't pretend to be anything other than that. Psychologists are out there charging tons of money and profiting from this, and they may have never even been supervised or given feedback about how they are delivering MI. Why do we not have a problem with that but can head straight to burning AA at the stake (to borrow from the concept of colorful language being presented in this thread)?
 
Interesting language to describe this. It definitely provokes the idea that there is someone behind the curtain trying to manipulate society. Please forgive me for not taking the last sentence in this statement seriously.

No, I definitely don't think AA is responsible for the influence it commands on society. I'm just commenting on the fact that for many Americans AA is synonymous with treatment for substance abuse. AA is embedded in our culture. Maybe that's a better word.


Again, numbers would be good here. I've already made it clear that I disagree with courts or other regulating bodies mandating AA specifically. That's an interesting political issue on its own - they can and have mandated things like CBT/MI too which also are not necessarily effective for everyone.




I'm assuming that you mean the Minnesota Model probably, because no one in their right mind would charge or pay that much for simply Twelve Step Facilitation, which by the way is not associated with AA formally at all - it's a way that psychologists and other providers can charge patients by trying to facilitate people getting involved in AA or other 12-step organizations.

I get the sense that you are equating things like Celebrity Rehab, etc with AA. The outlandish treatment costs you see out there have nothing to do with AA itself. Some programs work within a 12-step framework but they usually do a lot of other things too, and again, that's not AA (which is free). I also question the efficacy of those programs. However, for every 1 person in your anecdote that might pay that much money for some niche treatment, there are probably over 100 that are funded through block grants that go through a variety of different types of treatment. The whole concept of a 28-day program was just arbitrarily created by insurance companies back in the day too. There was no data to support it they just had to decide how much they were willing to pay for. A lot of what you see these days are just basically brief detoxes and then a transition to some outpatient form of care quickly.

With the ACA there is a greater emphasis on brief interventions and medication, including replacement therapies and better integration with primary care. We're already seeing an evolution here.



Great! Seems reasonable.


Could you explain this more? It's a vague statement and I'm not sure what you mean. It would be helpful if you could be more specific here.
Sure. I think patients who feel like failures because AA didn't work for them need to be reassured that there is not something fatally wrong with them, certainly not a progressive fatal illness. Epidemiological studies are pretty clear on that.
 
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Pragma, I think you are underselling the stranglehold AA has in this country. I understand that this may not be AA's fault, as they claim to be a program of attraction. But the stranglehold is real.

I've worked with physicians who were sentenced to long-term AA attendance by the physicians health service. I've worked with nurses similarly sentenced to AA. I've heard about airline pilots sentenced to AA. I've worked with people caught up in the court system who are sentenced to AA. And I've worked with many, many patients who have been strong-armed into AA meetings by well-meaning providers. I've also worked with many patients whose well-meaning families have strong-armed their loved into AA meetings which do not work for that patient. The biggest travesty, perhaps, is the rehab industry. The majority of outrageously expensive rehab programs offer primarily TSF. For $25K per month.

I mention AA as a resource to patients. When a patient is struggling and previously found AA helpful, I help the patient to explore whether going back makes sense. But as a psychologist I also feel responsible for commenting on the fact that society has oversold the beneficial effects of the AA program.
Seems like you are choosing very strong negative language. Many in the AA community actually agree that people shouldn't be court ordered or otherwise coerced to attend. Others see it as an opportunity to help the courts and society. The people with addiction problems tend to be pretty resistant to all of it, hence the level of coercion. Should AA attendance be a part of that? Probably not. On the other hand, as a clinician, I have to ask why the patient is being so resistant to AA, not because they need to attend, but it usually points to other things to work on. Anger at religion, significant social anxiety, lack of commitment to change, etc.
 
Sure. I think patients who feel like failures because AA didn't work for them need to be reassured that there is not something fatally wrong with them, certainly not a progressive fatal illness. Epidemiological studies are pretty clear on that.
I'd agree with you here re: reassuring patients. But I still don't get your point. Moreover, you seem to be invoking some literature and suggesting that you've got epidemiological clarity on the issue of addiction. Really, part of why I keep invoking the term "heterogeneous" is because that's what epidemiological studies show. Which is why treatment experts out there are pointing to the need for a range of treatment options and support services available to fit the client - AA is just one small part of that picture.

The black and white thinking about AA really is an odd thing to observe here in this thread.
 
