The Irrationality of Alcoholics Anonymous

The biggest issue I have with a court mandating AA is that it is not licensed treatment. It's a support group.

Treatment options are rarely cheap. Or free. If the court orders formal treatment, who pays? The drug addict who has blown through their entire savings? Who may not have health insurance? (Even if you do, most insurance caps out at 30 days for inpatient rehabilitation which is rarely enough time to recover--and doesn't consider that relapse is possible and likely given that many folks have to go at this multiple times.)

Until healthcare makes other treatment options more affordable and accessible then addicts are essentially left with non-treatment options like AA.

I would personally love to hear about a free (or extremely low cost) treatment that has availability options similar to AA. Many people would.

CrastersBabies said:

(Even if you do, most insurance caps out at 30 days for inpatient rehabilitation which is rarely enough time to recover--and doesn't consider that relapse is possible and likely given that many folks have to go at this multiple times.)

Click to expand...

And even if you do, most rehab is still the same 12-step dogma.

There isn't much as far as actual medical treatment in the US.

SBI has been tested for provision by physicians, nurse practitioners, nurses and other providers, and it has been tested in emergency departments, primary care clinics, and other contexts. In many clinical settings, this means those who have access to medical care through Medicare, Medicaid, private insurance, or other means may be able to find a provider that offers this care. For risky drinkers identified as needing more intensive intervention, there are other structured protocols that are also evidence-based, many of which are also covered under existing public and private insurance policies.

For example, SBI with referral and treatment (SBIRT) is covered under Medicaid in Vermont:
http://sbirt.vermont.gov/wordpress/wp-content/uploads/2014/02/Medicaid-Billing-Codes-for-SBIRT1.docx

It is covered in Colorado to those on the Medical Assistance Program:
https://www.colorado.gov/pacific/si...ntion and Referral to Treatment (SBIRT)_0.pdf

It is covered under Medicaid in Oregon:
http://www.sbirtoregon.org/billing_codes.php

It is covered under Medicaid in Iowa:
http://www.healthcare.uiowa.edu/icmh/documents/SBIInformationalLetter.pdf

And so on. The problem generally is finding a provider. Dr. Mike Fleming ( https://www.youtube.com/watch?v=u08e6lKRgME ) helped develop the SIMmersion online training course for providers of SBI, which is designed to be used in brief encounters. Most of the SBI interventions studied in the research literature were limited to 10 (at most, 15) minute interactions, with multiple interventions over time.

Since it is becoming a billable intervention and since there is a well-tested training model available, one can only hope that the numbers of providers will increase.

Added: Canada has made SBI an integral part of its National Treatment Strategy to address substance abuse: http://www.ccsa.ca/Resource Library/nts-systems-approach-substance-abuse-canada-2008-en.pdf

I'm not saying SBI is the only answer. I'm saying it is a criminal shame that it is recommended as the foremost option by the CDC and the WHO, and is covered by many forms of medical insurance, and has an evidence-based means of training providers, and is relied on internationally as a key first step of public health initiatives, and is still not well-known by many in the US, including what seems to be a predominance of medical providers and court jurisdictions.

That is not the fault of AA. It is, however, a damn shame.

Medicaid options are great, but not everyone has medicaid or qualifies. Many might fall in the health insurance cracks, so to say. It's easier now, though.

Filling out a medicaid form isn't something you crank out in 10 minutes, drop off at the facility, then walk out with medicaid. I used to volunteer to assist low income folks (many who were addicts) with filling out assistance forms. The form for my county is 47 pages long asking for information that can take time to obtain.

Waiting periods are 45 days to get approval (or denial).

Now that 45 days have passed and you get approval, are you still wanting to get clean? Or have you changed your mind? Even though I'm there to help them fill out their forms, about 30% would throw their hands up and say, "Look, never mind. I'll figure it out." Are they not ready? Or was that just a missed opportunity?

That said, facilities that will take medicaid (in many areas)--or, are state-run--may have no room. No empty beds and usually a waiting list. Some facilities have a TOTAL of 8-10 beds with waiting lists that go 6-12 months out. 100-120 people ahead of them. Some don't even have a waiting list and tell you to call back the next day and ask if there's something available.

SOME private companies take medicaid. Navigating that system isn't easy, though. Some have limits as to how many medicaid patients they will accept and cap it out.

This is clearly a problem with our health and social support system. But it does impact the options. Lots broken here.

Not saying that AA is the only way, but still pointing to the fact that no program is as accessible (pretty much 24 hour assistance) and affordable. You need help RIGHT NOW? You can get it with AA.

