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Hello everyone and welcome back. In this section we begin discussing
twelve step models and their importance in relation to addiction.
So let's begin by going to slide two. As we can see here, when we talk about
twelve step models they are not really theories. They are more of philosophy
or models for living and recovering from addictions. Twelve step models have
been around for a long time. However they began to be popularized by
Alcoholics Anonymous. That has since been expanded into many other models
such as Narcotics Anonymous, or Gamblers Anonymous, or Sexaholics Anonymous,
or whatever it may be. Twelve step models have also been incorporated into
the standard treatment models for addictions. Some classic examples of these
are Pioneer House and Hazelden. Materials from both of these groups were
ultimately incorporated into the Willmar State Hospital in Minnesota. As a
consequence, all of this material from Willmar State becomes known as the
Minnesota Model.
So, let's begin talking about Alcoholics Anonymous in slide three. It was
founded by Bill Wilson and Bob Smith. As we see here, Alcoholics Anonymous
was originally very similar to many other support groups that were out there
such as the Washington Movement and the Keeley Leagues. Originally, AA was a
rehabilitative moral model and also partially derived from the Oxford Group.
As the development of AA continued on it began to emphasize a disease
concept more than a moral concept. This occurred primarily to the advances
in the knowledge about addictions of the time. Ultimately, AA became much
larger than the other support groups. It spread across the world and since
its inception has shaped alcoholism treatment in a wide variety of different
systems. Every later separate group that has come after AA has been
evaluated against AA.
So, what are some underlying concepts that AA describes? First of all, as we
see in slide four, alcoholism is an incurable, progressive, and often fatal
disease. It is also described as a body and mind disease. One of the big
things about this model is that alcoholism is also considered to be a
spiritual problem and that alcoholics are emotionally impaired people.
Basically, what these individuals do is to try to drink to compensate for
some particular inadequacy. But, due to their biochemistry or their
genetics, the person becomes addicted to alcohol. This then creates a
circular process. You get more inadequacy...more drinking. Then the person
begins to have more problems physically, mentally, and spiritually. And
later you have to continue drinking to prevent the withdrawal symptoms.
In addition, and as we can see in slide five, Alcoholics Anonymous and other
groups contend that alcoholism is a permanent condition. It can be arrested
but can never be cured. Thus for the individual he must be going to AA or
your prognosis is hopeless.
There is a wide variety of steps that occur in AA and these are shown on
slide six. You can read in the big book about these steps and more
information on that. Let's walk through a few of these. We have admitted
that we are powerless over alcohol and that our lives had become
unmanageable. We ultimately came to believe that a Power greater than
ourselves could restore us to sanity. We made a decision to turn our will
and our lives over to the care of God as we understood him. The reminder of
these steps are shown in the next two slides including asking God to remove
our shortcomings, making lists of people we have harmed, and on, and on, and
on. In addition to the general steps of AA there is also a variety of
traditions that go along with AA. These are both shown on slides eight and
nine. One of the key ones is the requirement to belong to AA; all you have
to do is to stop drinking. That is the only requirement. And, anonymity is
extremely important. So again, both of these sets of materials, the twelve
steps and the twelve traditions for AA are extremely important.
So, what are some issues associated with AA? Well, as we see in slide ten,
when we look at it from an early examination model there was minimal
empirical support for it. AA literature did not emphasize the disease or
medical model at its inception. Basically, the disease or a medical type of
explanation was used to explain to the client what was going on. Even at the
time when AA was developed the disease model was still not clearly defined.
As time passed, AA models began to incorporate the findings of Jellinek. It
used the "X" factor talked about earlier as the underlying cause of
alcoholism.
Later, as shown in slide eleven, the "X" factor becomes a genetic problem.
The problem with this is that genetics models have problems with validity
and reliability. However, that does not stop AA and other modals from
claiming alcoholism was genetic. Again, we have to remember that correlation
and causation are different.
So what about the empirical basis for AA? Well, as we can see in slide
twelve, there was not much separate for identifying the cause of addiction
or the models success. And that had to do with the anonymity and a wide
variety of other issues.
