Moving on From Crime and Substance Use

Transforming Identities

Robinson, Anne, Hamilton, Paula

• Publisher: Policy Press
• Year: 2016
• ISBN:
  9781447324713
• Edition: 1
• Topic: Social Sciences
• Subtopic: Criminology
• Index: Social Sciences

Desistance is one of the big news stories of the criminological world. Research suggests that, as 'offenders' turn their backs on crime, they often change their identities as well as their behaviour. Yet we know much less about how reforming or transforming identity might be affected by gender, age or ethnicity. This book focuses on diversity and showcases research from a wide range of authors in the field. It considers the similarities and differences between desisting from crime and recovering from addiction. Taking the desistance and recovery debates in unfamiliar directions, it examines the experiences of change for individuals seeking healthier and more successful futures.

NINE

Alcoholics Anonymous: sustaining behavioural change

James Irving

Introduction

Alcoholics Anonymous (AA) is the world’s largest and most recognisable recovery ‘programme’, and the Twelve Step Programme is central to its philosophy. AA is a global organisation of 2.2 million members (AAWS, 2001), with a reported 3,651 weekly group meetings in the United Kingdom (AAWS, 2015). AA has made many claims in its literature about the programme’s effectiveness (AAWS, 2001), yet Groh (2008, 44), for example, states that: ‘Overall, the AA literature is characterized by inconsistent findings, with researchers continuing to debate the role of AA in promoting abstinence (Emrick et al, 1993; Humphreys, 2004; Kownacki and Shadish, 1999; McCrady and Miller,1993; Tonigan et al, 1996).’ Kelly et al (2009, 237) add to the debate, referring to almost the exact same studies, ‘Rigorously conducted empirical reviews of AA-focused research indicate that AA participation is helpful for many different types of individuals in their recovery from alcohol dependence.’ One author suggests that claims of AA effectiveness are ambiguous whereas the other suggests a consensus of positive opinion regarding effectiveness.

This chapter explains how AA members sustain long-term behavioural change, or in other words, how members of AA maintain their sobriety. To achieve this, I constructed a conceptual model of change from AA’s core texts, Alcoholics Anonymous (2001) – colloquially known as the Big book – and The twelve steps and twelve traditions (1952), and a review of academic literature. The model was then empirically tested in interviews with 20 long-term abstinent members of AA who each narrated various dimensions of their recovery as it had unfolded over time.

The model has four components. First, motivation to engage (MtE) refers to the circumstances or pressures under which an individual seeks help from AA. Once a member has joined AA the transition to recovery takes time, often years, and is aided by AA’s Twelve Steps, sponsorship and relationships formed among AA’s wider social network. This forms the second component, structured social engagement (SSE). Third, the effects of joining and participation in AA are an increase in an individual’s personal agency (PA). The concomitant effect on behavioural outcomes (BO) represents the fourth component.

A brief history of AA

[Q]uite simply the most successful self-help organisation ever established. (Davidson, 2002, 4)

Other recovery groups and organisations, such as the Washingtonians (1840), Fraternal Temperance Societies (1842) and Native American recovery ‘circles’ (1737) predated AA (Blocker et al, 2003). Yet, since its inception, AA has become a yardstick against which all other mutual-help organisations are measured (Kurtz and White, 2005). AA dates back to 10 June 1935, in Akron, Ohio (Borkman, 2006), the day that Dr Bob Smith had his last drink. His co-founder, Bill Wilson, had been abstinent for five months at that time (Kurtz, 1979).

Both men were originally part of the Oxford Group, a Christian organisation combining social activities with religion. Their teachings were religious in nature, and some of their core beliefs are reflected in AA’s tone and practices (Davidson, 2002). The Oxford Group practised public and one-to-one confessions, group discussion characterised by honesty, unselfishness and repentance for past wrongdoing (Davidson, 2002). Drawing on the practice of the Oxford Group, AA also aimed for personal change, not just abstinence. However, believing that their emphasis on God would be problematic for most alcoholics, Smith and Wilson began to focus solely on helping other alcoholics achieve sobriety. Thus, AA was established in its own right rather than as a sub/splinter organisation of the Oxford Group (Valverde, 1998).

