My own experience

By an AA member

I first came into contact with Alcoholics Anonymous 20 years ago. I had just been discharged from mental hospital after a suicide attempt and after losing two jobs within a few weeks. AA was the main thing which kept me going over the following months, although I also got help from family, friends, my doctor and my therapist. I have not had an alcoholic drink since my first AA meeting. I have had many problems getting my life together since then, not least with depression.

With the benefit of hindsight depression was probably one of the reasons why I drank, but the drinking was more a cause than an effect of my problems.

I still attend AA meetings regularly. I do not want to drink again and I still value the support I get in maintaining sobriety, among other things by listening to people who have had a harder time than I have, have only just stopped drinking or are still trying to stop. AA is also part of my social life.

Carrying the AA message

The 12th step of the AA programme encourages its members to carry the AA message to other alcoholics. The proposition that helping others helps you to stay sober has support in peer-reviewed scientific literature as well as in the practical experience of AA groups. In London, where I live, current initiatives include AA members speaking to school children about their experiences, giving presentations at magistrates courts, working with the probation service and supporting AA meetings at prisons. A seminar about the work of AA was held at the Houses of Parliament in March 2005 and a repeat of this is due in May 2006.

AA has been particularly successful in working with some leading hospitals which provide treatment for alcohol dependence. AA meetings are held in the hospitals and AA members give separate talks to the patients to help them to think about becoming members too.

In other hospitals AA meetings may be held in the premises without such a close working relationship. There may be a clash of cultures. There are sometimes strong contrasts in general approach and language between AA members and those who work professionally in the field of addiction, although both sides are usually trying to achieve what is essentially the same thing.

Working with AA

A doctor in charge of an alcohol treatment unit once told me that I was the first AA member he had met. Others may strongly encourage their clients to try AA without having any direct contact with the fellowship themselves.

Professionals who want to make optimal use of AA as a resource may sometimes need to make a greater effort to understand its programme, meet with members involved in outreach activities and attend a few “open” meetings (which should usually be done far enough away from where you work to ensure that you do not meet your own clients). This is surely not a disproportionate time commitment. It can enable the professional, for instance, to tell his or her patients or clients at first hand what they should expect. You do not have to become an alcoholic yourself (or apply the ‘Minnesota Model’, which involves integrating the AA programme within treatment) to get to this point.

Why should you make the effort? Partly because there is now a sound body of scientific evidence suggesting that AA does work for a significant number of people with drink problems. It operates at no cost to the taxpayer and is paid for entirely by voluntary contributions from those members who can afford to make them. It is also most active outside normal working hours and thus complements the help that can be provided at a professional level.

The need for AA to adjust

AA members actively involved in its public relations activities may need to make an equivalent effort to understand other people’s points of view and find common ground. Involvement in AA outreach activities helps to achieve this up to a point as does, for instance, reading some scientific literature, contact with professionals, attending conferences focusing on alcohol problems and involvement in working groups at a local level.

One of the co-founders of AA, William Wilson, acknowledged that some AA members ‘decry every attempt at therapy except our own’ but the majority ‘don’t care too much whether new and valuable knowledge issues from a test tube, a psychiatrist’s couch or revealing social studies’.

AA has changed considerably over the 20 years I have been a member. There are, for instance, more people under 30 and more women. There are meetings focused on the needs of young people, women, gays and lesbians and some provision in Central London (although still not nearly enough) for child care. It was rare in the 1980s to see anyone from racial minorities at meetings. Now it is rare not to see them. The fellowship is making every effort to provide help to people whose first language is not English or who may have other communication problems or disabilities.

The Internet and email has also helped to spread the AA message. For instance the basic ‘Alcoholics Anonymous’ textbook is now available online in full text in English, French and Spanish as well as being available in hard copy in many other languages.

The anonymity tradition

There is sometimes a tendency to over-interpret the AA anonymity tradition. It only requires members to maintain anonymity at the level of press, radio, film etc. The second cofounder of AA, Dr Robert Smith, argued that maintaining anonymity at any other level and in particular “being so anonymous you can’t be reached by other drunks” was itself a breach of the anonymity tradition. He also considered that AA members should let themselves be known as such in the community.

