The Applied Psychology of Addictive Orientations | Chapter 1

Index

1.1. Historical background of Twelve step methodology

The origins of the Alcoholic Anonymous (AA) movement can be traced back to a few seminal groups of middle class white alcoholics in Ohio and New York in the 30’s led by its founders Bill W. and Dr. Bob S (White, 1988). A member of an evangelical religious group (the Oxford group) convinced Bill W that “release” from his alcoholism was possible through religious discipline. After having a religious experience referred to as his “hot flash”, and achieving sobriety he went on single handedly to help other alcoholics though, it was after his meeting with Dr Bob and several years of experimentation that Alcoholics Anonymous was really set in motion (op cit).

The Twelve Steps (Table 1) were first published in 1939 and contain the original concepts and inspiration of Alcoholics Anonymous based on six principles of recovery (Table 2). The book is now often referred to as the “The Big Book” revealing its pivotal importance in the AA philosophy. The Twelve Steps were attributed to three sources (Hopson, 1996), the Oxford group, Dr. William Silkworth (this being Bill W’s doctor who had also helped him achieve sobriety) and William James’s book “Varieties of Religious Experience” (James, 1902). This provided the conceptual basis for the necessity of the subjugation of the self and the acknowledgement of powerlessness, which became known as the first step of AA (op cit).

One dominant underlying principle that has its roots firmly placed in the original experiences of these founding members, is that the alcoholic is unable to exercise choice with regard to drinking, and that the power to live without drinking must come from a source other than, and greater than the self. This is well illustrated by a quotation from AA literature:

“Lack of power, that was our dilemma. We had to find a power by which we could live and it had to be a Power greater than ourselves. The abuse of alcohol is a sign of an underlying spiritual disorder which can only be addressed through surrender to a higher (spiritual) power: Our liquor was but a symptom. So we had to get down to causes and conditions” (AA, 1976, p.64 italics added).

Table 1.1: The Twelve Steps of Alcoholics Anonymous

1. We admitted we were powerless over alcohol – that our lives had become unmanageable.

2. Came to believe that a Power greater than ourselves could restore us to sanity.

3. Made a decision to turn our will and our lives over to the care of God as we understood Him

4. Made a searching and fearless moral inventory of ourselves.

5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.

6. Were entirely ready to have God remove all these defects of character

7. Humbly asked Him to remove our shortcomings.

8. Made a list of all persons we had harmed, and became willing to make amends to them all.

9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

10. Continued to take personal inventory, and when we were wrong, promptly admitted it.

11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of his will for us and the power to carry that out.

12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs”. (Alcoholics Anonymous, 1976).

Table 1.2: The 6 principles of recovery

We admitted we were powerless over alcohol.

We got honest with ourselves.

We got honest with another person, in confidence.

We made amends for harm done to others.

We worked with other alcoholics without demand for prestige or money.

We prayed to God to help us to do these things as best we could.

In 1952, Twelve Steps and Twelve Traditions was published (Hopson, 1996) and here the philosophy of the original Twelve-steps was further elaborated. The Twelve Traditions were first formulated to establish principles to guide the group life of AA groups and bring under control those circumstances, such as competition for leadership and individuals searching for prestige, that had destroyed other alcoholic mutual-aid efforts. Subsequently other Twelve-Step Fellowships have emerged, with their own published equivalents of Alcoholics Anonymous, such as the Twelve Steps of Overeaters Anonymous. Such publications have adapted the Twelve-step philosophy from AA so as to encompass other addictive behaviours.

From humble beginnings and a membership of 100 in 1939 (White, 1988), AA itself has grown into an international, multinational fellowship and has given rise to similar fellowships for other addictions with an estimated 1.7 million members (McCrady and Miller, 1993). At its most basic AA may be considered to be a method of helping those who have declared their wish to stop drinking, that being the only criterion for membership. However, it may also be seen as much more, as it does not just involve itself with the removal of the offending behaviour and in helping with relapse prevention. With the utilisation of the Twelve steps profound changes in behaviour, cognitions, values and relationships are expected longer term, so this process of therapy can be seen as having aims of grand and deep personal transformation.