But I still don't get your point.
it sounds like he is getting at some of the same issues that I was trying to point out...that AA as a "support group" is somewhat different from AA as a "cultural phenomenon" and that latter is where the negative consequences of AA can emerge. And yes, its completely true that this can happen with formal schools of psychotherapy as well, but they simply aren't as ubiquitous in popular culture as AA has become. We can debate the intentions of AA all we want or what "true AA" or "real AA" looks like as some in the pro camp seem to be doing here (inherently difficult given its nature), but it seems somewhat besides the point. It is a thing that is out there and was deliberately designed (for good reason) to be decentralized and amorphous. At an individual level, regular involvement seems to be correlated with positive outcomes. Even if it isn't tied to drinking outcomes (and I hold no doubt it would beat a waitlist control), it could improve overall quality of life for involved attendees. AA also has some messages that can be very problematic from a clinician/public health perspective (e.g. controlled drinking is not possible). This discourages treatment-seeking among a significant subpopulation of users because the AA/TSF framework is simply so endemic in our culture and within substance use facilities. Anyone spending an hour at an AA meeting or in virtually any substance use facility in the country, I suspect will see this. Heck, I think at least half of the step presentations I saw in groups have included some form of that statement. I think I was about 30 minutes into my first addiction practicum (VA IOP program) when I started to parse out pros/cons. I still ultimately feel it offers a net positive, but I'm not sure why it should be unacceptable to acknowledge/discuss the negatives.

None of this is to say that AA as a whole is a bad thing or that AA is to be blamed for the situation. However, I think its important to recognize the fact that it has had a broader societal impact and has shaped our views around addiction. Sometimes for the better, sometimes for the worse. Can't speak for others, but that is really all I have been saying the whole time.
 
it sounds like he is getting at some of the same issues that I was trying to point out...that AA as a "support group" is somewhat different from AA as a "cultural phenomenon" and that latter is where the negative consequences of AA can emerge. And yes, its completely true that this can happen with formal schools of psychotherapy as well, but they simply aren't as ubiquitous in popular culture as AA has become. We can debate the intentions of AA all we want or what "true AA" or "real AA" looks like as some in the pro camp seem to be doing here (inherently difficult given its nature), but it seems somewhat besides the point. It is a thing that is out there and was deliberately designed (for good reason) to be decentralized and amorphous. At an individual level, regular involvement seems to be correlated with positive outcomes. Even if it isn't tied to drinking outcomes (and I hold no doubt it would beat a waitlist control), it could improve overall quality of life for involved attendees. AA also has some messages that can be very problematic from a clinician/public health perspective (e.g. controlled drinking is not possible). This discourages treatment-seeking among a significant subpopulation of users because the AA/TSF framework is simply so endemic in our culture and within substance use facilities. Anyone spending an hour at an AA meeting or in virtually any substance use facility in the country, I suspect will see this. Heck, I think at least half of the step presentations I saw in groups have included some form of that statement. I think I was about 30 minutes into my first addiction practicum (VA IOP program) when I started to parse out pros/cons. I still ultimately feel it offers a net positive, but I'm not sure why it should be unacceptable to acknowledge/discuss the negatives.

None of this is to say that AA as a whole is a bad thing or that AA is to be blamed for the situation. However, I think its important to recognize the fact that it has had a broader societal impact and has shaped our views around addiction. Sometimes for the better, sometimes for the worse. Can't speak for others, but that is really all I have been saying the whole time.
This sort of nuanced view is very close to my own. I wouldn't have a problem with critiques if they are presented acknowledging the mixed bag. That's what I am forced to do all of the time with these types of patients - acknowledge what it is, what else is out there, ideological divides regarding abstinence-only treatment and support models vs. others, and then let them make their own decision. It's like the field has its own ambivalence at this stage. In this thread I've seen active anti-AA sentiments, which is what I am responding to. Any sensible clinician should be able to articulate what you just wrote in your post.
 
Here is AA's position on alternatives. If you haven't read it before it's available here: http://www.aa.org/assets/en_US/p-29_howAAmemCoopProf.pdf

2. A.A. is in competition with no one.

Our ability to help other alcoholics is not

based on scientific or professional expertise.

As A.A.s, we are limited to sharing our own firsthand

knowledge of the suffering of an alcoholic,

and of recovery.