This may be feasible in North America, but in Europe it is perhaps more an ideal to be strived for. I am a professional myself, although I do not practise in the field of addictions. I do not tell my colleagues at work (whom I have only known for about 18 months) about my past drinking problems and my membership of AA. When I get to know them better, and if it were to serve a useful purpose, I might perhaps do so.

References

1 www.alcoholicsanonymous.org.uk/geninfo/05steps.shtml 2 See Zemore SE, Kaskutas, LE and Ammon LN (2004) ‘In 12-step groups, helping helps the helper’, Addiction 99, 1015. 3 See www.hazelden.org/servlet/hazelden /go/INFO_MNMODEL 4 See, for instance: Vaillant, GE (2003) ‘A 60-year follow-up of alcoholic men’ Addiction, 98, 1043- 1051. Gossop M, Harris, R, Best D, Man L-H et al, ‘Is attendance at Alcoholics Anonymous meetings after inpatient treatment related to improved outcomes? A 6 month follow-up study’ Alcohol and Alcoholism, Vol 38 No 5 421-426. Project MATCH Research Group (1997) ‘Matching alcoholism treatments to client heterogeneity: Project MATCH post treatment outcomes’. Journal of Studies on Alcohol 58, 7-29. 5 ‘Let’s be friendly with our friends’,AA Grapevine March 1958. 6 www.aa.org/bigbookonline/. 7 ‘Doctor Bob and the Good Oldtimers’, page 264, 1980 AA World Services inc

Alcohol Alert (2006) is published by The Institute of Alcohol Studies an initiative of the Alliance House Foundation, www.ias.org.uk

Alcoholics Anonymous is self-help, not treatment

Alcoholics Anonymous is not really a treatment for alcoholism but a community resource for those wishing to stop drinking. Uncontrolled studies of AA have shown that people who affiliate with AA tend to stop drinking and find that their lives improve in many respects (Emrick et al. 1993).

However, evaluating AA alongside professionally delivered interventions presents problems and perhaps should not be done.

AA, the original 12 Step program, is not a fixed form of “treatment” and people are free to participate in different ways. Some go a few times and then drop out. Others go more often, but do not actively participate in meetings or “work the program.”

It is possible that both dropouts and passive participants gain some benefit from the AA experience, but this has not been adequately researched. Only a minority of those ever exposed to AA seem to become full, active members over a long period and consistently “work” all the steps.

There is evidence that certain types of people may be more likely to fully affiliate with AA than others (Ogborne and Glaser, 1981; Emrick et al., 1993), but more research is needed and some studies may no longer be relevant given the current range and diversity of AA groups. However, it seems likely that AA would appeal to those who have experienced serious alcohol-related problems and who can accept the need for abstinence and the term “alcoholic”.

When professionals refer clients to AA, as adjunctive therapy, on the assumption that they will benefit from such referrals, it is reasonable to ask about the outcomes of these referrals and to compare these outcomes with those achieved by other means.

Project MATCH (1997) included a 12-step facilitation intervention and results showed that those who were encouraged to go to AA did as well as those provided with other interventions.

Concise Alcoholics Anonymous and TSF Research Summary

All the elements of TSF have moderate to strong research support, most of which has been replicated.

NB: AA does not participate in research but individual members do. The huge volume of peripheral research supports a strong case for recommending AA participation by alcoholics. Additionally, testimony of the effectiveness of AA are the two million current sober members of Alcoholics Anonymous.