1.2. The Minnesota Model and AA

Attending fellowship meetings is one way of gaining access to the Twelve-Steps. A further way is attending one of the Minnesota Method treatment centres, now commonly called Twelve-Step Chemical Dependency centres. The method originated in the USA where the first program was opened in the 50’s at the Minnesota State Hospital. The founders of the original Minnesota method centres were AA members in recovery and introduced AA’s principles to the treatment of alcoholism. Thus the central feature of this method is the Twelve-step philosophy of the Anonymous Fellowships which is used as a pivotal vehicle for therapeutic change. Its principal treatment goals are abstinence from mood altering substances and an improved quality of life (Cook, 1988a). Published outcome studies from these programs are rare but are important to consider. This is because today it is quite a common treatment approach for alcoholism and drug addiction in both group and one to one therapy contexts and is utilised widely throughout the USA and in other parts of the world (Nowinski, 1996).

1.3. Some assumptions of MM and the Fellowships

In the next section the Fellowship’s and the Minnesota Method’s key assumptions and common goals are looked at. Due to its religious overtones and integration of the disease concept of addiction the “philosophy” has attracted criticism and it is with these two features that the discussion will start.

1.3.i. Disease concept

According to AA tradition, alcoholism and drug addiction are chronic and progressive “illnesses” of unknown aetiology that affect the body, mind, and spirit, and they are characterised by a person’s inability to reliably control his or her use of alcohol and or drugs and so it is thought the only effective remedy is abstinence. AA and other Twelve Step programs assume that there is no cure for alcoholism or other addictions, and when speaking of recovery from addiction, they emphasise the concept of “recovery” as a permanent ongoing process as opposed to cure.

Viewing alcoholism as an illness has been traced back to 200 years ago (White, 1988) and although not adopted widely at this time the illness, or disease concept, was resurrected by the early members of Alcoholics Anonymous in the late 1930’s. Alcoholism was recognised as a disease by the American Medical Association (AMA) and the World Health Organisation (WHO) in the mid 1950’s. These set the stage for a medical interpretation of alcoholism often referred to as the American disease model (Rogers & McMillin, 1989).

The model posits that alcoholism is an irreversible disease process, it emphasises physical dependency, genetic predisposition, progressivity and specific stages of change. The main features of this illness include the symptom of “loss of control”, where control is lost over the amount the addict will consume or take once drinking has commenced, and craving, where the addict experiences an uncontrollable urge to drink.

This model is however not without its critics. Heather (1990) regards the model as outdated and criticises it for lack of evidence. Peele’s (1990) criticisms lie with the wealth of evidence which questions the disease concept premises of loss of control, irreversibility and craving. Further problems with this model include its failure to explain how or why people overcome addictions without treatment or professional help, or indeed why individuals benefit from different treatment approaches.

Another area of criticism concerns the untoward effects of the sufferer’s conceptualisation of addiction. It has been frequently argued that this conceptualisation of their condition can greatly influence clients’ understanding of their problems, for instance when viewing alcoholism as a disease, this view may serve to absolve the individual from personal responsibility (Durand, 1994). It is also well established that factors such as motivation, commitment to change and “willpower” are instrumental in achieving sustained abstinence (Marlatt & Gordon, 1985), and it is possible that individuals who view their condition as biologically determined, either as a disease or genetic predisposition, or otherwise inflicted, may not believe they have the power to change. Indeed what has been proposed is that because of the self fulfilling prophecy effects that would result from adopting a biological explanation of one’s behaviour, the addict may not attempt to moderate their behaviour. Instead, the addict may be inclined to interpret any return to the behaviour or substance after a period of abstinence as constituting a full blown relapse to an unavoidable state, and so resume their previous high level of consumption (op cit)

Moreover, the disease concept cannot account for addicts who successfully abstain without treatment or for those who spontaneously go into remission. These are common occurrences (Waldorf & Biernacki, 1979). Research has indicated that quite a high proportion of people who become involved in addictive behaviour require no formal treatment intervention and that they moderate their behaviour independently (op cit.). McCartney (1996) states that the number vary considerably from study to study and across the addictions possibly up to 50-60 percent in alcohol and smoking addicts and up to as many as 80 percent of heroin addicts.