Until another system pops up that can compete with that, then it will continue to remain the top option. Again, not saying that's a good thing. I'd rather see mental health and healthcare in general take a step in a more diverse direction.

CrastersBabies said:

You need help RIGHT NOW? You can get it with AA.

Click to expand...

Some people can get help with AA. What research there is (admittedly very little & not very good) indicates that about 5-8% of people who start AA find a substantial benefit from it.

For some others, the outcomes are worse for them than if they had not tried AA. This includes those who are sent through the court system in an not entirely voluntary way, but it also includes people with an experience like kuwisdelu, who may come to the belief that if they fail at AA, then there is no point in trying, because it is either AA or nothing.

Added: Look, I'm not objecting to AA for those for whom it works. I'm saying that the best evidence is that it works for a very limited number of people (although it may work very well for them, which is great). But--critically!--be careful about recommending it without substantial caveats, because that very recommendation can make things worse for some people. We have testament to that in this very thread.

Recommending AA is not itself an entirely benign procedure.

CrastersBabies said:

You need help RIGHT NOW? You can get it with AA.

Click to expand...

...assuming AA is the kind of help you need.

If it is? Great!

If not? Sucks to be you.

I'm really sorry about that. Sucks, indeed.

This isn't exactly new. This has been an issue for a while, especially since court mandated treatment programs are often AA based, and they have been argued to violate religious freedom (since AA references "God" a lot, and regardless of what some people say, the word "God" comes with some very specific Abrahamic religious associations), and yes, the success rate is not terribly high.

AA groups are free, which is one part of their appeal, I think. My dad quit drinking by going to therapy and taking antidepressants (his drinking issues were partially self-medicating depression, which of course only made it worse in the long run). But not everyone has the money for therapy and antidepressants.

But cost aside, there's something very seductive/appealing to AA and its associated groups (al anon and so on) however. My mom got into al-anon when she had it up to here with my dad's drinking issues (I think her decision to be zero tolerance actually did pressure him to go to therapy, though he never went to a 12 step group because of the god thing, and because he'd rather have died than sit in a circle doing what he considered navel gazing--he was pretty introverted). Interestingly enough, my mom's still a member, even though my dad stopped drinking more than 10 years before he died, and he died 9 years ago. I've asked her who the other addicts in her life that's she's still worried about enabling are, and she never really answers me (it's not me, since I have maybe one drink a week).

She obviously gets something out of going, and we've been around and around about the scientific evidence (or lack thereof) behind the actual efficacy of 12 step groups. She's a very scientific person generally, but she has a blind spot there. She lapses into non falsifiable tautologies, like "people who fail at AA do so because they don't commit to the group or process, or they don't really want to get better. When people are ready to commit, it helps them..."

At least in her case, it's not hurting anything. I'd worry more if someone with a serious drinking issue tried AA and failed, then assumed there were no other programs or approach that could possibly benefit them, since everyone "knows" AA is the "best."

.

benbradley said:

Drinking is SO demonized in AA that for members it is the worst possible thing that one could do or that could "happen" to one. Thus it's not surprising that many long-term members who drink again end up committing suicide. AA members interpret this as "the progression of the disease," that even as you're absinent and working the steps, the disease progresses, and that if you drink again your drinking will be at the point where it would have been had you been drinking all along. So in an AA member's mind, it's no surprise that "this disease" kills you.

Click to expand...

How common is this? I am curious because I know someone who did this.

.

Pyekett said:

bombergirl69, I'm reposting this question because I think it got lost at the page turn.

Perfectly happy if you'd rather not respond, just really interested in the answer if you're so inclined. When wearing a different hat, I've looked very hard for such research and found myself left wanting.





Added: I don't blame AA for not being research evidence-based or for its model dominating the US model for risky drinking response pathways in the legal and medical systems. It's a shame that there hasn't been more attention paid to approaches that are more evidence-based in the research sense and have substantial research behind them in other countries. Those approaches are designed as pathways for more widespread use across the entire population.

Being evidence-based is also critical for quality assessment and improvement if it is part of a court-mandated response, or if it is being promoted by organizations that use tax dollars for their support structure even if not directed towards AA, or if it is being recommended by physicians. In those cases--and in other contexts--having solid numbers matters. It matters a lot.

Not important to AA, and not their mission. I get that. But yes, important for external reasons, even if not internally important to AA or those who find it does serve them well.

Click to expand...

Hi and not being a dick at all wanting citations!