We know: -

• that Twelve Step Facilitation reduces alcohol abuse, improves related consequences, and improves employment prospects.
• that Alcoholics Anonymous has good efficacy, and that Peer Sponsoring/social support is an essential element in AA’s success.
• that recovering people who help recovering people maintain better sobriety and have greater involvement in the general community.
• that men, women, adolescence, African-Americans, Hispanics and gay men benefit from AA. That all socio-demographic groups are represented.
• that AA is also suitable for head trauma victims, and methadone patients.
• that AA has wide acceptance and is readily available in almost all communities. The current global membership of AA is approximately 2.06 million.
• that participation in Alcoholics Anonymous improves medication compliance for mental health patients, improves psychological functioning, Improves coping, reduces child abuse and domestic violence, reduces healthcare usage, reduces hospitalization, reduces medical symptoms, reduces subsequent treatment demand, reduces mortality, and reduces associated costs.
• that healthcare workers have good success rates for substance abuse treatment and recovery from alcoholism that can be improved with AA participation.
• that alcoholics with social networks supportive of drinking have better outcomes if they initiate AA attendance while in treatment.
• that affiliation with AA is enhanced if prospects gain an awareness of the culture and methods used by AA and that sobriety is better than drinking prior to attending AA.
• that 80% of Australian, 87% of USA, and 65% of UK doctors believe that Alcoholics Anonymous is the treatment of choice for alcoholism, but overall they do not understand how AA works.
• that more than 80% of specialist alcohol and drug treatment staff support Alcoholics Anonymous treatment referral and 92% of another specialist A & D service requested training in 12 Step approaches.
• that AA Peer Sponsor contact at the healthcare worker office/institution increases initiation and sustained attendance at AA meetings.
• that active and regular AA participation is one of the more effective ways to effect lifestyle changes for alcoholics.
• that routinely engaging patients in continuing outpatient care is likely to yield better outcomes..
• that most people in the early stages of alcoholism seek help from GP’s or Community Health Centers.
• that individuals with substance abuse medical conditions benefit from integrated medical and substance abuse treatment, and approaches such as TSF can be cost-effective.
• that for every $1.00 invested in intervention with alcoholics $4.30 is saved in future healthcare costs.

The Symptoms of Alcohol Dependence or Alcoholism

What symptoms of alcoholism does adjunctive Brief-TSF address?

Brief-TSF and the symptoms of alcohol abuse.

Medical, psychosocial and spiritual professional healthcare workers are regularly presented with symptoms of alcohol abuse that are readily assessed or which may be masked by other symptoms; or denied.

The Brief-TSF course explores the signs and symptoms of alcohol abuse and dependence and provides screening and assessment tools along with best practice evidence based application of their use.

Medical symptoms of alcoholism.

The medical symptoms of alcoholism are; Hangovers, blackouts, injuries, lethargy, weight gain or loss, poor coordination, high blood pressure, impotence, vomiting, nausea, cirrhosis of the liver, pancreatic disease, brain damage, peripheral neuropathy and tolerance to alcohol.

Psychological signs of alcohol dependence.

The psychological symptoms of alcohol dependence are; Poor concentration, sleep problems, cloudy thinking, depression, anxiety/stress, aggression, loss of control of drinking, denial of effects of alcohol.

Social aspects of alcohol abuse

The social aspects of alcohol abuse are; Difficulties and arguments with family or friends, difficulties performing at work or home, unemployment, withdrawal from friends and social activities, legal problems, financially insecure.

Spiritual affect of alcohol addiction.

The spiritual affect of alcohol addiction are; Dysthymia or mild chronic depressed, ‘restless, irritable and discontent’ (Alcoholics Anonymous, 1976 p Page xxviii), self-centered, insecure, self-pitying, resentful, fearful and feeling useless.

Healthcare workers such as nurses, doctors, psychologists, social workers, faith based workers (pastors, Rabbis, priests, ministers, other clergy), counselors and trained volunteers will recognize these symptoms and be able to address them after completion of the Brief-TSF training course.

Brief-TSF incorporates screening, assessment, disturbing denial, identifying loss of control of alcohol, taking an alcohol abuse and treatment history, assessing effects of alcohol and drugs, relapse prevention, psychological aspects and an overview of Alcoholics Anonymous (AA).

Stages of Affiliation with Alcoholics Anonymous

How do alcoholics get to AA?¹

AA has grown to over 100,000 groups with more than two million members simply on word-of-mouth recommendation. Often the recommendation has come from friends, family, employers, healthcare workers or law courts.

People progress through stages of affiliation with others and with Alcoholics Anonymous in pursuit of solutions to their problems. Two paths are identified; Direct Affiliation and Facilitated Affiliation².

The stages are not necessarily discrete where a person moves in clear progression from one stage to the next. A person is more likely to move up and down, sometimes jumping a stage in regression or progression. However, AA reports that 51% of current members stayed sober from their first meeting.