One of the problems here is that the majority of the studies examining outcome look solely at treatment populations and thus individuals included in them are almost certainly unrepresentative, as it is likely that many people never present for treatment and yet still recover. Data on their number, their attempts to abstain, successful or otherwise, as well as the degree of usage are not available because those who spontaneously recover are generally a hidden population. It may be the case that those users with the highest quantity of usage, or severity of problems, are the ones that present for treatment. In that case the findings from studies of treatment populations are only relevant to this particular group and cannot be applied to non-treatment populations. The differences between these two populations are likely to be critical, one of which is the “non-treatment” population’s independence and self-reliance. In one study it was indicated that a “non-treatment” population of alcoholics who were able to stop drinking on their own were proud that they were able to do this and in conjunction with this they didn’t want the stigma of being labelled an alcoholic, which may have occurred if they had sought formal treatment options (Tuchfeld, 1981).

It has been argued that the concept of spontaneous recovery maybe a misnomer as there is nothing spontaneous about any recovery, and it might be more appropriate to refer to these individuals as self-treaters (Klingemann, 1994). This is because the recovery of self–treated individuals requires a high degree of personal motivation to change and is greatly enhanced by such factors as having an effective network of supportive family and friends, being in employment and/or being financially secure (Tuchfeld, 1981).

AA has often been criticised for its support of the disease concept (Riordan & Walsh, 1994) as the disease concept is negatively described as emphasising the pathological not the healthy. Further criticism stems from practitioners’ adoption of an expert role. When the disease view is assumed, the likelihood is increased that clients will be seen as untrustworthy people in “denial”, not responsible for their predicament, and for whom recovery goals are designed and directed solely by treatment staff (op cit). On the other hand the disease model has provided a means of expanding the diagnosis, treatment and the funding of such research of alcoholism and has done a great service in relieving the burden of guilt from both alcoholics and their family members (Burman, 1994). This may occur as with addiction being seen as a disease the individual need not blame themselves or others for their condition. Other models of addiction, in contrast to the medical model, would also probably not view the addict as responsible for the condition, but would hold the individual responsible for changing their condition. This is because addiction is often understood to be a learned adaptive behaviour, a coping mechanism for a distressing environment. Nevertheless, addiction is now believed to have multiple determinants and is often described as a “biopsychosocial” problem (Marlatt, Baer, Donovan & Kilahan, 1988). This phrase is now in common usage, and its truth would not be contested by many working in the MM or 12-step traditions. Indeed, Wallace (1996) suggests an extension of the term to “biopsychosocialspiritual” to draw attention to the traditional AA emphasis on spiritual factors in the process of recovery from addiction. A consideration of spiritual issues in Twelve step methodology is the next topic to be considered.

11.3.ii. The religious nature of the Steps and Spirituality

It is in the context of AA�s conceptualisation of alcoholism that professionals are most frequently faced with, and urged to address, spiritual issues in treatment (Alcoholics Anonymous, 1980). Although it is often the disease concept which is emphasised as a fundamental factor in Minnesota Model/AA view of addiction, the aetiology and treatment of addiction is also seen in fundamentally spiritual terms. Miller & Kurtz (1994) have posited that the essence of AA�s program is not to be found in the disease model. Rather, it is discovered in the comprehension that an alcoholic�s best hope for sobriety is through recognising the need for help, and accepting help from a transcendent higher power, referred to as God in AA�s Twelve steps.

From an AA perspective it is argued that it is not only the physical and mental aspects of addiction, such as detoxifying and recovering from the acute effects of dependence, that need to be addressed. It is crucial that the addict is encouraged to fully consider the spiritual issues that are fundamental in the expression of addiction (Alcoholics Anonymous, 1976). The treatment of the physical and mental, though necessary, are not sufficient to ensure a lasting recovery. Practitioners who accept the importance of the spiritual dimension view addiction as much more than a physical problem and acknowledge its aetiology as involving a three fold process involving not only body and mind but spirit as well. In this context, the term spirit is frequently understood to refer to the contribution to recovery made by a client�s congruous relationship with the environment in which he or she lives (Chapman, 1996)

Spirituality in AA is often explained as a three-tiered concept comprised of an affinity with others, self and a higher power. Specifically, "Basic to these three dimensions is a sense of connection with self and other-than-self, and behaviours that reinforce this felt connection" (Alcoholics Anonymous, 1976, p.414). Without this fundamental sense of connectedness, spiritual symptoms of addiction include a sense of disharmony, disjointedness, isolation, a lack of sense of self and lack of self worth, and it is these characteristics that most proponents of the Twelve Step philosophy believe leads alcoholic individuals back to addiction even when they are successfully detoxified and have begun to return to normal drinking (Alcoholic Anonymous, 1976). It is thought that it is through the consideration and development of spiritual qualities such as relatedness to others and a sense of purpose in being that the key to providing ongoing stability is found.

