This chapter reviews research examining outcomes of Alcoholics Anonymous (AA) for special populations. It begins by discussing what is meant by the term “special populations” and why the question of if and how AA is beneficial for special populations needs to be considered. The chapter then examines studies of outcomes of AA participation among women, adolescents, and the elderly, racial and ethnic minority groups, disabled individuals, and people with co-occurring substance abuse and mental illness. It concludes by summarizing what existing research shows about the outcomes of AA among special populations and issues that future studies should address.
AA is often viewed as a spiritual organization, but it is less commonly recognized that helping others is a fundamental part of AA's conception of spirituality. Helping others by bringing AA's program to other alcoholics (articulated in Step 12) is understood as the culmination of AA's program and the behavioral manifestation of a spiritual awakening (Step 11). Also, members are encouraged to help in all stages of their involvement in AA's, and it is this helping that is thought to keep them sober. Accordingly, the current chapter addresses the question of whether helping benefits the helper from an empirical standpoint-and specifically, whether helping might contribute to recovery in the context of AA involvement. In addition to describing AA's approach to helping, we review research on associations between helping and (a) health outcomes in the general population, (b) recovery in diverse mutual help groups, and (c) recovery from chemical dependency within and outside of AA. We find evidence supporting benefits for helpers in each of these domains and tentatively conclude in favor of helper therapy principles. However, the work is limited by the lack of experimental studies and by problems in defining helping. Other concerns are that "over-helping" can be worse than not helping at all and that helping may sometimes harm the intended recipients. Recommendations for further research are to address these limitations. Particularly useful would be research designing and testing interventions aiming to increase helping, perhaps informed by social model programs and principles.
This chapter is directed at defining the nature of spirituality and its relationship to empirical research and clinical practice. A preliminary understanding of the spiritual experience can be achieved on the basis of diverse theoretical and empirically grounded sources, which will be delineated: namely, physiology, psychology, and cross-cultural sources. Furthermore, the impact of spirituality on mental health and addiction in different cultural and clinical settings is explicated regarding both beneficial and compromising outcomes. Illustrations of its application in addiction and general psychiatry are given: in meditative practices, Alcoholics Anonymous, and treatment programs for addiction singly and comorbid with major mental illness. Given its prominence in Alcoholics Anonymous and related Twelve-Step groups, spirituality plays an important role in the rehabilitation of many substance-dependent people. The issue of spirituality, however, is prominent within contemporary culture as well in the form of theistic orientation, as evidenced in a probability sampling of American adults, among whom 95% of respondents reply positively when asked if they believe in “God or a universal spirit.” Responses to a follow-up on this question suggest that this belief affects the daily lives of the majority (51%) of those sampled, as they indicated that they had talked to someone about God or some aspect of their faith or spirituality within the previous 24 h (Gallup, 2002).
Alcoholism treatment has evolved to mean professionalized, scientifically based rehabilitation. Alcoholics Anonymous (AA) is not a treatment method; it is far better understood as a Twelve-Step Recovery Program within a voluntary self-help/mutual aid organization of self-defined alcoholics. The Twelve-Step Recovery Model is elaborated in three sections, patterned on the AA logo (a triangle within a circle): The triangle's legs represent recovery, service, and unity; the circle represents the reinforcing effect of the three legs upon each other as well as the "technology" of the sharing circle and the fellowship. The first leg of the triangle, recovery, refers to the journey of individuals to abstinence and a new "way of living." The second leg, service, refers to helping other alcoholics which also connects the participants into a fellowship. The third leg, unity, refers to the fellowship of recovering alcoholics, their groups, and organizations. The distinctive AA organizational structure of an inverted pyramid is one in which the members in autonomous local groups direct input to the national service bodies creating a democratic, egalitarian organization maximizing recovery. Analysts describe the AA recovery program as complex, implicitly grounded in sound psychological principles, and more sophisticated than is typically understood. AA provides a nonmedicalized and anonymous "way of living" in the community and should probably be referred to as the Twelve-Step/Twelve Tradition Recovery Model in order to clearly differentiate it from professionally based twelve-step treatments. There are additional self-help/mutual aid groups for alcoholics who prefer philosophies other than AA.
