“Honestly, all that religious talk turned me off.”
“The meeting was like sitting in a chimney – I practically choked to death.”
“I was the only person there without a tattoo.”
Attending the wrong 12-step meeting can turn off some patients, despite the substance abuse treatment support offered by Alcoholics Anonymous (AA) and similar programs. Because of the stigma associated with alcohol or drug addiction, most patients are ambivalent at best about attending their first 12-step meetings. Feeling “out of place”—the most common turn-off—can transform this ambivalence into adamant resistance.
Simply advising an addicted patient to “call AA” is tantamount to giving a depressed patient a copy of the Physicians’ Desk Reference and telling him or her to pick an antidepressant. Not all 12-step meetings are alike; 50,000 AA meetings are held every week in the United States (Box 1).1-7 Recognizing the differences between the groups in your area will help you guide your patients to the best match.
In prescribing a 12-step program, consider these six patient factors: socioeconomic status, gender, age, attitude towards spirituality, smoking status, and drug of choice.
12-STEP THERAPY: AN AMERICAN ‘RELIGION’
More than 50,000 AA meetings, 20,000 NA meetings, and at least 15,000 Alanon/Alateen meetings are held every week in the United States. Other 12-step fellowships that model the AA approach include Gamblers Anonymous, Sex and Love Addicts Anonymous, Overeaters Anonymous, Cocaine Anonymous, Smokers Anonymous, Debtors Anonymous, Dual Recovery Anonymous, and Co-dependence Anonymous.
The combined membership of AA, NA, and Alanon/Alateen is approximately 2 million. To put this in perspective, if the 12-step approach was a religion—as some have proposed1 —it would have more U.S. congregants than Buddhism and Hinduism combined.
Although 12-step therapy has been a central tenet of community-based substance abuse treatment for more than 50 years,2 only recently has it become a focus of clinical research. Two major national multicenter clinical trials3,4 and several important but smaller clinical studies5-7 have found that 12-step-oriented therapies achieve modestly better abstinence rates than the psychotherapies with which they were compared.
Socioeconomic status
Matching patients with meetings according to socioeconomic status is not elitist—it’s pragmatic. Patients generally feel most comfortable and relate most readily at meetings where they feel they have something in common with the other members. For example, when a newly recovering middle-class alcoholic visits an AA group that is frequented by homeless and unemployed alcoholics, chances are that he will become more ambivalent about attending meetings. After all, he was never “that bad.”
A good practice is to give your patients an up-to-date 12-step meeting directory (Box 2). Suggest that they identify the meetings where they think they will feel most comfortable, based on the neighborhoods in which they are held.
Patients in early recovery often are terrified of encountering someone they know at a 12-step meeting. One strategy for patients concerned about protecting their anonymity—as many are—is to attend meetings outside their own neighborhoods but still in areas that match their socioeconomic status. Similarly, referring patients to meetings that are “closed to members only” might reduce their concerns about exposure.
Once a patient has connected with a 12-step program, matching by socioeconomic status becomes less important. Many begin to see similarities between themselves and other addicted individuals from all walks of life. In the beginning, however, similarities attract.
Your patient’s gender
Though women were once a small minority in AA and Narcotics Anonymous (NA), today they make up about one-third of AA’s membership and more than 40% of NA.8 One factor that may have boosted the number of women attending 12-step programs is the increased availability of women-only meetings.
Most cities have women-only meetings, and they generally will be a good place for your female patients to begin. Evidence indicates that gender-specific treatment enhances treatment outcomes.9,10 Women-only meetings tend to be smaller than mixed groups, and the senior members are often particularly willing to welcome newcomers.
Although it is severely frowned upon, the phenomenon of AA or NA members attempting to become romantically or sexually involved with a newcomer is common enough that 12-step members have coined a term for it: “13-stepping.” Newly recovering patients are often emotionally vulnerable and at risk of becoming enmeshed in a potentially destructive relationship. Beginning recovery in gender-specific meetings helps to reduce this risk.
Your patient’s age
A 12-step meeting dominated by people with gray, blue, or no hair can quickly put off teens and young adults in early recovery. Though these meetings with older members are likely to include persons who have achieved long-term and healthy recovery (making such meetings ideal territory for finding a sponsor), finding peers of a similar age is also important.