TCPR: Dr. Chappel, you’ve been involved in addiction medicine for many years. What are some of the major advances that you’ve seen over that time?
Dr. Chappel: One advance was the concept that “addiction” is a chronic disease of the brain. In 1992, ASAM (American Society of Addiction Medicine) published the results of a research project whose purpose was to define alcoholism in light of findings in the neurosciences. In that paper, they defined alcoholism as “a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.” They went on to say, “The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial” (JAMA 1992;268:1012-1014). The implications are that people who become addicted are going to need continuing treatment in much the same way as patients with hypertension, diabetes, or other chronic problems.
TCPR: And how was this definition different?
Dr. Chappel: We had been using an acute care model prior to that, and, unfortunately, managed care generally still ascribes to this acute care model in that they typically cover only very brief periods of treatment, usually only detoxification in a hospital setting. They have essentially ignored the wealth of data we have accumulated indicating that it often requires a long period of residential treatment combined with immersion in Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) followed by monitoring for up to five years to achieve and maintain abstinence. The results of these longer and more intense programs are quite favorable.
TCPR: Have there been any other major shifts or findings in the field?
Dr. Chappel: Yes, the second thing that came out of the 1990s was the biggest psychotherapy research project that has ever been funded by the government, that being “Project Match.” Project Match demonstrated that 12-step recovery, particularly participation in AA, worked as well as other approaches in the early phases of alcoholism, and worked better the longer the follow-up. In the three-year follow-up, there was a clear and significant edge to 12-step participation if abstinence was taken as the preferred outcome (Alcoholism 1998;22: 1300-1311).
TCPR: And yet in the literature you often hear Project Match discussed negatively.
Dr. Chappel: Yes, some view the project as a failure because the researchers found that cognitive behavioral therapy and motivational enhancement therapy were no better than 12-Step facilitation therapy. But this is a negative spin on the findings in my opinion. The positive spin is that all three treatment approaches are helpful in the care of patients with alcoholism.
TCPR: AA is sometimes said to be a “spiritual” program, and other times referred to as a “religious” program. Is there a difference between these terms?
Dr. Chappel: Religion is something that is organized by a group of people. It has a theology that is followed, along with a catechism or some set of beliefs. It includes a membership induction process where a person learns these beliefs and then follows as a member of that particular organization. The only thing that AA shares with religions is the fact that they have organized meetings. The only requirement for membership is the desire to stop drinking—you don’t have to have a belief in anything.
TCPR: So, there isn’t any specific AA theology?
Dr. Chappel: There is no AA theology except that there is a “higher power” that exists and it is up to the individual to define what that is for him- or herself and to make contact with it. This is spirituality, to be sure, and the big difference between religion and spirituality, in my view, is that religion is something that you get from outside, from other people, whereas spirituality is an internal experience.
TCPR: Can you better define the AA experience of spirituality?
Dr. Chappel: When people start clearing up their problems with others (Step 9 of AA) and spend some time trying to make conscious contact with their higher power (Step 11), the spiritual experiences become more frequent and stronger. And these experiences are very personal matters. One of the ways you can tell that people are growing spiritually is that they become less judgmental, and more accepting and tolerant. The benefits of working a spiritual program of living such as AA’s 12 steps can be found in the section of the “Big Book” often referred to as the Twelve Promises.
TCPR: Can you suggest a good way for psychiatrists to introduce our alcoholic patients to AA?
Dr. Chappel: An excellent way was described by Sisson and Mallams (Am J Drug Alcohol Abuse 1981;8:371-376). They took 20 alcoholics and they made a standard referral to 10 of them, where they gave them the phone number to AA and told them to go to meetings. For the other 10, the researchers called the Central Office of AA for them (with their permission, while they were still in the office). They were promptly connected with someone in AA to take them to a meeting that night, and one hundred percent of them went. None of the control group ever attended a meeting. So this is what I do in my practice. I get the person’s permission, then call the Central Office and tell the person who answers the phone who I am and that I have a person interested in AA. I give them their first name, their age, their sex, and what the person does for work. Then I tell them that this person would like to go to a meeting and ask if it would be possible for someone to talk to him or her and make an arrangement for that. Then I hand the phone over to the patient and, most of the time, they make a meeting that same day. In fact, one time someone from the Central Office arrived to pick up the patient before I’d finished my session with him. That has only happened once, but it surprised me and must have shocked the patient. (Editor’s note: You can find contact information for the Central Office in your area at www.alcoholicsanonymous.org/en_find_meeting.cfm?PageID=29.)
TCPR: What else should we know?
Dr. Chappel: There are some basic things that physicians need to learn about AA in order to improve their ability to competently refer someone to AA and to support them through the 12-step process. They need to know what a Central Office is, they need to know something about the literature that exists: The Big Book, The 12 & 12, Living Sober, plus some of the key pamphlets like “The AA Member, Medications and Other Drugs.” They need to know something about what happens at meetings. I don’t think there is any substitute for actually going to a few meetings oneself and getting to know some of the people in AA. The NIAAA (National Institute on Alcohol Abuse and Alcoholism) recommends in its 12-Step Facilitation Manual going to at least 10 open meetings and reading the first 164 pages of the text Alcoholics Anonymous (AA’s “Big Book”). I also recommend that physicians engage the services of AA’s CPC committee.
TCPR: What’s the CPC Committee?
Dr. Chappel: It’s the “Cooperation with the Professional Community” committee. Any place that is big enough to have an AA Central Office will have a CPC committee. They take a special interest in working with physicians, telling them about the meetings in the area, taking them to meetings if they want to go to them, talking to them about their own recovery, or going over the literature with them. They will explain what it is to be a sponsor, what a home group is, and other aspects of AA. If a physician doesn’t know these basic fundamentals, it makes it much more difficult to genuinely and authentically recommend that a patient go to an AA meeting and get involved in the program. It would be like referring patients to an emergency room without being able to tell them what to expect once they get there.
Editor’s Note: For an elaboration of Dr. Chappel’s views on 12-step programs you can read “Twelve-step and mutual-help programs for addictive disorders” (Chappel JN – Psychiatr Clin North Am – 01-JUN-1999;22(2):425-46).