The Twelve steps explicitly include gaining awareness of a higher power, turning one�s will over, making amends to others, and prayer and meditation. Spiritual elements also include acceptance, this being the opposite of attempting to take control and full command. The research investigating the spiritual element of treatment is limited though there is some evidence to suggest that this feature of an accepting and open stance is an optimal coping style for managing the symptoms of addiction (Marlatt, 1995). Other central elements of a spiritual theme include humility and forgiveness both of which are thought to be involved in recovery process (Miller, 1998). In conjunction to this the practice of forgiveness, an important feature of the Twelve Steps has been found to be associated with higher life satisfaction in general (Poloma & Gallup, 1991 in Miller, 1998).

It is often alleged that the Twelve Steps represent a religious program of treatment rather than spiritual and a number of professionals see this approach as tantamount to a call to religious conversion (Warfield & Goldstein, 1996), and it is this element which has been seen as one of the more difficult aspects of the Anonymous Fellowships� approach (Buxton, Smith & Seymour, 1987). In the first writings of the movement there is a strong flavour of religion and frequent references to "God". The Twelve step organisation has over the years moved towards the use of the term "Higher power" and in general refinements have occurred as the first writings have been reviewed and debated. Chapman (1996) however puts the relationship between spirituality and religion in perspective stating that, "Spirituality, then, is an aspect of alcoholism recovery that involves more than a consideration of religious principles. It encompasses the belief that individual human beings are but a part of a larger reality, and as such are charged with a participatory rather than dominating role in that existence, religion may be an important part of one�s spiritual life, but it is at best one dimension of a seemingly far more complex aspect of the human condition" (Chapman, 1996, p.45)

One feature which distinguishes AA from organised religion is the lack of dogma, and the freedom to choose what the nature of their higher power may be. The emphasis is not on what kind of Higher power is embraced, but rather an acceptance of the idea of human limitations and, "A power greater than ourselves". Instead of rigidity of interpretation within the framework of "higher power" there is great flexibility in what the individual chooses to define as their higher power. Initially it is quite often seen as the power within their own personal treatment group, or alternatively in nature. The concept of a higher power is central to the program and most though not all will come to believe in such a concept, to whom they can pray, look for guidance and turn over their conscious wills. In brief, the Twelve Steps are a guide to a life-long spiritual journey that is "recovery" (Nowinski & Baker, 1992).

Considering addiction as having a spiritual dimension poses a distinct problem for empirically oriented practitioners and theoreticians as this additional feature of addiction is often viewed as non-scientific and mystical and as such should have no place in mainstream practices (Warfield & Goldstein, 1996). It is possible that it is this connection to a higher power which poses the biggest problem for practitioners when considering Twelve Step methodology. This probably has at its roots the common view that spirituality should be a subject exclusively for religion. This perspective, it has been suggested, could also be a result of a bias created by the dominance of a Western view of health and healing present in the training of most therapists and therapists (Pedersen, 1988). Such training is often dominated by Western values of self reliance, independence and cause and effect explanations. Professionals who have been taught to recognise such values may be too narrowly focused on addressing physical and mental needs alone and because of this they have no room or, indeed, framework within which they can incorporate spiritual ideas.

Chapman, (1996) argues that without looking at the spiritual dimension of addiction it is not possible to adequately ground the addict in his or her living environment or allow the opportunity for the addict to overcome his/her isolation which is so frequently reported. This perspective is being incorporated by the broader psychotherapeutic community, where the realm of the "transpersonal" is increasing in popularity (Clarkson, 1998).

When considering the criticisms for the incorporation of a spiritual dimension, room must be made for the strong evidence which suggests that spiritual involvement is associated with a decreased risk of alcohol/drug use and dependence (Miller, 1998). More than a dozen studies have found that alcohol/drug abuse is associated with a lack of sense of meaning in life, relative to normal samples (Crumbaugh & Maholick, (1969) & Black, (1991), in Miller, 1998) There is also some evidence which suggests that drug use correlates, inversely, with reported importance of religious values (Khavari & Haron, (1982); Perkins (1985) cited in Cook, Goddard & Westall, (1997).