This chapter explores the influence of the AA model on self-help fellowships addressing problems of drug dependence. Fellowships that have adapted the twelve-step recovery model to other substances of abuse are reviewed; next similarities and differences between AA and drug-recovery twelve-step organizations are examined; finally, we present empirical findings on patterns of attendance and perceptions of AA and Narcotics Anonymous (NA) among polydrug-dependent populations, many of whom are cross-addicted to alcohol. Future directions in twelve-step research are noted in closing.
Misconceptions about Alcoholics Anonymous (AA) abound in spite of (or because of) the thousands of theses, dissertations, books, professional and popular articles, and Internet commentaries that have been written about AA. One of the most pervasive characterizations of AA is that it is a "treatment" for alcoholism—a characterization that distorts the meaning of both mutual aid and alcoholism treatment. This article describes 12 character-defining moments in the history of AA that highlight the differences between AA and alcoholism treatment.
Several forces combined in the 1950s to profoundly change the way alcoholism was treated in the United States. Anderson, Bradley, and Hazelden staff combined strategies to revolutionize alcoholism treatment across the spectrum of social rehabilitation services and hospital-based care. Prevailing psychiatric services, heavily influenced by psychoanalytic practices, were abandoned in favor of an emphasis on patient education, therapeutic group process, peer interaction, and the development of life-long support systems through AA. The addition of the alcoholism counselors, many of whom were recovering AA members, was a key ingredient in aligning a closely identified professional with the alcoholic to foster integration of Twelve Step principles and practices in everyday life. Dignity, respect, and hope for recovery became the cornerstone of the Minnesota/Hazelden Model. The resulting treatment model is recognized as an effective, evidence-based approach for alcohol and drug dependence. One of the strongest commendatory statements has come from the staff of the National Institute on Alcohol Abuse and Alcoholism who, in a report to the U.S. Congress, identified Twelve Step-based professional treatment as effective as other approaches and a model that "...may actually achieve more sustained abstinence" (2000, p. 448). Clearly, AA's impact on professional treatment cannot be underestimated. Perhaps Dan Anderson summarized it best: "Without the initial and sustaining impetus of [AA], none of our treatment efforts could have been realized" (Anderson, 1981, p. 3).
Participation in the twelve-step mutual-help organization, Alcoholics Anonymous, has proven to be an effective means of helping individuals with alcohol dependence achieve lasting sobriety. Although many patients choose to attend AA of their own accord, clinicians’ facilitation of AA involvement (“Twelve-Step Facilitation” [TSF]) has shown to substantially increase the likelihood that patients will become engaged with these freely available resources. Importantly, many individuals with alcohol dependence never seek help from addiction specialists, yet often encounter other health professionals due to alcohol-related physical or psychological problems providing an opportunity for intervention. However, for clinicians who do not specialize in addiction treatment, knowledge about what AA actually is and does is often lacking, and confidence in implementing TSF strategies is low. This chapter provides essential information for clinicians working in non-specialty settings who have little knowledge of, or experience with, AA or TSF, but who may wish to utilize proven strategies to augment existing interventions by helping educate, link, and engage patients with AA. Detailed information on the origins and specific elements of AA is provided along with recommended TSF approaches and strategies to aid the non-specialist in building effective interventions for patients with alcohol dependence.
In addition to being a widely used and effective approach for alcohol problems, AA has been central to the development of several types of nonprofessional recovery programs. Known as "social model recovery," these programs were staffed by individuals in recovery and they encouraged program participants to become involved in AA as a way to address their drinking problems. In addition, they relied on the traditions, beliefs, and recovery practices of AA as a guide for managing and operating programs (e.g., democratic group processes, shared and rotated leadership, and experiential knowledge). This chapter reviews the philosophy, history, and recent changes in several types of these programs, along with a depiction of AA's influence on them. Programs examined include neighborhood recovery centers, residential social model recovery programs, and two types of sober living houses: California Sober Living Houses and Oxford Houses. Recent outcome evaluations on both types of sober living houses are presented.