A.A. members have one unique qualification

for helping problem drinkers, of course—our

personal experience. We have been there. But

in addition to our specific A.A. function of sharing

our experience, we can also cooperate with

others dealing with alcoholism as long as we

are guided by our Twelve Traditions.

The A.A. Traditions on being self-supporting,

on being nonprofessional, on avoiding controversy,

and on not affiliating also suggest that

A.A. members not criticize, obstruct, or hinder

any other efforts to help alcoholics.

We A.A. members can help best, not by

passing judgments, but again simply by sharing

our own personal experience.


3. Non-A.A. agencies and professionals are


under no obligation whatever to abide by A.A.’s


Traditions. The Traditions are strictly for the


guidance of A.A.


But it helps in more effective cooperation if

such agencies and professionals can be made

familiar with A.A.’s Traditions.

4. A.A. members who are professionals need to


make it very clear in which capacity they are acting


or speaking—at all times.


A.A. has among its members men and

women who are trained psychiatrists or physicians

of other disciplines, members of the clergy,

jurists, social workers, corrections officers,

nurses, educators, counselors, community

organizers, executives, administrators, labor

management consultants, or the like.

Many of these A.A.s—apart from their own

personal membership in A.A.—work in non-

A.A. programs concerned with alcohol problems.

Their professional or occupational skills

and services are in no way a part of their A.A.

membership.
They are paid for their professional

or job performance, not for what they do to

stay sober in A.A. This is not always understood

by their fellow A.A. members, or by their

non-A.A. co-workers.

So it is very important that such A.A.s

always clarify the difference between their

employment and what they do as A.A.

members.

A.A. Guidelines for Members Employed in

the Alcoholism Field and the section on the

Eighth Tradition (especially pp. 169-171) in the

book Twelve Steps and Twelve Traditions help

both these members and the rest of us think

straight about the differences between the professional

and the A.A. roles.


5. A.A.s can also be good volunteers in non-A.A.


programs—as long as it is clear that they do not


represent A.A.


Many A.A. members—lay people as well as

professionals—also help alcoholics in numerous

non-A.A. ways as volunteers in non-A.A.

activities in the alcoholism field. But we do so

as private citizens concerned about the health

problem of alcoholism, not as A.A. members

and not as representatives of any A.A. body or

of A.A. as a whole.

For best results in cooperation with non-

A.A. community efforts, we need to stop short

of structurally or formally linking A.A. with

any other program or enterprise, no matter

how worthy.

6. We cannot discriminate against any prospective


A.A. member, even if he or she comes to us


under pressure from a court, an employer, or any


other agency.


Although the strength of our program lies in

the voluntary nature of membership in A.A.,

many of us first attended meetings because we

were forced to, either by someone else or by our

inner discomfort. But continual exposure to A.A.

educated us to the true nature of our illness. We

then developed a desire for a happy, sober life

like that of other members we saw, and we

attended meetings willingly and with gratitude.

So we have no right to withhold the A.A.

message from anyone—no matter who referred

that person to us, or what his or her attitude is

at first. Who made the referral to A.A. is not

what A.A. is interested in. It is the problem

drinker who is our concern.

Regardless of our initial opinion of any newcomer,

we cannot predict who will recover, nor

have we the authority to decide how recovery

should be sought by any other alcoholic. Some

of us need different kinds of help, and it may


come best from non-A.A. sources, as pointed


out in Alcoholics Anonymous (p. 74) and Twelve

Steps and Twelve Traditions (p. 61).


7. As we mature in A.A., we generally become

less fearful and rigid.

Those of us blessed with recovery in A.A.

need to remember that modesty will win more

friends for A.A. than smugness, arrogance, or a

know-it-all attitude. Saying “We know the only

way to recovery” is an egotistical luxury we can

no more afford than we can afford resentments.

However, shortly after we come into A.A.

and begin to recover, we naturally feel great

relief. We may find ourselves praised; within

A.A., we begin to build a good reputation,

which gradually replaces the shame of our

drinking days.

This can easily turn into highly intense gratitude

and loyalty to A.A. Then, almost before

we know it, we may find ourselves sounding

possessive and sensitive about A.A.—as if it

were an exclusive society with a monopoly on

the truth.

As recovery continues, we recall that thousands

of us received aid from families and

friends, a hospital or a clinic, a physician or a

professional counselor. We realize that the

boss who fired us, the relatives who scolded

us, or the cop who warned us also helped

us—helped us see we had a drinking problem.

We begin to outgrow our defensive possessiveness.