To move forward by embracing a broader consideration of spirituality which does not view it as solely a feature of organised religion may well enable practitioners to overcome their own and their clients� objections to the perceived religious orientation of AA.

1.3.iii. Recovery

Rather than "cure" being a goal within the philosophy of the Fellowships and the Minnesota Model, the emphasis is on the idea that one�s addiction can be arrested through working the Twelve Step program and by the regular attendance of meetings.

Since addiction is seen to be an incurable disease, abstinence is proposed to be the only way to keep the disease at bay. This condition is recognised as difficult to maintain but with the help of regular attendance of fellowships meetings it is a goal which is achievable and rewarding. It is thought that other addictive behaviours such as drug taking and gambling share features of alcoholism and so these behaviours amongst others have been incorporated into the Twelve step philosophy, and abstinence is a goal similarly applied across this whole range of addictive behaviours.

It is thought that once someone has become addicted, this addiction stays with them, and that maintaining sobriety and having order and balance requires life long vigilance, so the Twelve Steps of AA are seen not as a treatment program as such, but a suggested pathway of ongoing recovery. With no cure as such, the solution for the problem of addiction is thought to involve the restoration of power and order to a dis-empowered and disordered life (Alcoholics Anonymous, 1980). The essence of recovery is thought to stem from a changed lifestyle (habits and attitudes), and a gradual spiritual renewal. This process is often said to be akin to a spiritual journey in-as-much as recovery encourages a progressive change not only in habits, but in values and attitudes. Relapse is thought to occur before the first drink is taken or drug is used as the process of relapse starts when ongoing, active recovery stops. This is thought to occur when an individual feels OK enough to stop going to meetings, and stops remembering the consequences of their active using days.

1.4. Usefulness of fellowships

Alcoholism and drug abuse are among the most pressing and expensive social concerns in the health care field today, and the potential numbers involved that need assistance are exceedingly high. It has been estimated that approximately 7 per cent of all persons who drink have some significant symptoms of dependency (Hilton, 1987). Many models of treatment exist, and though still under researched, probably the best known publicly is the Twelve Step philosophy as it so easily accessible, it is free and it is often recommended in conjunction with other therapeutic interventions. The program is recognised by many practitioners as one of the most effective and user-friendly resources for helping alcoholics (Riordin & Walsh, 1994). With the consideration of the constant pressure on time limited therapy, the free support available within the Twelve Step network is invaluable. Some researchers have been very positive about AA concluding that it is without question that AA have helped very large numbers of people to remain abstinent over long periods of time (Emrick, Tonigan, Montgomery & Little, 1993).

According to Norwinski and Baker (1992) the flexible and pragmatic nature of the program indicates that it would be hard for anyone not to find something useful in it. The Twelve Step programmes have broken down complex psychological points and ways of living into easily understood simple phrases making it more accessible. For example, from a more orthodox perspective, the first three steps confront the denial and the loss of control around addictive use through the acknowledgement of powerlessness. These elements of denial and loss of control are also important aspects which would be worked on within other methods of treatment, but in the Twelve Steps are presented in a simple and easily digestible way. Phrases commonly used in the literature, such as "let it go" and "turn it over" emphasise the importance of simplicity.

Perhaps the most important aspect is the extensive support network and structure that the Twelve-step community offers. One of the greatest risks of relapse occurs in the transition from primary care and getting back to a normal way of life, without the dependency on substances or behaviours. The support offered by the Fellowships can greatly ease this transition and unlike other treatments provide ongoing, life long support, with meetings taking place in many locations nationally and internationally.

1.5. The spread of the philosophy to embrace other addictive behaviours

The Twelve-step programme of AA has provided a framework for the many forms of "Anonymous" groups. As a treatment for addicts the statistics on number of fellowships and chapters, membership and attendance are impressive and quite staggering. It has been estimated that one in 10 adults in the US has attended an AA meeting and that more than one in eight has attended a Twelve Step meeting of some kind (McCrady & Miller, 1993) In addition to this White (1988) reported on the existence of over eighty Twelve step related fellowships, some of the more well known include Narcotics Anonymous, Over eaters anonymous, Gamblers anonymous, and Sex and Love Addictions anonymous. There are also groups designed to support family and friends of people who are suffering from addiction, for example Al-Anon is a Twelve-step programme for the families of alcholics.

