Thursday, November 18, 2010

Term Paper on Alcoholics Anonymous

Term Paper on Alcoholics Anonymous

Founded in Akron, Ohio, in 1935 by two alcoholics, Bill Wilson and Dr. Robert Smith, Alcoholics Anonymous (AA) has grown to become the most popular self-help organization in the world for individuals with alcohol-related problems (McCrady, Horvath & Delaney, 2003). Latest figures indicate that there are 2.2 million members worldwide, ninety-seven thousand of which live in Canada (Alcoholics Anonymous World Services website, March 10, 2003). For many people, self-help towards abstinence through AA is the only treatment for alcoholism they receive and for others the program serves as an adjunct and/or follow-up to professional treatment (Tonigan & Hiller-Sturmhofel, 1994). However, it is crucial to remember that popularity does not equal efficacy and in light of the numbers of people choosing or being referred to AA it is important to determine whether or not the program is an effective treatment for alcoholism.

Despite decades of research, the answer to the question “Does Alcoholics Anonymous work?” remains controversial. While anecdotal and correlational data suggests AA attendance is associated with decreased drinking and maintenance of sobriety (Connors, Tonigan & Millar, 2001; James, 1978; Emerick, 1987; McBride, 1991; Pettinati, Sugerman, DiDonato & Maurer, 1982) empirical research has failed to support the efficacy of AA over other alcoholism treatments (Bebbington, 1976; Miller & Hester, 1986) and in some cases no treatment at all (Kownacki & Shadish, 1999; Miller, 1997). This essay will review several lines of evidence against the position that Alcoholics Anonymous is an effective treatment for alcoholism.


Randomized Clinical Trials
To date randomized clinical trials have generally failed to support the efficacy of AA over other treatments. In a controlled experiment Miller and Hester (1986) found AA to be no better or worse than alternative treatments for alcohol problems while other research involving alcoholic employees who were randomly assigned to inpatient treatment, compulsory Alcoholics Anonymous meetings, or a choice of options revealed that participants assigned to AA did least well and required more additional treatment than those assigned to other treatment groups (Miller, 1997). More recently a meta-analysis of twenty-one controlled experiments by Kownacki and Shadish (1999) revealed that randomized experiments indicate that at best AA is no better than other treatments and in the case of mandated attendance may in fact be significantly worse. While nonrandomized studies have shown AA to have more positive treatment outcomes compared to other treatment and controls.

These findings suggest two things: (1) AA is a less effective option than other programs for alcoholics who are mandated to undergo treatment. This becomes important when one considers that over one third of AA members are coerced into attendance by courts, prisons and employee assistance programs (Bufe, 1998). (2) Successful outcomes attributed, by correlational studies, to Alcoholics Anonymous may instead be the result of pre-existing personal factors, such as an individuals motivation to succeed in treatment and a belief that the program will work for them.

Attrition Rates
Another indication of the ineffectiveness of AA is the high drop out rates among members. While AA claims that seventy-five percent of its long term members maintain abstinence (Thurstin et al. as cited in Fiorentine, 1999) this fails to take into consideration the fact that between eight-seven and ninety-five percent of new members drop out within the first year (Bufe, 1998; Galaif & Sussman, 1995). McIntire (2000) questions the validity of these high attrition rates by stating that many first time attendees are not alcoholics seeking help, but rather are friends and family members there to lend support to an alcoholic member or other people (students, professionals) seeking information. Evidence for a rebuttal of this type would necessarily involve a comparison of the drop out rates between “open” and “closed” meetings, which McIntire does not provide.

Emrick (1987) provides further evidence of AA’s lack of “holding power” citing research that found alcoholics assigned to AA treatment drop out within the first ten meetings (68%) at a much higher rate than those treated professionally.

While it is unrealistic to suggest that in order to be considered effective AA must work for everyone, these large and rapid dropout rates do suggest that the current reliance on AA as the mandated treatment of choice for alcoholism should be questioned.

Seventy to ninety percent of people with alcohol problems will relapse (Hodgins in lecture, Psyc 501.13) and these lapses in abstinence have been shown to be more problematic for AA members than for non-members. In a controlled study comparing the effectiveness of AA and Rational Behavior Therapy, Brandsma et al. (as cited in Kownacki & Shadish, 1999) found that three months after treatment, incidents of bingeing was higher among the AA treated alcoholics. Also, research by Polich et al. (as cited in Galaif & Sussman, 1995) indicates that people attending AA are more likely to report severe consequences and symptoms of dependence after a relapse.

