A meeting of the Washingtonians. Courtesy Illinois Addiction Study Archives.
Change processes
What are the essential processes through which AA helps members change? Although the answer to this question surely varies across individuals, the following dimensions are typically important.
A sobriety-focussed action programme
AA recommends – although it does not mandate – that members make efforts to change in ways captured in various slogans and in the 12 steps (see Table 14.1). The goal of this action programme is not simply abstinence, but “sobriety,” which AA defines as a fulfilling, responsible, generous, and serene way of life. The importance of these broader changes is implicit in the construction of the 12 steps. Although Step 1 is of paramount importance, it is also the only mention of alcohol in the 12 steps.
The steps are central to AA literature, are referred to by speakers in meetings, and are often specifically “worked” with sponsors (e.g., Step 5). In early recovery, members are typically advised to focus solely on taking Step 1 seriously (e.g., “Don’t drink. Go to meetings. Ask for help”). They will be advised to take things “one day at a time” and to work for short-term goals. The stories and discussions they listen to at AA meetings and the guidance from their sponsor will provide them with many hints on coping and problem-solving. Their first priority is to deal with their drinking, but the 12 step programme will also cue them to examine psychological problems such as self-centredness, chronic dishonesty, and pervasive resentment. Step 4, in which one catalogues honestly one’s shortcomings, is a key part of this process of self-examination and may relieve years of accumulated shame and guilt.
The steps also comprise recommendations to repair relationships that have been scarred by the member’s drinking. This includes both atoning for past transgressions (Steps 8 and 9) and conducting oneself more forthrightly and kindly when interacting with others in the future (Step 10).
AA is “a selfish programme” and each individual is working for sobriety for his or her own sake and not to please anyone else, and he or she thus gives no hostages to fortune. If members relapse, they are not rejected but may return any number of times to try again. When stable sobriety is achieved, the programme will finally include “twelfth-stepping,” but, by then, members should have learnt that in the process of helping other people they will help themselves and confirm their own strength. That said, members are expected to proselytize, “pull people down lamp posts” or put their own sobriety at risk.
As mentioned, the steps are supplemented by numerous slogans: “fake it until you make it,” “put some gratitude in your attitude,” “keep it simple, stupid (KISS),” “easy does it, but do it,” “first things first” It is easy, but wrong-headed, for educated professionals to poke fun at AA’s many slogans and seemingly simplistic advice. Most of the practical advice offered by AA members directly parallels that which a scientifically informed cognitive behavioural psychologist would offer, albeit in different words. Two of many possible examples make the point. “Avoid slippery people, places, and things” contains the same wisdom as, “Let’s examine what stimuli lead you to drink and then make a plan to avoid those relapse triggers.” “Watch your stinking thinking” is but a more pithy way of emphasizing how automatic cognitive distortions can shape substance use behaviour.
Coherent, flexible ideas
In Persuasion and Healing, a classic text of psychiatry and anthropology, Jerome Frank (1973) noted that, across cultures, healers offer a philosophy or narrative that explains why the sufferer is ill and how the pain can be relieved. AA fits this characterization, providing a coherent yet flexible philosophy that makes members feel understood and gives meaning to their experience. They are suffering from “the disease of alcoholism,” which is pictured as metaphorically akin to an “allergy to alcohol.” Their constitution is such that they will react to this drug differently from other people. They can never be “cured,” but the disease will be “arrested” if they never drink again.
Yet AA’s definition of disease is broader than that of traditional medicine, comprising emotional and spiritual elements as well as physical ones. This broad conception allows members more “latch-on points” with the AA programme than would a purely biological view, in that most alcoholics have problems in addition to drinking to which AA’s philosophy can speak. Through a process of continually telling and retelling the story of their own experience of alcoholism, AA members integrate AA’s narrative about alcoholism into their own life story (Humphreys, 2000). It can also serve to “keep the memories green” so that motivation for recovery can continue.
The flexible nature of AA philosophy is evident in its “spiritual rather than religious” posture (Kurtz, 1991). The 12 steps unambiguously talk about God as a Higher Power essential to recovery, and yet there are geographic areas (e.g., Sweden) where most AA members are atheist or agnostic (Mäkelä et al., 1996). Relatedly, though the founders of AA were Protestants, it claims among its members countless Catholics, as well as Jews, Muslims, and Buddhists (Humphreys, 2004). In the mind of some members, their Higher Power is the AA fellowship itself, a stance captured in the equation “G.O.D. = Group Of Drunks.” We will give extensive attention to spiritual issues in Chapter 15. Here, suffice it to say that AA’s conception of “God as we understand Him” is broad enough to cover almost any interpretation of a Higher Power that a member wishes to employ.
The influence of the fellowship
Individuals trained in psychotherapeutic techniques are inclined to think of change in terms of individual behaviours, thoughts, emotions and insights. As described, all of these are implicated in AA’s change process, but this should not lead observers to overlook the reality that, unlike psychotherapy, AA is a living, breathing social network that an individual may join for a lifetime. Indeed, although the 12 steps and spiritual framework of AA are important, sophisticated research has established that the most consistent mediators of AA’s benefits are social in nature (Kelly, Hoeppner, Stout, & Pagano, 2011).