I'll flip through some files today and grab more current stuff, but these are abstracts

http://www.tandfonline.com/doi/abs/10.1300/J020v21n01_01

here is a quote from that abstract An increase in AA activities, other than AA meetings, between baseline and the year 1 follow-up was also associated with a higher odds of sobriety, highlighting the importance of increased AA involvement in the period immediately following treatment episodes.

http://alcalc.oxfordjournals.org/content/38/5/421.short

Significant improvements in drinking behaviours (frequency, quantity and reported problems), psychological problems and quality of life were reported. Frequent AA attenders had superior drinking outcomes to non-AA attenders and infrequent attenders. (although authors note that "improvement" did not mean "cure")

http://www.tandfonline.com/doi/abs/10.1300/J020v18n01_02

Increased engagement in AA-related practices and beliefs was predictive of statistically significantly more abstinence and less intense drinking when drinking occurred.

I'll see if I can find some others

Fruitbat said:

Let's not forget it's also extremely common for alcoholics to want to be able to keep drinking but just "control it better." But if they could do that then why didn't they after the first eight times they got dried out (or whatever). I mean, if they could drink in moderation, then they wouldn't be alcoholics.

Click to expand...

There are structured approaches that do not involve the 12-step approach of AA but instead focus on harm reduction. These are studied, published in the research, and have measurable and reproducible rates of success.

Many times the reason risky drinkers "didn't after the first eight times" is because they didn't have any additional supports.

Part of the problem is that it is prevalent to think it is either AA or you're on your own. You might be on your own, if you do not (or just think you do not) have access to other supports.

Generally you aren't on your own if you live in other countries whose medical and public health systems have a better track record than the US of handling substance abuse problems. You might not even be on your own in the US, not if you are made aware of other options you might already have, and not if the general public is made more aware by conversations like these leading to better funding and access as a priority.

Just saying, just because that's how they want it to work and try to demand that it work, that doesn't mean that's the nature of the beast.

Click to expand...

Nope. But there is research on this. A lot of research. That's research the rest of the world seems aware of, as well as the CDC and the WHO.

Also, I don't know where the success rates mentioned in this thread are coming from. AA is anonymous so I don't see how they'd be able to keep records on people. And then even if that was accurate, what program does better?

Click to expand...

This is in the text of the article linked.

"In his recent book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, Lance Dodes, a retired psychiatry professor from Harvard Medical School, looked at Alcoholics Anonymous’s retention rates along with studies on sobriety and rates of active involvement (attending meetings regularly and working the program) among AA members. Based on these data, he put AA’s actual success rate somewhere between 5 and 8 percent. That is just a rough estimate, but it’s the most precise one I’ve been able to find."

"A meticulous analysis of treatments, published more than a decade ago in The Handbook of Alcoholism Treatment Approaches but still considered one of the most comprehensive comparisons, ranks AA 38th out of 48 methods. At the top of the list are brief interventions [SBI] by a medical professional; motivational enhancement, a form of counseling that aims to help people see the need to change; and acamprosate, a drug that eases cravings."

.

There are also studies showing negligible gains, which can get into the discussion of what "attendence" definition one is using (how often? sponsorship? participation in social activities?)

My point is that it is not true that there is "no support" for AA involvement. There is. But anyone who says that AA is the only way, that only AA works, that AA cures people, that people who don't get anything out of AA are doomed is also IMO uninformed.

The whole issue of mandating treatment (of any sort)is an interesting one, but one not limited by any means to AA. The aea of motivational interviewing arose to address that vary thing in a medical setting, namely, helping people move through stages of readiness for change so that they do make positive life changes (lose weight, stop smoking, eat more broccoli, whatever)

Fruitbat said:

Pyekett, what you say may or may not be the truth. There are many studies, and many of them conflict with other studies.

Click to expand...

I mean this gently, and I say it with respect: we can agree to disagree. I will maintain great respect for you and your passion.

There is evidence, and there is research, and there are systematic meta-analyses of the research studies to assess which studies were better done to help guide us through the morass of research literature. There are also position statements by major health organizations which are not being attended to by those who determine policies and funding.

There is really nothing to argue about because again, AA does not endorse nor try to negate any other philosophy. It's just there for anyone who chooses to go there. It's other people who are saying they "heard people at AA" say this or that. That is not AA saying they are the only way.

Click to expand...

On this we completely agree. I will say it again that I do not place fault or responsibility for the lack of awareness of other approaches at the feet of AA.

I do hold governmental policy, judicial, and medical systems accountable for not seeking out and promoting other approaches.

.

bombergirl69 said:

Hi and not being a dick at all wanting citations!

Click to expand...

Hey, thanks.