However, as we see in slide thirteen, practically, AA models had a lot of
advantages. It gave reasons why a person became an alcoholic in a way a
person could understand. It also gave a progression of steps that a person
must undertake to resolve the addiction. This was different from all the
other models before AA which tended to use psychoanalysis, which did not
work well at all, or some kind of moral underpinning which said to trust in
God and that's about it. So this model is giving a wide variety of steps to
help the individual. As time went on AA began to develop an advocacy group
and these individuals also work with individuals who had problems with
addictions. Now, regardless of what one thinks about AA empirically or about
what one thinks about AA spiritually or emotionally, the impact of AA on
addictions, specifically alcohol treatment has been huge. It has helped
thousands and thousands of people not just within the United States but
across the world.
However, there are some problems with twelve step models and these are shown
on slide fourteen. For many twelve step programs you must buy into the model
completely for the treatment to be successful. That means you must buy into
the spirituality component of the model. Other models are seen basically as
misguided, or irrelevant, or just plain wrong. Some of these other models
are considered to be just plain dangerous. Classic example of that is
Controlled Drinking, from the learning model.
In addition to that as seen in slide fifteen, the use of correlational
evidence is huge within the AA community. A lot of people have used AA so
the conclusion must be that it works for everyone! So there is a lot of "buy
in" by politicians, judges, therapists, etc. In addition to that, you must
incorporate a twelve step approach into your treatment model regardless of
whatever that model is. If you do not your treatment program must be bad.
The consequence is as we see on slide sixteen, lots of people enter twelve
step programs but also lots of people drop out. Lots of people do not buy
the spirituality component of the model. The consequence of all of this is,
for many individuals in power positions, that is, through the judicial
system, probation/parole, or even in substance abuse treatment the notion is
this, if you do not go to AA or a similar organization you really are not
serious about your treatment. As a consequence, you can have legal sanctions
garnished against you. Ala, they throw you in jail.
In addition as we see in slide seventeen, for twelve step programs there are
many treatment issues as well. For example: you must a continuous or
permanent involvement in AA for your program to be successful. The problem
is that it is not backed up by the data. In addition, AA members must help
others. And that is true, AA members do help a wide variety of individuals
with alcohol problems. However, it has been taken to its extreme. That is,
only recovering alcoholics can really treat alcoholics. This notion, again,
is not backed up by the data. Also, it assumes that anyone who has gone
through AA or other twelve step programs can counsel alcoholics without any
kind of other training. The problem with this is that the lack of skills and
knowledge of even basic counseling techniques can do more harm than good.
This is especially true when one talks about dual diagnosis clients or
clients with other types of problems such as marital problems.
So, in conclusion, as we see in slide eighteen, twelve step programs have
been around a long time. However, there has been minimal research that has
been done on many of these programs due to the anonymity associated with
these groups. From a causal standpoint, twelve step programs also have
minimal validity explaining what causes addition. Most of the research we
use and talk about within twelve step programs is basically related to
treatment.
Empirically, many twelve step programs as we see in slide nineteen also have
problems with the basic underpinnings of what causes additions. That is, the
genetics problems. And many of the programs that use this rely on
correlational research. Further, anonymity creates a lot of problems for
empirical research and also lots of people who enter twelve step programs
also dropped out. But, regardless of whatever anyone thinks about AA it is
used by many, many treatment agencies. And you need to become extremely
knowledgeable about the model so that at least you can understand what other
people are talking about. There are many good things about AA and we will
talk about those as we talk about treatment. However, there are also
limitations within AA and you need to remember that from a theoretical
standpoint of causing a particular problem such as alcoholism the scientific
validity of many discussions that go along with that just do not fit. And
they just do not hold up when you look at them under empirical scrutiny.
Well, that concludes this section of basically theoretical models of
addiction. In our next section we are going to begin discussing aspects of
pharmacology. Until then, we hope you are enjoying the class and hopefully
we will talk to you soon.
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