The AA fellowship gives members new friends, introduces them to a social network that does not centre on drinking, relieves their loneliness, helps them to structure and employ their time, and lessens the social stigma of having a drinking problem. This network also provides social reinforcement and encouragement, which is particularly important in the early stages of recovery when members are often struggling to build a new life and tempted to return to their old ways.
The fellowship is also a key way for AA to instil an essential ingredient of change: hope. The network of experienced, sober role models makes recovery seem possible to even the most disillusioned drinker. AA does not work through an abstract set of ideas but through those ideas being found persuasive and possible by the individual. The most apt theoretical definition of the disorder and the pathways to recovery would remain useless if AA did not have the ability to convince newcomers that AA can meet their particular problems and show them personally the way ahead. AA can carry this conviction because the experienced members of the fellowship so evidently know what they are talking about; they, too, have been through it all and know every stratagem of deceit and denial while at the same time bearing tangible witness to the possibility of success.
Professional facilitation of AA affiliation
Which patients are likely to affiliate with AA? Like professional treatment, AA is not a panacea. Its membership is primarily composed of people who have suffered from at least moderate and typically severe alcohol dependence, and group cohesion is therefore built around total acceptance of the abstinence goal. A person with a low-severity drinking problem who is pursuing a controlled drinking goal is highly unlikely to find AA compatible. The founders of AA fully accepted that some problem drinkers could return to “drinking like a gent,” but that was not the population they created their organisation to help.
Beyond that universal feature of AA, meetings are so variable in composition and process that predicting a priori who is a good match for “AA writ large” is a nearly meaningless exercise. Rather, the question for a clinician and patient to explore is whether a comfortable niche can be found in a particular kind of AA meeting. In any referral to AA, the clinician should emphasize the diversity of the organisation’s groups, which cannot be appreciated in a single visit to a single meeting. The location and time of day a meeting is held may lead it to draw members from particular social strata. The Wednesday evening AA meeting in the spare room above the petrol station or in the basement of a local church will feature a different cast of characters than the lunchtime meeting in the financial district. Some chapters have standing rules of serving a particular subpopulation, for example men, women, gays and lesbians, nonsmokers, barristers, or physicians. Some groups will emphasise the spiritual aspect of AA much more than others. Some meetings have such large attendance (e.g., 100 people) that a newcomer can slip quietly into the back row unnoticed, whereas others are small affairs where everyone knows each other, and a newcomer will always be noticed and specifically welcomed.
Rather than exhaust the patient by relating all the potential variants of AA, the clinician can convey the simple message that it may take some time and perseverance to find the group that most suits the patient’s needs. Clinicians can increase the likelihood that AA will “stick” by helping the patient talk through important decisions about a “home group” and a sponsor. This is particularly important for patients who have a history of poor interpersonal relationships. It can be useful for the clinician to inquire, for example, whom the patient is considering asking to be a sponsor and what about the person makes them worthy of such trust. Likewise, the clinician can help the patient to explore why a particular meeting felt safe and comfortable whilst another was anxiety-producing.
The clinician’s attitude about trying AA should be optimistic but not dogmatic. Most patients understandably dislike having AA “rammed down their throat.” Indeed, an oppositional subset may resist AA not because it wouldn’t help them but because they want to show the therapist who is the captain of their ship. If a sincere effort at AA affiliation is not productive during the current treatment or if the patient has had consistently negative experiences with AA in the past, the clinician should not scold the patient; rather, the task becomes finding other sources of support for sustaining change in drinking behaviour.
In making referrals, clinicians should be aware that simply mentioning AA and providing a brochure or phone number yields low rates of uptake. In contrast, explaining the basic workings of AA meetings, addressing anxieties about attendance, and providing a direct introduction to a trusted, experienced AA member all dramatically increase the chances that a patient will give AA a try (Timko, DeBenedetti, & Billow, 2006). Clinicians who occasionally attend open AA meetings will enhance their credibility as informants and build up valuable contacts with local groups. Other strategies for facilitating AA attendance and creating synergies between treatment and AA are available free of charge in the Twelve Step Facilitation Handbook produced by the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA; Nowinski, Baker, & Carroll, 1999, downloadable at http://pubs.niaaa.nih.gov/publications/ProjectMatch/match01.pdf).
In making referrals, the clinician should remain alert for two patient concerns. First, occasionally an errant AA member will tell a newcomer that the organisation forbids the taking of psychiatric medication. The clinician can provide patients concerned about this issue AA’s statement on medications, which enjoins members from “playing doctor” (free of charge on the Internet at http://www.alcoholics-anonymous.org/en_pdfs/p-11_aamembers.pdf). Second, because many people are uncomfortable speaking in front of groups, the clinician should offer reassurance that speaking in meetings is not a requirement of membership. New members may simply sit and listen for months on end if they wish. In the case of a patient whose discomfort about these matters approaches a phobia, the therapist could suggest exploration of online AA meetings (directory available at http://www.aa-intergroup.org/directory.php).
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