This chapter draws on AA membership surveys, US general population surveys, and longitudinal treatment data to compile profiles of those ever exposed to AA in their lifetime, those who no longer report AA meeting attendance, and those who attend AA meetings currently. We consider demographics (gender, age, ethnicity, marital status), receipt of specialty treatment, and short- and long-term abstinence rates among these AA exposure groups. Results suggest stability in the representation of women and minorities among the AA membership, but a decline among youth. Fully one-half of those completing AA's most recent membership survey reported that they had been abstinent for more than 5 years. Those receiving specialty treatment any given year are likely to report AA exposure that year. Disengagement from AA does not appear to necessarily translate to loss of abstinence among those with initial high levels of AA exposure, but long-term abstinence is more likely among those with continued engagement.
Twelve-step programs represent a readily available resource for individuals with substance use disorders. These programs have demonstrated considerable effectiveness in helping substance abusers achieve and maintain abstinence and improve their overall psychosocial functioning and recovery. Despite these positive benefits associated with increased involvement in twelve-step self-help programs, many substance abusers do not affiliate or do so for only a short period of time before dropping out. Because of this, clinicians and researchers have sought ways to increase involvement in such self-help groups by facilitating meeting attendance and engagement in other twelve-step activities. The present chapter reviews the impact of treatment program orientation and specific interventions designed to facilitate twelve-step program involvement, subsequent meeting attendance, engagement in twelve-step activities, and alcohol and drug use. The findings of studies evaluating these approaches indicate that it is possible to increase twelve-step involvement and that doing so results in reduced substance use. The results suggest that incorporating these evidence-based interventions into standard treatment programs may lead to improved outcomes.
Alcoholism has often been referred to as a “spiritual disease,” especially within the context of Alcoholics Anonymous (AA). Consistent with this view, spiritual growth and development have been a central focus within the recovery process. AA, in this respect, offers a spiritual path to recovery from alcohol use disorders. In this chapter, we focus broadly on spiritual change in recovery, particularly in relation to involvement in AA. We open with a discussion on defining spirituality and provide an operationalization of spirituality for present purposes. We next provide a conceptualization of alcoholism as a spiritual disease. This is followed by a review of topics pertaining to spirituality and AA. In this regard, we identify the core spiritual beliefs in AA, the AA practices thought to be relevant to spirituality, and the subjective experiences of spirituality in AA. We also discuss the important issue of spiritual awakenings. Following this, we survey the literature on changes in spirituality during the process of recovery from alcoholism.
In this chapter, we explore the spiritual functioning and well-being of individuals and how this relates to mental health and recovery from alcoholism within the conceptual framework of Alcoholics Anonymous. We raise the question of whether the spiritually oriented focus of AA is a critical factor in achieving recovery. We suggest that examining the findings from a large body of research on religion and mental health may provide further insight into this question. Specifically, we assert that the mechanisms through which the spiritual focus of AA may influence recovery from alcoholism may be similar to the mechanisms through which spirituality may influence mental health. These potential explanatory mechanisms include the provision of a community, a narrative framework for meaning-making, a means of coping through submission and redemption, and prescribed lifestyle behaviors.
Researchers have observed that a majority of addicted persons who are encouraged and facilitated by treatment providers to attend twelve-step (TS) programs either drop out or sporadically use twelve-step programs following treatment. This is troubling given considerable evidence of TS program benefits associated with regular weekly attendance and ubiquitous reliance by treatment professionals on these programs to provide important support services. This chapter reviews and advances theory of TS utilization and dose that is supported by prior research, multivariate models, and scales that predict risk of TS meeting underutilization. Advancing theory should organize and clarify the process of initial utilization, guide intervention development, and improve adherence of TS program referrals, all of which should lead to improved treatment planning and better outcomes. Three theories are integrated to explain processes that may influence TS program dose: the health belief model, self-determination theory (motivational theory), and a person-in-organization cultural fit theory. Four multidimensional scales developed specifically to predict participation are described. Implications for practice and future research are considered in a final discussion. Information contained in this chapter raises awareness of the need for TS-focused treatments to focus on achieving weekly attendance during and after treatment.