With no less devotion to A.A., but

without our former fanaticism, we start to lose

our fear that some non-A.A. program or professional

will usurp A.A.’s role, or take away our

newly found pride, gratitude, and other good

feelings. The longer we A.A. members stay

sober, the more likely it is that we will say,

“Anything that works toward recovery for the

alcoholic is good, and this includes hospitals,


rehabilitation centers, state or provincial alcoholism


centers, religion, and psychiatry—as


well as A.A.”


Perhaps we become more “attractive” examples

of what A.A. can do, in line with our

Tradition Eleven.
 

As I have maintained previously, AA is not a "treatment program." Its self-help. And yes, I agree they are largely responsible for the fuzzy boundary and perception that is out there in the popular culture.

The "higher power" is part their model, and isn't for all, but to me, it is simply and vehicle for instilling humility, transparency and accountability, which is always a winner in addition treatment. This county's current, and unfortunate, disdain for religiosity and spirituality is really not needed in this discussion if you ask me.
 
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What it is technically and what it is in practice, are two different things. Maintaining the former does not cancel out the latter.

Not sure I follow. What it is, both technically and in practice, is self-help/peer support. I thought most of us agreed on that point?

However, like i said, I agree that it is not always presented that way.
 
The article is right on the money. Conflating treatment with 12-steps is a problem. 12-step programs are voluntary and pretty much free. When they work for people, great. Attendance should not be mandated. When I was in charge of substance treatment, it was introduced as a support for sobriety that many people find helpful. We would take people who were interested to meetings. About half were interested and about half of those described themselves as members. Just because a lot of the members see it as the only path to recovery (which is not what the founder stated in the main text) doesn't mean we should present it as such and it is a problem when 80% of treatment programs do according to the article.
 
Is group therapy..like for anxiety disorders, etc considered just a self-help group or treatment? What's the difference really? Is it that 1 on 1 there would be an individual treatment plan..where in groups it's more general?
 
Is group therapy..like for anxiety disorders, etc considered just a self-help group or treatment? What's the difference really? Is it that 1 on 1 there would be an individual treatment plan..where in groups it's more general?

The difference is if there is no group leader who is professionally trained in mental health services and the treatment of the disorder in question. Such is the case with AA.
 
Is group therapy..like for anxiety disorders, etc considered just a self-help group or treatment? What's the difference really? Is it that 1 on 1 there would be an individual treatment plan..where in groups it's more general?
Like erg said, when it is facilitated by a professional then it is not self-help. There are also some stark differences between group therapy and AA, as well. No AA meeting I have ever seen is much like any group therapy session I have ever seen. In an AA meeting commenting on others sharing is discouraged, in group therapy that is part of the process. In AA, individuals will typically take turns sharing in uninterrupted segments for about 5 minutes and usually only share once. Group therapy is much less structured and more like a conversation between the members. There are also non-professionally led group therapies. Several of my therapists used to attend one. They referred to it as a "men's group". From what I gathered this was very much like a traditional professionally-led psychotherapy group which given the fact that a number of the members were psychotherapists that's not too surprising.
 
I've just heard that they tend to use the "worst" Psychologists for group therapy..because often you don't need much experience with therapy/or any at all, to lead those kind of sessions?
 
I've just heard that they tend to use the "worst" Psychologists for group therapy..because often you don't need much experience with therapy/or any at all, to lead those kind of sessions?

Who's they?

Group therapy is very hard and takes much skill to do optimally. Not to be confused with psychoed groups.
 
I've just heard that they tend to use the "worst" Psychologists for group therapy..because often you don't need much experience with therapy/or any at all, to lead those kind of sessions?
This is completely untrue. Read more Yalom and Linehan (re: DBT) to see how difficult group therapy and balancing different patients' psychopathologies in one service delivery can be. Usually, in clinical training you get experience running groups, on externships/internship, so whoever misinformed you may consider because they have novice therapists running groups, then groups must be easy. This is a fallacy.