Facilitation plays a significant part in the process of AA affiliation as approximately 60%³ of AA members seek help from the helping professions prior to attending AA.

These stages of affiliation generally follow Prochaska and DiClemente Stages of Change model and are;

• Pre-contemplation,
• Contemplation,
• Preparation,
• Non-affiliation,
• Affiliation,
• Misaffiliation,
• Affiliation-mandated,
• Supra-affiliation,
• Altruistic affiliation,
• Ambivalent affiliation,
• Disaffiliation,
• Re-affiliation.

For full chart of Stages of Affiliation download PDF file below.

Attached Files:

• microsoft-word-stages-of-affiliation-with-alcoholics-anonymous.pdf (72 KB)

Designed By Professionals for Professionals

Brief-TSF is a professionally written continuing professional education program for healthcare workers.

All disciplines of the helping profession who come in contact with patients may benefit from Brief-TSF training for alcoholism.

The professions included are nurses, doctors, psychiatrists, psychologists, social workers, faith based workers (pastors, priests, ministers, Rabbis, and other clergy) and counselors.

Brief-TSF may also be used by trained and supervised volunteers.

Craving Reduction Medications

What medications are used in the direct treatment of alcoholism?

Anti-craving drugs and Brief-TSF, a good combination.

The process of Brief-TSF supports the use of anti-craving medications to aid in alcoholic relapse prevention. Most prescribing authorities require that alcohol craving medications be accompanied with counseling. Evidence based best practice guidelines recommend the use of craving reduction drugs where appropriate

Alcoholics Anonymous has a clear policy on the use of medications to help restore health. As always AA makes suggestions to its members;

• During their drinking days, many alcoholics made their problems worse by mixing liquor with sedatives, tranquilizers, marijuana, or other drugs. They may cling to the pill or drug habit even after they stop drinking. It will probably also be wise if you encourage the alcoholic to seek medical advice from a physician knowledgeable about the special problems recovering alcoholics experience. Using medications or discontinuing their use without proper professional guidance may be dangerous, and either course may lead a sober alcoholic back to the first drink.

(The pamphlet "The A.A. Member – Medications and Other Drugs" discusses the problem in detail.) (AA, 1976).

’Alcoholics Anonymous and the Use of Medications to Prevent Relapse’.

This study did not find any strong or widespread negative attitudes toward medication for preventing relapse among AA members. Most of those who experienced unfavorable pressure continued taking their health medication (Rychtarik et al, 2000).

Two Craving Reduction Medications

There are two alcohol anti-craving drugs recommended for alcoholism or alcohol dependence. These are; acamprosate tablets (Campralâ„¢) and naltrexone tablets (Reviaâ„¢).

A new formulation – long-acting Injectable naltrexone – is currently under development. May 2007 – Now available in the USA.

Naltrexone Tablets (ReViaâ„¢)

A Cochrane Review of 29 studies from around the world concluded that naltrexone provides real help to people trying to moderate their drinking and "should be accepted as a treatment for alcoholism.”

This study reported that in comparison to placebo, a short-term treatment of naltrexone (ReViaâ„¢) significantly decreased relapse by as much as 36% over and above normal rates, and significantly reduced withdrawal symptoms.

Naltrexone and intensive psychosocial treatment, such as counseling or attending AA meetings, was superior in the medium-term. (Srisurapanont et al, 2005).

Acamprosate (Campralâ„¢) Tablets

Seventeen randomized, placebo-controlled trials of acamprosate (Campralâ„¢) were reviewed covering 4087 alcoholics. Continuous abstinence rates at 6 months were significantly (54%) higher in the acamprosate-treated patients compared to placebo patients. Acamprosate also had a modest but significant beneficial effect on retention in treatment (Mann et al, 2004).

Overall, patients treated with acamprosate (Campralâ„¢) exhibited a significantly greater rate of treatment completion, time to first drink, abstinence rate, and/or cumulative abstinence duration than patients treated with placebo. The drug’s reliable effect on prolonging abstinence, in conjunction with an excellent safety profile, suggests that acamprosate may be useful for a broad range of patients with alcohol dependence (Mason, 2001).

Drinking and craving alcohol must be addressed first

What is Brief-TSF?

