12-Step groups are an integral part of treatment for those with alcohol and other drug use disorders. Over the past 15 years convincing evidence has emerged to demonstrate that among severely dependent individuals, 12-Step focused treatments work as well as or better than other treatments, and 12-Step meeting attendance moderates the effects of treatment on outcomes-especially in the long-term. Nevertheless, these effects are tempered by the large number of individuals resistant to 12-Step attendance, and the profound downside of premature treatment dropout among this group.
While there are useful empirical strategies to increase 12-Step attendance for resistant individuals (e.g., accompanying individuals to a meeting), there also are many effective strategies clinicians have adopted in their real world practice that are typically absent from the treatment literature. These include matching individuals to specific meeting characteristics (i.e., “meeting matching”) and highlighting to resistant individuals that the most robust mechanisms of change in 12-Step meetings tend to be common processes such as sober social support, as opposed to 12-Step specific processes such as powerlessness.
Living in New York City, I frequently have guests from out of state and out of the country visit me. Like any good host, I attempt to match my recommendations for leisure activities to my guests’ interests. After all, the city offers unparalleled access to nearly anything one could desire, including kite boarding under the Verrazano Bridge. The same can be said for 12-Step groups in well-populated areas. Over the years, I have attempted to match specific clients to specific 12-Step meetings. While there is absolutely no data on 12-Step meeting matching, it is an unstructured but often practiced technique among clinicians.
There are Web sites for “Gay AA” or meetings specifically for adolescents, so why do we not get more specific in our referrals to meetings in cities where the opportunity exists? Are we breaking some tradition that naïvely asserts that the composition, demographic characteristics, or type of meeting should not matter? Are we afraid of profiling or offending certain clients?
While idealistic goals should be lauded, they do not reflect reality. This is particularly true among those less motivated to attend 12-Step groups. Why not match our message to the individual to reduce resistance? After all, we are essentially selling meeting attendance. We are saying “the research shows that if you go to these meetings you are more likely to stay clean and have better overall outcomes.”
A good marketer would never try to get an 85-year-old woman to buy a subscription to a heavy metal magazine. Even if she received a free copy and read it, she would be unlikely to subscribe. This has been acknowledged by researchers focusing their efforts on matching client characteristics to specific elements of treatment (e.g., higher anger to more client-centered techniques). Yet to my knowledge, there is little to no information on matching client variables to specific 12-Step meetings.
What would be the difference if a 24-year-old male musician who is extremely resistant to attending AA went to a meeting in Williamsburg, Brooklyn (a neighborhood noted for its under-30 hipster scene) on a Friday night? How would his perception about 12-Step attendance be different if he went to a meeting on the Upper East Side of Manhattan (a neighborhood noted for its hedge fund manager scene) instead?
Clinicians often have a wonderful understanding of the mutual support groups in their area, yet this type of matching is rarely done, even when the opportunity exists. While I would have a hard time finding an “AA for atheists” meeting in the Bible Belt, in New York City I could choose among seven meetings a week. However, while working within the limits of geography reduces the choice of meetings, the overall spirit of matching individuals to meetings still can be applied to one or two specific meetings in one’s area. For example, matching individuals to very broad meeting characteristics (e.g., “social” meetings vs. “Big Book” meetings) might offer another method for engaging resistant clients.
Moreover, aside from alternative mutual support groups (e.g., Women for Recovery), which are a wonderful resource, the rise of online virtual meetings also can be a useful means to meeting matching for those who live off the grid or whose social anxiety has become a barrier to meeting attendance. Although many people will claim “a meeting is a meeting,” a greater portion probably will agree that individuals should go to meetings where they feel most comfortable and want to attend. When you can’t attend those, then a meeting is a meeting.
The most resistant
Forcing a resistant individual to attend 12-Step groups might not work regardless of the meeting characteristics, especially when the therapist’s attempts to influence that individual are based on potentially polarizing ideas such as spirituality or the idea of powerlessness. A common saying for newcomers in 12-Step groups is “take what you need and leave the rest,” or simply “don’t drink, and go to meetings.” Popular books such as Undrunk attempt to “translate” 12-Step groups for the newcomer to reduce resistance.
However, this has not entirely been adopted as part of many traditional substance abuse 12-Step facilitation strategies, which still try to foster specific 12-Step cognitions and beliefs as a means to encourage meeting attendance-even with resistant clients. Consequently, some professional treatment paradigms can actually end up being more rigid than the spirit of the 12-Step meetings themselves.
What is most interesting is that research on the underlying mechanisms of 12-Step groups, or treatment in general, points to common, universal mechanisms of change such as sober social support, self-efficacy, stimulus control and maintenance of harm appraisals as more robust indicators of maintaining abstinence compared to the belief in a Higher Power or admitting one’s powerlessness over substances. While having baseline beliefs that correspond with 12-Step philosophy are indicative of increased meeting attendance, and in turn better outcomes, to my knowledge there is no evidence indicating that these beliefs mediate the relationship between meeting attendance and outcomes similar to the common processes that underlie every 12-Step meeting.
Most clinicians will acknowledge the futility of attempting to foster a 12-Step specific cognition in a highly resistant client. Taking a more client-centered approach that focuses on these common mechanisms of change could be a more useful method to foster meeting attendance in resistant individuals-at least for those who are receptive to the general concept of mutual support groups as a means to achieve sobriety. The most powerful factors that facilitate positive substance use outcomes, at least in the short term, are these common mechanisms that can be achieved through many means, such as close family support. All too often, a large support network that encourages stimulus control and highlights self-efficacy is non-existent, leaving the burden on outside mutual support groups.
12-Step groups have profound benefits to the individual and society. They nurture both well-studied and empirically supported common change factors, such as social support, and less understood but possibly equally important universal cognitive ideals, such as acceptance where one is in the moment and a sense of gratitude. If we can focus on whatever it takes to get individuals to meetings (within ethical boundaries, of course), without getting caught up in semantics or our ideal scenario for clients in the long-term, we might realize significantly greater benefits for the large majority of clients who have been turned off by the narrow and foreign focus of many traditional 12-Step facilitation approaches. A meeting is a meeting-but only when someone attends that meeting.
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Frederick Muench, PhD, is a clinical psychologist and the president of Mobile Health Interventions. He recently was awarded funding from the National Institute on Drug Abuse (NIDA) to create an interactive text messaging system to help those in substance abuse treatment maintain long-term sobriety. He also is a consultant at the National Center on Addiction and Substance Abuse (CASA) at Columbia University. Muench’s e-mail address is
- Moos RH. Active ingredients of substance use-focused self-help groups. Addiction 2008; 103:387-96.
- Morgenstern J, Labouvie E, McCrady BS ,et al. Affiliation with Alcoholics Anonymous after treatment: a study of its therapeutic effects and mechanisms of action. J Consult Clin Psychol 1997; 65:768-77.
- Muench F, Morgenstern J. Common and specific mechanisms of change in drug treatment. Poster presented at the 2001 American Psychological Association annual convention, San Francisco.
Addiction Professional 2010 November-December;8(6):22-24