White and Kurtz (2008) note the unique and distinctive features that have helped AA surpass the achievements of every other recovery group. Among these are: AA’s growth and geographical spread, with more than 2 million members across 150 countries; its influence on the treatment of drug addiction and upon the treatment ‘industry’ generally (White, 1998); and its lasting influence on popular culture (Room, 1989). White and Kurtz (2008) trace a core element of AA’s therapeutic practices – the ‘helper principle’ (Riessman, 1965) – to a chain of events and relationships involving Bill Wilson and another early AA member who had been treated by Carl Jung. Jung had suggested that, in a relatively small number of cases, recovery from alcoholism had been affected by a profound spiritual experience augmented by a commitment to supporting others in a similar predicament. This suggestion from an eminent psychiatrist helped AA to cast the medical and psychiatric professionals into a supporting role, rather than allowing their discourses to potentially co-opt and subordinate AA (Kurtz, 1979; Valverde, 1998). This ‘arm’s-length’ approach to professional intervention has since been replicated in other studies on mutual-help groups (Humphreys, 2015).

AA believes that a person, who has experienced alcoholism and subsequently achieved stable recovery, has a greater capacity to gain the confidence of another alcoholic. Shared knowledge of a common problem has been termed ‘experiential knowledge’ (Borkman, 1976), being a cannon of wisdom set aside from expert and common knowledge, and so occupying a middle ground. In AA’s therapeutic practices, the sharing of experience is characterised by honesty and takes the form of an uninterrupted series of monologues within a set group context – the AA meeting (Arminen, 1996; 2004). The dyadic relationship between sponsor and sponsee involves sharing deeply personal, and sometimes humiliating, information. The sponsor is familiar with the Twelve Step Programme and this reciprocal sharing process is a pre-requisite for building trust (AAWS, 1952; Smith, 2007). These practices were carried forth by the co-founders, Wilson and Smith, helping to shape AA’s distinctive dynamics of communication and its therapeutic mechanisms for behaviour change.

Models of behavioural change

Prochaska and DiClemente’s (1984) transtheoretical model (TTM) of health behaviour change has ‘received unprecedented research attention’ (Armitage, 2009, 196). TTM has also been widely adopted in health practice in relation to weight loss, smoking cessation, alcohol and drug abuse, condom use and medical compliance (Velicer et al, 1990). The model is a theoretical, integrative description of how people modify a problem behaviour or adopt a more positive form of behaviour, based on the notion that an individual typically passes through six conceptually discrete stages: pre-contemplation, contemplation, preparation, action, maintenance and termination (Prochaska et al, 1992). However, no clear consensus exists on TTM’s overall validity, Cahill et al (2010), while Kraft et al (1999) argued that there are more stages of change and Callaghan et al (2007) find no clear evidence that matching a person to treatment relative to their ‘stage-of-change’ status, increases behavioural improvement.

Progression through these stages is not linear. The model is usually represented in a cyclical form, suggesting that the individual progresses through the stages in a clock-wise fashion. However, an individual can regress, and so take an anti-clockwise turn. To a degree this is expected, given the high relapse rates among alcohol and drug users (Velicer et al, 1990; Mäkelä et al, 1996). Migneault et al (2005) suggest that there are other dimensions which describe where a person is in relation to each of the six stages of change, including: processes, decisional balance and self-efficacy.

The properties of these constructs are conceptually analogous to AA’s theory of change. The psychological state of an individual prior to committing to the AA Twelve Step Programme is a clear ‘fit’ with these constructs. Migneault et al (2005, 438) describe processes as ‘a set of activities in which individuals engage during behavioural change’. Decisional balance describes a moment in time that a person becomes open to the prospect of behavioural change and thus relates clearly to MtE. It is therefore given explanatory and theoretical primacy here as this is the first step towards behaviour change. My study presents data from long-term abstinent members of AA. Understanding motivation ‘unlocks’ the other concepts incorporated into the behavioural model that I propose.