Brief-TSF can be used with males, females and youth of any age and is readily adaptable to various cultures or lifestyles.

Brief-TSF is ideally suited to primary care as well inpatient clinics, outpatient clinics or office practice.

Brief-TSF incorporates screening and assessment instruments and methods for differentiating between alcohol abuse and alcoholism.

Brief-TSF is ideally suited for counseling that is a required component of craving reduction medication prescribing.

The generic spiritual principles are acceptable to most treatment organizations and religions.

The basic Brief-TSF principles can be adapted and applied to drug addiction, excessive gambling, eating disorders and emotional problems that have psychological, emotional, physical, spiritual and mental aspects.

Brief-TSF is a both a Harm Prevention and a Harm Minimization strategy. By intervening earlier in the progression of alcoholism much harm will be prevented.

The overall recovery goal of the program is the restoration of health and freedom from the effects of addiction to the drug alcohol or alcoholism.

Brief-TSF addresses the medical, psychological, social and spiritual effects of alcoholism.

Brief-TSF can be utilized by doctors, nurses, psychologists, social workers, faith based workers, trained volunteers and counselors.

How does Brief-TSF work for the alcoholic?

The process of Brief-TSF disturbs denial and highlights the negative effects of alcohol on their lives, to such an extent, that alcoholics are motivated to take action and to sample Alcoholics Anonymous. Brief-TSF is not a therapy program per se; it is the facilitation of patients helping themselves (self help) in a mutual help paradigm.

Brief-TSF can be utilized in three situations as adjunctive to your normal program of practice:

• As a ‘discrete’ structured intervention.
• As an ‘opportunistic intervention’ or relapse prevention, where you can utilize elements as necessary.
• As a ‘knowledge base’ – You will have an awareness and understanding of Brief-TSF theory and methods, and AA practices and culture; you will be able to respect and support a patients choice of treatment while addressing other issues in your special area of practice.

Professional Intervention Program

BriefTSF is suitable for use by generalist healthcare workers; including doctors, nurses, psychologists, social workers, faith based workers and counselors.

Universality of BriefTSF

The basic Brief-TSF principles can be adapted and applied to drug addiction, excessive gambling, eating disorders and emotional problems that have psychological, emotional, physical, spiritual and mental aspects.

AA is often recommended as adjunctive to formal alcoholism treatment

The following are some governments and significant organizations who recommend Alcoholics Anonymous and craving reduction medication as an adjunctive components of professional alcoholism treatment. Some examples are -

Australia ;

• McCabe D., and Holmwood C. (2003), Co morbidity of mental disorders and substance use in General Practice. Commonwealth of Australia, Department of Health and Ageing.
• Shand F, Gates J, Fawcett J, and Mattick R. (2003), Guidelines for the Treatment of Alcohol Problems, Australian National Drug and Alcohol Research Centre (NDARC).
• Dale A. , and Marsh A. (2000), Evidence Based Practice Indicators for Alcohol and Other Drug Interventions; Literature Review, Best Practice in Alcohol and Other Drug Interventions Working Group. Western Australian Government.

Britain ;

• Strang J., (Chair) , (1999), Drug Misuse and Dependence – Guidelines on Clinical Management. Department of Health, England, Scotland, Wales and Northern Ireland.
• Slattery J, Chick J, Cochrane M, Craig J, Godfrey C, MacPherson K, Parrott S. (2002), Health Technology Assessment of Prevention of Relapse in Alcohol Dependence. Health Technology Board for Scotland. National Health Service.

Canada ;

• Roberts G & Roberts A., (1999), Best Practices in Substance Abuse Treatment and Rehabilitation. Office of Alcohol, Drugs and Dependency Issues, Health Canada.

New Zealand;

• Bushnell J., (1999). Guidelines for Recognizing, Assessing and Treating Alcohol and Cannabis Abuse in Primary Care. New Zealand National Health Committee. July 1999.

United States;

• The National Institute on Drug Abuse (NIDA), (July 2002), Principles of Drug Addiction Treatment; A Research Based Guide. National Institute Health Publication No. 00-4180.
• American Society of Addiction Medicine (ASAM).
• USA – National Institute on Alcohol Abuse and Alcoholism (NIAAA)