Taken together, these findings seem to imply that with its central belief that an alcoholic is powerless to control his/her drinking, AA is unable to provide members with skills that will allow them to effectively cope with lapses in abstinence and this leaves them vulnerable to a self-fulfilling prophecy of uncontrollable drinking and more severe relapses. An important question that remains to be answered is how attrition is related to relapse. Do members quit because they relapse or do they relapse because they quit?

AA’s explicitly spiritual/religious framework makes it a less effective treatment for atheists, agnostics and people who are struggling with their beliefs about God. Tonigan, Miller and Schermer (2002) found (1) that atheist and agnostic clients attended AA meetings significantly less often and were more likely to drop out than others, and (2) that while AA attendance was associated with increased abstinence regardless of beliefs, attendees who were unsure about their religious beliefs drank more, on drinking days, and suffered more severe consequences than others.

Considering that AA’s effectiveness for long term abstinence has been found to be positively correlated with the number of meetings attended it appears that treatment recommendations involving AA attendance would be less appropriate for alcoholics who are self identified as agnostic or atheist and those who are ambivalent about religion.

Cult-like Qualities
Alcoholics Anonymous has several “cult-like” traits among them are: a) AA members encourage and foster dependence on the program as the only road to recovery (Bufe, 1998), b) a strong affiliation with the group results in a lack of other social involvement and withdrawal from nonmembers (Galaif & Sussman, 1995), c) association of one’s “Higher Power” directly with the program leads some to become “addicted” and unable to maintain a life outside the program (Yoder as cited in Galaif & Sussman, 1995), d) AA is dogmatic and those who do not accept and embrace its concepts may be made to feel unwelcome or unworthy (Bufe, 1998).

These qualities, while serving to enhance group cohesiveness may make affiliation with the program more difficult for those who may be struggling with the key notions of powerlessness and a “Higher Power”. This may well be a contributing factor to AA’s high attrition rates and leaves perhaps the most vulnerable alcoholics to slip through yet another crack.

Natural Recovery
Still further evidence against AA’s efficacy as a treatment for alcoholism is found in the documented rates of spontaneous remission or natural recovery. In a review of the research on spontaneous recovery among alcoholics, Smart (as cited in Bufe, 1998) estimates the rate of natural recovery to be 3.7% to 7.4% per year. A more recent study by Dawson in 1996 (as cited in Peele, 1998) reported that 20 years after the onset of alcohol dependence, 90 percent of those never treated were either abstinent or drinking asymptomatically.

Upon comparison of the figures above with AA’s success rates where it is estimated that between 2.9% and 7% of those who have attend AA achieve long term sobriety (Bufe, 1998) and that between 50% and 68% of active members become sober or drink significantly less (Emrick, 1987) it seems evident that AA at best is no more effective as a treatment for alcoholism than natural recovery.

Based on the literature reviewed here there are several conclusions that can be drawn about AA as a treatment for alcoholism:
1. The strongest research support for AA efficacy is correlational which is unable to attribute improvements directly to AA and may in fact be due to an individual’s motivation to become and maintain sober.
2. Randomized clinical trials have generally not shown AA to be more effective than other treatments; instead indicating that mandated AA treatment may be less effective than alternatives.
3. Attrition is a large problem for AA, with approximately 68 percent of new members dropping out within the first ten meetings and between 87 and 95 percent no longer members after the first year.
4. Relapse when it occurs is more severe in both quantity and consequences for AA members than for other alcoholics.
5. AA may not be effective for alcoholics who are religiously ambivalent.
6. AA fosters dependence on the program and may become a substitute “addiction” resulting in withdrawal or conflict with family and friends who are nonmembers.
7. AA success rates are lower than the rate of natural recovery from alcoholism.

In the end these conclusions lead to the bottom line that Alcoholics Anonymous is not a particularly efficacious treatment for alcoholism. At best AA is no more effective in the treatment of alcoholism than any other treatment, including the passage of time, and may in fact be worse for the alcoholic coerced into treatment.

There are several reasons that might account for the AA’s apparent lack of efficacy in the scientific literature and these involve the foundations of the group itself. As a faith based organization Alcoholics Anonymous is not concerned with proving, scientifically that it works. For members why and how AA works or for whom it does or does not work for are not of great concern, it works for the people who work the program.

However the fact that correlational and anecdotal evidence suggests that AA does work to initiate and sustain abstinence should not be ignored. In order to work towards ending the efficacy controversy further research should attempt to understand why so many people drop out of AA early on and what, if anything, brings them back. As well, the difference between the outcomes of voluntary versus coerced members suggests the need for more research comparing coerced and volunteer participants on outcomes of AA versus no treatment. This design would help to clarify the relationship between motivation and treatment. Finally, with the growing research on relapse prevention in addictions treatment it may be useful to investigate how successful AA members cope with stressful situations and relapses.

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