Decisional balance

Some day he will be unable to imagine life either with alcohol or without it. Then he will know loneliness such as few do. He will be at the jumping-off place. (AAWS, 2001, 152)

Velicer (1990) and colleagues explain processes, decisional balance and self-efficacy as being operationalised as psychometric constructs which can be used to assess where, psychologically or behaviourally, an individual may be on each of the six stages of the TTM. For example, work on decision making attempts to address decisional balance by weighing the pros and cons an individual perceives when continuing or terminating a negative behaviour (Janis and Mann, 1977, cited in Mignealt et al, 2005).

To understand how this ‘decisional balance’ corresponds to behaviour change, we need to sketch the dynamics of this psycho-social variable. As a starting point, individuals who have experienced external pressures, formal and informal, can be assumed to be contemplators who are considering their situation in relation to changing behaviour. Ajzen’s (1991) theory of planned behaviour (TPB) conceptualises attitudes according to positive or negative evaluations of future behaviour change. Armitage et al (2003) argue that this evaluation identifies underlying behavioural beliefs. The social pressure exerted upon the individual shapes a ‘subjective norm’ – expectations associated with positive behaviour change. Within TPB, this is understood to represent the perceived effects of entering treatment. As a corollary to subjective norms ‘behavioural intention’ is informed by the strength of intent to act – to what lengths would a person go to change a problematic behaviour? The tension present in conceptualising this component of behaviour change is partly overcome by assessing attitudinal ambivalence: ‘[being] unable to imagine life either with alcohol or without it’ (AAWS, 2001, 152).

Armitage et al (2003) observe that a person may simultaneously hold supportive and non-supportive beliefs towards a particular behaviour. For example, the ephemeral calming effect of drugs or alcohol on an individual works both psychologically and emotionally, so providing ‘negative reinforcement via amelioration of an unpleasant negative affect’ (Witkiewitz et al, 2005, 16). Removing the unpleasant feelings associated with withdrawal from excessive alcohol use, by drinking more alcohol, despite the known consequences, evidences an inability to cope without drinking.

Thus, as these ‘attitudes of ambivalence’ are equalised, a cross-over effect characterises the individual’s thinking that locates him or her at the contemplation, preparation or action stage. Cross-over is achieved when the perceived pros and cons associated with a behaviour become more closely aligned, a balancing of the scales. As the ‘decisional balance’ becomes ripe for tipping, the individual becomes more receptive to the notion of positive change and more capable of processing salient information, as he or she prepares to take action (Armitage and Connor, 2000).

Alcoholics Anonymous’ active theory of change

First, I consider the mechanisms underlying an ‘active theory of change’. Identification with other self-identified alcoholics is achieved at AA meetings and supported by peer interaction. The Twelve Step Programme directly addresses alcohol dependency. Each individual is supported through the programme by a sponsor who has achieved a substantial length of continuous sobriety having been through the Twelve Steps him or herself. AA’s active theory of change also rests on the development of a spiritual dimension to be nurtured and incorporated into an individual’s life. Members of AA describe experiencing a change in behaviour towards alcohol that goes beyond the usual clinical outcome measures such as reduced alcohol intake and medical co-morbidities (Humphreys, 2004).

Because AA is a complex entity, no single mechanism can account for change (Kurtz, 1979; Smith, 2007). As Kelly and McCrady (2008) argue, it is likely that there are simultaneous mechanisms occurring in an individual that are both psychologically and socially activated. An individual may feel ‘pulled’ deeper into the AA Fellowship as he or she attends AA meetings, acquires a sponsor, applies the Twelve Step Programme, and participates in the supportive network of recovering alcoholics (Smith, 2007).

AA meetings

The formal arena and first point of contact for those seeking help from AA is the meeting. The basic purpose is that AA members may ‘share our experience, strength and hope with one another’ (AAWS, 1952, preamble). There are two basic types of AA meetings. Closed meetings are for members and potential members only, those with a ‘desire to stop drinking’, (AAWS, 1952, 143). The ‘open’ meetings are accessible to all, although members of the public would not be allowed to participate in any of the rituals and practices of the meetings (Donovan, 1984; Borkman, 2008).

In ‘speaker/discussion’ (open or closed) meetings (Smith, 2007; Armine...