One of the primary reasons for a psychotherapy group is the service delivery. In the VA, you can treat 6-10 people in 60 to 90 minutes (and bill for it); these groups are interesting, where patients learn from each other, commiserate with one another, and develop camaraderie towards one another and whatever ails them. For example, in a Seeking Safety VA group, you have Veterans who have been in combat (usually) and are also grappling with substance use...so Who better to share their deepest, darkest fears, then with other Veterans (your brothers & sisters in arm & ailment) and the therapists running the groups? Also, a skilled-clinician is important in any group therapy because things can escalate pretty rapidly (among members - so group rules are key), and it is important for the group facilitator to re-direct, while inquiring further, and clarifying meaning for the benefit of the other group members, so that the group is advantageous to all those involved rather than counterproductive. That is hard...when your group du jour involves Severe Mental Illness, Truma (either remote Childhood, or recent situational, like Domestic Abuse), Personality Dysfunction, Substance Use, Health Changes, Changes in Age/Lifestyle/ Economy, Gender Status, Relationship Status....Wow, I could go on and on.

For example, one of the most challenging parts of running a substance use group (in my experience) is stopping the group from the reminiscing about the 'good times' that drugs/EtOH brought them. One must gently and therapeutically remind them why they are there...and it's not to glorify how hypothetically 'cool smoking a joint and chugging a beer, in stand still traffic was,' back in the day. Sure, comments like those always get a hearty laugh from the group, but the hypothetical patient would not be there had he/she not lost his/her partner/kids, job, health, and now require court-appointed groups + individual therapy once weekly. Right?

As you can tell by my post, I am passionate about groups. I love groups, in fact. And I 100% do not consider myself one of the worst therapists (sure, there are bad ones out there), but quite the contrary, I bank on the skills that I have, knowing that I can effectively foster healing, health promotion, introspection, and perspective to many patients (6-10) in one-90 minute session per week, which is unequivocally therapeutic, especially if for a consistent, duration (just like individual therapy). Plus VAs love it because it is cost-effective.

AA is a different animal than psychotherapy groups because you do not have that skilled facilitator. I have attended many groups, in several states, in support of a family member. I've also supported pts to say 'Keep up the good work,' if it seems so to them. AA is a unique process, but I've met people who've gone 20-yrs/regularly (!) who need the constant reminder to stop the addictive behaviors, and why alternative support/coping skills are where it's @, and the group provides that particular support (sometimes with a spiritual, existential component - but not always). Some agnostics/atheists go along for the common acknowledgement but intrinsically remain a skeptic to the utility of a higher being. If you really think about it, there is much social theory in support of groups socialization and membership, it is no wonder AA is effective for some but not all. Different strokes for different folks.
 
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Just to clarify. What I heard was that they if you didn't have formal training in therapy (or not very much) you could do group therapy, but you couldn't do individual therapy. So it makes it seem that individual therapy would be more complex/different, and require a lot more expertise..and it makes group therapy appear less important and less of a treatment. Just what I've heard, and my perception of what that means. Not saying either of that is accurate.
 
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Just to clarify. What I heard was that they if you didn't have formal training in therapy (or not very much) you could do group therapy, but you couldn't do individual therapy.

I think you might be thinking of psychoeducational groups. Not the same thing.
 
Just to clarify. What I heard was that they if you didn't have formal training in therapy (or not very much) you could do group therapy, but you couldn't do individual therapy. So it makes it seem that individual therapy would be more complex/different, and require a lot more expertise..and it makes group therapy appear less important and less of a treatment. Just what I've heard, and my perception of what that means. Not saying either of that is accurate.

Well, in training, you usually run groups with a more experienced facilitator (when we ran inpatient groups as a first-year, we were paired with a 3rd-year or intern). Group therapy and individual therapy are different in that they require different levels of expertise. They can both be complex, and true, individual therapy does require a different skill-set and close supervision when in training (see psychotherapy research that the best predictor of change is based on the one-on-one relationship btwn patient and therapist).

I would never consider group therapy "less important or less of a treatment." Sometimes it is all someone is comfortable with until they are ready to begin individual therapy. Like I said, the camaraderie of others with like-illnesses is HUGE. The take-home message: "You are not alone." And this bodes well with folks who have experienced life-long stigma from mental health treatment (i.e., their referring physician may say: 'try out a group, see if you like it'...then, said patient hears the benefits from other group members discussing their individual therapy). Different pathologies call for different types of therapies, and group psychotherapy is one option that is not less challenging, or less intense than the others. It is just different.
 