The steps in relation to other addictions

A degree of interpretative modification has been necessary for the steps to address a large number of addictive behaviours. For instance an important element of re-framing the steps involves the target symptom of the first step (alcohol). Originally there was one target symptom, which was alcohol, and this was interpreted as a symptom of underlying spiritual disorder. As knowledge has grown in the field, the abuse of other substances and behaviours such as food (over and under eating), sex, relationships and gambling are also thought to be symptoms of this underlying spiritual disorder. Therefore the steps have needed to be adjusted and reinterpreted in order to encompass these other addictive behaviours.

Interestingly, Step One defines "the problem" as whatever the issue is around which the particular Twelve-step program is constructed e.g. alcohol or food. What happens in the following steps is that the target problem is not mentioned again until Step Twelve. Thus what is encouraged is a broad examination of the functioning of the person in terms of their way of life, values etc. instead of an exclusive focusing on the target problem. This in many ways is little different to the process involved in many, but not all, forms of psychotherapy, where the presenting problem is eventually seen in the context of the overall functioning of the individual�s life.

One problem involved in the acknowledgement of other addictive behaviours is the concept and expectation of abstinence. It is clear that alcohol and drugs are non-essential to physical survival and therefore the idea of completely giving up these substances seems reasonable to many who have problems regarding any normal pattern of usage. On the other hand, when food is thought to be abused addictively and compulsively (under and over eating), there is no possibility of abstinence from the addictive substance. What occurs with behaviours where abstinence cannot be so clear cut is that a highly selective "abstinence" program of sorts is set up to modify the target symptom. For both the anorexic or overeater their particular program of "abstinence" involves the normalisation of their food intake, for the gambler the aim would be abstinence from all risk taking or gambling behaviour.

1.6. Research investigating the effectiveness of Twelve-steps

Research investigating the effectiveness of AA and other Twelve-step group has been reported as inconclusive (Hopson, 1996) and opinion for some time has been mixed. It has been claimed that Twelve step methodology has not been effectively researched and that there is little independent objective evidence to support its effectiveness (Georgakis & Shepard, 1998). McCrady and Irvine (1989) reviewed studies of the effectiveness of AA and found only two methodologically sound studies, neither of which indicated that AA was more effective than alternative treatments. The difficulty in being able to conduct research into the effectiveness of AA or other Twelve step programmes with scientific rigour may be in part due to difficulty in obtaining hard data. A further criticism includes the large percentage of alcoholics who drop out of AA (Galaif & Sussman, 1995). A further difficulty involves the accessibility of the groups themselves as they are closed i.e. the groups are anonymous and do not allow non member entry. Another reason why the research into the effectiveness of the Twelve Steps is a little thin on the ground is that it is only quite recently that the treatment has really been embraced as a reasonable alternative to other more orthodox methods. As it is a self help organisation it has taken time for the medical and research establishment to accept what the method has to offer and also to take it as a serious option for treatment and therefore research. It is also the case that there are inherent problems in the scientific study of any form of treatment for addictions, for example in relation to random allocation and establishing valid measures of outcome.

In spite of methodological problems aggravated by the anonymous, voluntary, self-selection of AA membership, it is also claimed that there is evidence which indicates that AA is a very useful approach for alcoholics. Chappel (1993) states that there is evidence which suggests that many alcoholics who become involved in AA find something they can use to improve their lives on a long-term basis. Emricks�s (1987) review of survey and outcome evaluations of AA alone or AA as an adjunct to professional treatment indicated that 40- 50 percent of alcoholics who maintain longer, active membership in AA have several years of total abstinence while involved, 60-68 percent improve, drinking less or not at all during AA participation..

Historically there have been elements of the philosophy which have troubled traditional therapists. One primary objection is that the Twelve-step approach is superficial and does not address the deeper psychological issues of the patient, (Johnson and Taylor, 1997). It could be said that this is a rather harsh criticism that indeed could be used against many forms of therapies, for example cognitive behavioural work does not aim to address deep psychological material but still is effective in many forms of intervention. It may also be argued that what is encouraged to take place through the working of the steps is a re-authorship of one�s life, and in many ways a complete turn around in attitude and assumptions. If this is the case then this form of treatment cannot be seen as superficial.