I'll flip through some files today and grab more current stuff, but these are abstracts ...
I'll see if I can find some others

Click to expand...

What I'm looking for in particular is evidence that "for those with severe substance use disorders, AA enhances sobriety rates." That is, evidence for the entire group of those with substance use disorders, AA is useful--not just for a certain subset or for those with certain qualities, such as high religiousity. I'm also looking for hard data with statistical and clinical significance for that entire group.

We might be looking for different things. That's okay, too. My interest is in population-based measures, and yours may be in individual possibilities. I focus on populations because one of my other hats is assessing evidence for justifying funding by public health organizations (that by their mandates are serving the entire population) and justifying judicial recommendations (that by their nature are addressing the needs of the population, not just, say, those with high religiousity).

There is no question that AA is extremely helpful for certain people. The evidence does not seem to be there to support it as an effective approach for most people. Again, that does not mean it isn't effective for some. I think the "irrationality" of the reference in the OP refers to the irrationality not of AA itself, but of having it promoted by other as the only way or even the best way for the group of all people with risky drinking behaviors.

That's external to AA, not internal to it.

.

CrastersBabies said:

I would personally love to hear about a free (or extremely low cost) treatment that has availability options similar to AA. Many people would.

Click to expand...

so would most providers!

But you do touch on a HUGE issue. What is the legal system to do with people who do pose some kind of safety risk (multiple DUIs) and indicate NO interest or ability (more often the case) in stopping? Yes, we have drug courts but those don't really address the "is treatment effective" question.

In AZ (at least used to be the case) 3 DUIs and you were joining tent city (prison). But other states (MT) people get 5,6, and waaaay more DUIs as judges are stuck, for exactly the reasons you stated, thnking"This person has no money and no insurance. THey cannot afford private therapy". Yes, the state will pay for some of it but not all of it and that person will be stuck with a bill that can be totally unrealistic.

Even inpatient treatment,as you (someone?) pointed outis only for 28 or 30 days, and then what? And yes, in MT we have a state run ("free") facility, but there is a 6-8 week waiting list.

So what are people to do?

i don't see that as the "fault" of AA, which again, is not treatment itself. It is just one option, which is not for everyone. Making other options cheap and available is obviously an EXCELLENT idea!

Fruitbat said:

Pyekett, AA and Al-Anon are anonymous. They are not being well studied when no one even knows who is there, let alone is able to track them through time.

Click to expand...

Right. You can get more information about the limited research that has been done regarding AA rates of success through the references I listed.

Also, AA/Al-Anon is not involved with "policies and funding." It operates on the donations of its members. So, I don't understand what you're talking about. I think you may have it mixed up with something else. ?

Click to expand...

Nope.

See my last post. This is a criticism of how AA is being used by other agencies, not of how AA runs itself.

ETA: It's about as laid back and nonpolitical as you can get. They don't argue. If people want to show up at a meeting, they can. That's it.

Click to expand...

Right. And if you want to assess various approaches to substance abuse management (including AA and others), you can.

I'd argue it is the responsibilities of public agencies who recommend or require interventions for those with substance abuse problems to do just that.

Added: I'd also argue that it is a good idea for those of us engaged in public discourse about these matters to touch on other approaches, at least in part. If other approaches are not a part of the public discourse, they should be. People should be aware of them, just as people should be aware of AA.

.

Fruitbat said:

Yeah, I agree that it seems other agencies are trying to "cheap out" and have AA do their work for them when that's not really what it is. Plenty of people who are in a structured professional program also go to AA for the peer support and social events. Peer support that follows a set of guidelines is not professional treatment. I mean, you don't even have to say if you're showing up at any meeting or not, it's very loose and voluntary. I guess the other agencies are pushing their clients off onto AA just because as others have mentioned, AA is free and treatment is expensive.

Click to expand...

Yep. This is a sad tale.

It's also a weight that AA never asked for. My understanding is that having people feel coerced into going to meetings does not make it better for those who really want to be there--for them, it makes it worse.

What an unkindness, to put it mildly.

.

Fruitbat said:

ITA. I guess the studies you mentioned must be that they are tracking the ones they forced to go to AA (or at least held jail over their heads if they didn't).

Click to expand...

No, not just those, but they are included, too. That particular study looked as best it could at what happened all people who came to AA for at least one visit during a given period of time, and how often they came back, and for how many times.

This included court-mandated attenders, but it also included people who entirely voluntarily tried the approach but for whom it didn't work. For some of these people, like (if I am reading correctly) kuwisdelu, a different approach might work. And so it's worth noting that there are other approaches to treatment.