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Just to clarify. What I heard was that they if you didn't have formal training in therapy (or not very much) you could do group therapy, but you couldn't do individual therapy. So it makes it seem that individual therapy would be more complex/different, and require a lot more expertise..and it makes group therapy appear less important and less of a treatment. Just what I've heard, and my perception of what that means. Not saying either of that is accurate.
Facilitating effective and safe group therapy is a difficult skill and there can be increased potential for harm. There are alot of people that probably don't know that so I could see how you could get the wrong impression. A few years ago, I took over a program that had a history of unlicensed people running groups. I put a stop to that right away because they were causing harm. In short, re-traumatizing trauma victims by insisting on disclosure and using the group pressure to push them to disclose. Bad stuff. These were well-intentioned caring people too.
 
Just to clarify. What I heard was that they if you didn't have formal training in therapy (or not very much) you could do group therapy, but you couldn't do individual therapy. So it makes it seem that individual therapy would be more complex/different, and require a lot more expertise..and it makes group therapy appear less important and less of a treatment. Just what I've heard, and my perception of what that means. Not saying either of that is accurate.
I can see this perception of the un-trained/less-trained people doing groups coming into play in my state where there is an "agency affiliated counselor" license and these people need no formal education though they often have a BA, and the only other requirement is that they take an HIV/AIDS course and are marginally supervised. They typically do things like psychoeducational groups, but sometimes process groups for state agencies and hospitals and I have never heard of one doing individual therapy with this license alone. In my area they have earned a bad reputation for mismanaging groups, especially trauma and grief groups. These agency affiliated counselors of course are not psychologists or master's level clinicians and at that level I have seen groups led brilliantly by talented people. In my internship the therapy group I co-led was one of the most challenging things I had to do. I have a lot of respect for good group therapists.
 
What it is technically and what it is in practice, are two different things. Maintaining the former does not cancel out the latter.
You are generalizing a lot here. What it is technically is what it is. The fact that some treatment programs try to use this concept does not negate the actual support group (not treatment).

There are tons of therapists out there pretending to do "CBT" but actually deliver crap. I'm not throwing out the concept just because there is crappy fidelity of implementation by some providers. And that's an actual treatment method.
 
You are generalizing a lot here. What it is technically is what it is. The fact that some treatment programs try to use this concept does not negate the actual support group (not treatment).

There are tons of therapists out there pretending to do "CBT" but actually deliver crap. I'm not throwing out the concept just because there is crappy fidelity of implementation by some providers. And that's an actual treatment method.

No generalizing, it's just the reality in many settings and contexts. Largest of which is the criminal justice system, which views AA as a treatment and utilizes it as such. Of course there are fidelity issues in any treatment or group setting, but few as ubiquitous and involuntarily mandated as AA. I'm not arguing that it's not a treatment at it's base. We can point to pieces of the seminal texts all day and say that it's not a treatment, that does little to change the reality of how it is viewed and implemented, though.
 
No generalizing, it's just the reality in many settings and contexts. Largest of which is the criminal justice system, which views AA as a treatment and utilizes it as such. Of course there are fidelity issues in any treatment or group setting, but few as ubiquitous and involuntarily mandated as AA. I'm not arguing that it's not a treatment at it's base. We can point to pieces of the seminal texts all day and say that it's not a treatment, that does little to change the reality of how it is viewed and implemented, though.
Yes, generalizing. You keep on referencing the "reality" and "many settings and contexts" but fail to support your generalizations here. For instance, where is it supported that the entire criminal justice system believes AA is treatment and utilizes it as such? The criminal justice system is a highly variable system, often using no treatment at all, treatment models such as TCs, etc. When it comes to jail diversion programs, often it is up to the subjective disposition of a judge. I'd agree that we shouldn't mandate anything less than an evidence-based treatment. But is that an AA problem or a problem with the criminal justice system? When you say "ubiquitous" you seem to account for the broad addictions treatment realm - much of which is not AA at all but borrow concepts. There are plenty of crap treatment programs out there that seem to fall within the lens you are choosing to view this issue from - a more objective viewpoint would separate out the actual AA organization from the others.

As I noted awhile back in this thread, the lack of nuance and just taking a black or white side regarding this issue is troubling to me. Some people may have had a good experience with AA, some bad, some may agree with it, some may not like the model. I'd appreciate it if people would stick to the data as consistently as they would with other issues though.
 
It's listed in their own materials that a significant percentage of their "members" were introduced to AA through the courts, when you break the numbers down, it's about 165k annually. Along with countless court cases questioning the legality of the practice would lead me to believe that this is no isolated issue. I'm fine with sticking to the numbers and data as long as we look at it from both sides.
 
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