The influence of the Twelve Steps recovery program of Alcoholics Anonymous (AA) is pervasive, but many psychiatrists treating patients with alcohol use—or other substance use— disorders may be unaware of exactly how it can help them in their work.
There are more than 50,000 AA meetings a week nationwide. Meetings are free, easily accessible, and unintimidating (speaking is not required, although eventually it is what works).
However, the Twelve Steps have been controversial recently, with books and articles declaring that they do not represent “evidence-based” treatment. While one can argue that AA is not really treatment per se, there is in fact a body of empirical research demonstrating its clinical utility. The largest trial was Project MATCH, which was a randomized controlled trial funded by the National Institutes of Health. The trial found that 12-step facilitation (TSF) therapy was as effective as cognitive behavioral therapy (CBT) or motivational enhancement therapy for reducing frequency and intensity of drinking. In TSF, a therapist uses a number of strategies to encourage optimal participation in 12-step meetings. (For more on the evidence for AA, see TCPR, June 2014).
The Twelve Steps of AA also apply to Narcotics Anonymous (NA), Cocaine Anonymous (CA), and other substance-specific groups; however, AA is the most common of these. The steps are both actual tasks and a sequence of psychological processes. In AA’s terms, this sequence leads to a “spiritual awakening,” but one can equally view it as progress in recovery from substances, as well as progress in learning how to live a more satisfying life.
“Give it a try,” is what psychiatrists might tell their new patients about AA, said John F. Kelly, PhD, Elizabeth R. Spallin Associate Professor of Psychiatry at Harvard Medical School and director of the MGH Recovery Research Institute. “And say, ‘Let’s talk about it next time.’”
Patients should go to 3 meetings a week, at first, said Kelly. Research has shown that this is the minimum number of meetings associated with abstinence. While the core literature of AA recommends 90 meetings in 90 days, for new members, researchers have found that there are no increases in engagement after 60 meetings—that the benefit plateaus at this point. Empirically, Kelly says, there is not enough evidence to show that 90 meetings in 90 days is beneficial.
The ideal way to introduce a patient to AA, said Kelly, is for the psychiatrist to know someone who is a member, and can take the patient to a meeting. And if the psychiatrist has other patients who are in recovery and going to meetings, those patients would be the best people to do this, he added. “The most surefooted way to get a patient to a meeting is to have them taken there by a peer who is in recovery.” Psychiatrists can accomplish this kind of introduction by asking for an experienced patient’s consent to be contacted by patients who are new to AA.
The next best method is to get a list of local meetings and identify with the patient which ones would be most convenient, said Kelly. (To find meetings, go to http://www.aa.org/pages/en_US/find-aa-resources and click on your location.)
Over the past 25 years, researchers have consistently found that TSF is effective, said Kelly, who points out that its effects have been shown to be equivalent to CBT, and other modalities. Since the aim of TSF is to encourage regular AA attendance, its benefits may be identical to the benefits of AA, although it is also possible that TSF helps via nonspecific aspects of any psychotherapy.
Actually working on the steps will be too complicated for brief psychiatric visits, said Kelly. “It’s more important to just prescribe some attendance at AA, and to have the patient come back and discuss their experience,” Kelly said. Encourage patients to say something at their AA meeting, if only to say their name and why they’re there. “Just talking at a meeting has been shown to increase rates of engagement and better outcomes,” he said. It might be something as simple as, “I’m checking it out, not sure if I’m an alcoholic, but I’ve had a problem and I’m finally doing something about it.’”
Psychiatrists need to warn their patients about not disclosing their medication status in AA, said J. Scott Tonigan, PhD, research professor in the Department of Psychology at the University of New Mexico. His advice is: don’t tell people, it has nothing to do with AA.
Along with Kelly, Tonigan 10 years ago surveyed AA members’ attitudes toward medications, and they found a “mixed bag” of responses (Tonigan JS and Kelly JF, Alcohol Treat Q 2004;22:67– 78). “While the core AA literature is nonjudgmental, our paper showed that there is a segment of AA members who are hostile to medications, who will say, “You’re not sober if you’re taking methadone, lithium, Prozac, and other psychotropic medications,” said Tonigan. Kelly and Tonigan have sat in on many open meetings, and they see no benefit to disclosing medication use. “The psychiatrist needs to tell the patient, ‘Your use of this medication is irrelevant to the Twelve Steps,’” said Tonigan.
When getting to Steps 4 and 5, in talking to the sponsor, the patient will have to disclose medications, noted Tonigan. The psychiatrist who is sensitive to Twelve Steps philosophy should prepare the patient for judgmental statements and suggest another sponsor if the patient gets the message that the medications are bad.
AA for severe alcoholism
Joseph Nowinski, PhD, author of the Twelve Step Facilitation Therapy Manual for the National Institute on Alcohol Abuse and Alcoholism (NIAAA), which was used in Project MATCH, said that it’s important for psychiatrists to tell patients to just go to some open meetings at first.