A further limitation concerns the lack of assessment involved in AA and other Twelve step programmes. In "the rooms" (i.e. the meetings) there isn�t a mechanism whereby people can have a professional assessment to investigate the extent of their psychological difficulties. Self selection for treatment is determined by the expressed wish to stop their addictive behaviour, this providing the only condition for membership of the group. This raises another problem, which is well illustrated by the figures from one study which claimed that between one half and a third of people with eating disorders have a biologically mediated mood disorder that would be helped by pharmacological intervention (Garfinkle & Garner 1987). If these people only attend fellowship meetings, and even if successful, they are missing out on further improved mental health if they do not have the possibility of a full medical assessment which may provide a basis for further interventions.

1.7. Positive impact of the fellowships

Researchers for some time did not seem particularly interested in self-help organisations in general, though currently it is thought that more individuals with alcohol related problems seek help from self-help groups than from any other source (Room & Greenfield, 1993). This indicates that the field of self help in relation to addiction could provide a fertile ground for comprehending a range of issues, such as factors that are attractive and effective in the change process.

Even though Twelve-Step fellowships have been under-researched and largely criticised there are those who support the movement. Chappel (1993) stated that AA is a highly successful treatment modality and should be recommended in conjunction with more traditional psychotherapy. In saying this, though, there are those who are wary of its effectiveness. Emrick (1987) claimed that AA had not been proven to be uniformly and uniquely effective in the treatment of alcoholism and questioned the prevailing practice of treatment professionals universally referring recovering persons to AA. This division in opinion emphasises the need for research to continue in this field investigating the central features of the methodology.

Given the current financial and social burden that many addictions place on society, the disappointing relapse rates and obvious misery that it causes for both sufferers and those around them, it is clear that a continued interest should be directed towards the potential utility of the fellowships. More specifically, some of the reasons for this are as follows. Participation in the fellowships is free and individuals can make as much use of meetings as they see fit, thus reducing the burden on state provision. One longitudinal study has in part confirmed this in that AA participation may actually lower health care costs (Humphreys & Moos, 1996). It can be said that the fellowships already have a profound impact on how services are delivered, with many studies drawing upon the support of AA in relation to outcome data or relapse prevention.

In relation to the fellowships� impact, this isn�t limited to financial or outcome considerations. Humphreys (1997) has argued that, "AA members have had a significant impact on the development of the disease concept of alcoholism, the portrayal of alcoholism in motion pictures, the creation of the National Council on Alcoholism and National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the development of the professional alcohol treatment industry" (Humphreys, 1997 p. 2105). In conjunction with this a number of studies have evaluated how AA affects behaviour (McCrady & Miller, 1993) and some promising lines of inquiry include the effects of mutual help participation on spiritual development, friendships and marriage and psychological functioning (Humphreys, 1997).

Project MATCH

Perhaps the most supportive study of Twelve-step methodology is that of Project MATCH, a national collaborative study of alcoholics treatment funded by the National Institute on Alcohol Abuse and Alcoholism. This study was initially designed to assess the effectiveness of matching the characteristics of clients to various popular treatments, these being Motivational Enhancement, Cognitive-Behavioural and Twelve Step Facilitation. The results revealed that there were actually few outcome differences between these treatment methodologies (Project MATCH, 97). This suggests that Twelve Step Facilitation is equally effective as more accepted methodologies. With this kind of support for a methodology which has typically been viewed with caution, further investigation of its theoretical underpinnings and key elements of treatment seems called for and appropriate.

One criticism which may be levied at this research may be that the actual working of the steps in a self help AA context may be somewhat different in comparison to how Twelve Step Facilitation therapy may be conducted in a "one to one" context. Though it must be said that the "one to one" was designed to get people into the fellowships and was not a "treatment" in itself, even so this is clearly a different situation when comparing it to a self help group. This criticism however cannot be assessed until more work has been conducted into this field, though what can be stated is that this methodology is becoming more acceptable and is up and running alongside the more orthodox and accepted treatment methods, and will hopefully attract more research designed to discover what the factors are that are at the root of its success.

In the next chapter a detailed description is given of the philosophy and organisation of the centre where the data for the research studies was gathered, in order to further contextualise the investigations.

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