Not so long ago Alcoholics Anonymous was regarded with condescension by many professionals working in the addiction field. A common view was that science-based techniques, like Cognitive Behaviour Therapy (CBT) had made the Anonymous Fellowships seem like a quaint and outmoded quasi-religious cult.
At the same time, there were encouraging signs of scientific method being employed in the evaluation of both AA’s effectiveness, and of the value of the 12-step based Minnesota Method as practised in many treatment centres (Cook, 1988; McCrady & Miller, 1993).
But the critical event leading to greater respect from the scientific establishment for the practices of AA was the publication of the results of Project Match in the 1990’s. This large-scale definitive study found that teaching alcoholics the basic tenets of AA philosophy and practice and encouraging participation in AA was at least as effective in facilitating recovery as was CBT.
Subsequently, research into how AA works has continued unabated, and I wish now to highlight in particular a recent study from the USA that has examined the role of 12-step attendance with respect to current concern with the problem of “co-morbidity” – that is, the presence in an individual of a psychiatric condition like major depression alongside that of drug/alcohol addiction.
It’s now generally recognised that addicts with a “co-morbid” diagnosis of major depression present a particular challenge in treatment. Participation in AA/NA was shown in 2003 to have a beneficial effect on abstinence, whether or nor co-morbid depression was evident (Kelly et al 2003). A very recently published study shows just how important attendance can be for clients with both diagnoses (Worley et al 2012). 12-step treatment of co-morbid substance use and major depression was investigated,
in comparison with use of CBT. This study shows that 12-step attendance in itself, regardless of strength of affiliation, mediated a significant reduction in depression. In turn, the lower depression mediated an improvement in substance use.
The improvement in depression in those treated by 12-step facilitation (TSF) actually exceeded that in a CBT group. Moreover, the beneficial effects of 12-step attendance on depression were also evident in those clients in the CBT treatment group who chose to attend the 12-step meetings. In summary, major depressive disorder is not an exceptional problem for those attending 12-step groups because AA attendance itself has a beneficial effect on depression, and lower depression leads to successful recovery from addiction.
There is an apparent problem in regard to clients with dual diagnosis or “co-morbidity”, as to which condition – the addiction or the accompanying psychiatric condition, in this case major depression – should have priority in treatment. If the findings in this study can reliably be confirmed then I think two conclusions emerge that illustrate the essential interdependence of the two tasks.
First, in this particular group of clients, it is important to reduce depression as a prelude to effective therapy for substance use. Second, AA attendance in itself helps bring that about reduction. What in particular is it about attendance at AA that is important in this process? It would appear that it is not all to do with enthusiastically following the programme, important though that might be. I would suggest that the most important factor is the sense of hope that comes from social identification (or fellowship) with those who have found a meaningful route to personal wellbeing in recovery.
Professor Geoffrey Stephenson
References
- Cook, CCH (1988) The Minnesota Model in the management of drug and alcohol dependency: miracle, method or myth? Part 2. Evidence and conclusions. |British Journal of Addiction
- Kelly JF, McKellar JD & Moos, R (2003) Major depression in patients with substance abuse disorders: relationship to 12-step self-help involvement and substance use outcomes. Addiction, 98, 499-508.
- McCrady BS & Miller WR (1993) Research on Alcoholics Anonymous: opportunities and alternatives.
- Worley, MJ, Tate, SR & Brown, SA (2012) Mediational relations between 12-step attendance, depression and substance use in patients with co-morbid substance dependence and major depression. Addiction, 107, 1974- 1983.
When I initially sought help for the drug and alcohol abuse that was threatening to swallow my life, I was diagnosed with bipolar disorder, prescribed zoloft, xanax and talk therapy. There was no mention made of me possibly being an alcoholic, by my doctor or therapist, although I was honest about my drug and drinking history. After three years I was still returning to drugs and alcohol and decided to try AA and quickly identified as an alcoholic. At nine months sober, I made the decision to try life without meds and therapy to see whether my bipolar symptoms were actually alcoholism and treatable using the spiritual tools I had acquired (the steps, a sponsor, sponsees, regular meting attendance, prayer, regular contact with other alcoholics, etc.). I tapered off the meds under a doctor’s direction, which as no picnic, but in a few weeks I found myself having less depression than I had while still on meds. 41 months later, I am able to manage the bipolar symptoms by using the tools of AA, a regular program of exercise, and a daily regimen of fish oil, b-vitamins, and st john’s wort.
I agree that identification and regular contact with like-minded people helps my depression (we call that ‘the fellowship of AA’). But working the steps to clear the wreckage of my past and working steps 10-11-12 daily I very much doubt I’d still be sober. Whenever I slack off on my AA program, the depression and elation intensify. Even with a strong program I am not completely free of peaks and valleys, but the sine wave is much shallower and the periods are days or weeks rather than hours or days. I have had periods off the st john’s wort, but I find it helps with the depression (it was recommended by my doctor).
I believe my manic depression had at least in part a spiritual component, and AA addresses that.