PSYCHOSOCIAL INTERVENTIONS

DISEASE MODEL APPROACHES (TRADITIONAL, MINNESOTA MODEL, 12-STEP-ORIENTED)

These approaches are grounded in the concept of substance misuse as a spiritual and medical disease. In their basic and original form they consist of self-help groups, that in the case of AA are widely available throughout the country.A variety of related models have evolved which range in intensity from structured outpatient to intensive, multimodal inpatient approaches of several months duration.

AA was founded in 1933 by a stockbroker (Bill W.) and a physician (Dr Bob). The basic philosophy of Alcoholics Anonymous is that of reaching out to other alcoholics to help everyone stay sober. This philosophy derived from the personal experience of Bill W, an alcoholic, who one day, on the verge of relapse to drinking, realised that he had to speak to another alcoholic in order to stop himself from drinking. The alcoholic he found to speak to was Dr. Bob. Their rationale was published in 1939 as 'Alcoholics Anonymous' also known as 'The Big Book'. It established AA for all alcoholics, including atheists and agnostics; indeed, AA is a spiritual and not a religious programme.

Additional insight into the mechanism of AA effectiveness can be gained by examining various AA slogans. These include 'One day at a time', 'Easy does it', 'Let go and let God','Keep it simple','HOW' (honesty, openness and willingness),'HALT' (hungry, angry, lonely and tired), 'First things first'.

Common objections to attendance can be addressed as follows:

Religiosity:

AA is spiritual and not religious; the requirement is a belief in a Higher Power, rather than a God, and atheists are welcome at groups.

Talking in groups:

There is no requirement to talk at AA; members can say 'pass' when it is their turn.

Anonymity:

This is protected rigorously.

Drinking:

The only requirement is a desire to stop drinking, rather than actual sobriety.

There is no one individual in charge of AA meetings, and over the early years, meetings were often chaotic to the extent that the organisation's survival was threatened. In response to this some organising principles evolved which became known as the 'Twelve Traditions' (appendix 12, page 155).

Outcomes for AA attenders are mixed, as with all forms of treatment for addiction. Drop-out rates are high, and approximately half those who attend AA have left within three months (Anonymous, 1989). Despite this high drop-out rate, for those who remain, the abstinence rate is excellent - the average length of sobriety amongst active members is approximately six years (Anonymous, 1996). Indeed, one of the most consistent and robust findings is that of a correlation between AA attendance and positive drinking outcomes. In one study of over 8000 patients attending treatment programmes in the USA, those who were also attending AA at one-year follow-up were 50% more likely to be abstinent than those who were not attending AA (Hoffman & Miller, 1992). There are many studies replicating these results and similar results have also been reported for NA involvement (Christo & Graney, 1995). However, a recent meta-analysis of the role of AA in treatment outcomes found only a modest correlation between AA involvement and drinking outcomes (r=0.21) (Tonigan,Toscova & Miller, 1996). Some studies also demonstrate that the more involved one is with the process, the better the drinking outcome (Tonigan,Toscova & Miller, 1996). Abstinence rates for 12-step treatment programmes (rather than AA) are quite good, with 50% abstinence at 12 months being a typical outcome figure (Hoffman & Miller, 1992).

Narcotics Anonymous.

NA was formed in 1947 in response to the discomfort many narcotic and other drug addicts felt when attending AA meetings. The Twelve Steps are the same as AA's but with the word alcohol replaced by addiction or addict where appropriate.

The approach is abstinence from all drugs including alcohol. NA has its own 'Big Book' entitled 'Narcotics Anonymous' (1983). Another group based on the same principles has also developed over the last 25 years: Cocaine Anonymous (CA).

Al-Anon.

One Gallup poll found that 24% of people interviewed said that their life had been affected by an alcoholic in some way (Robertson, 1988). The oldest family-based group is Al-Anon, and was started by the wife of Bill W. The central theme is one of addiction as a family disease, and that relatives of the alcoholic person must focus on their own need for help, rather than on the alcoholic person. This simple philosophy was (and is) revolutionary for people who have spent most of their energy and time concentrating on the alcoholic. Additionally, the relative must learn to free themselves of feeling responsible for the alcoholic's disease; the concept of 'tough love' is central to various attitudes which must be learnt:

• Not to suffer because of the action or reactions of other people;
• Not to allow ourselves to be used or abused in the interest of another's recovery;
• Not to do for others what they should do for themselves;
• Not to manipulate situations so others will eat, go to bed, get up, pay bills etc.;
• Not to cover up another's misdeeds or mistakes;
• Not to create a crisis;
• Not to prevent a crisis if it is the natural course of events.

Al-Ateen is an off-shoot of Al-Anon for teenagers.

Contact details for AA and similar groups can be found in appendix 12, page 155.

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Alcohol Guidelines index

The above information is copyright of Dr Bruce Trathen MBBS MRCPsych (2006). ISBN 0-9545164-0-0. The author grants permission for these guidelines to be downloaded, copied and distributed freely, but does not grant permission for their sale.