Part 3

Alcoholics anonymous: a model of effective social intervention for alcohol abuse.

If the SIMOR model accurately represents the social identity transition in recovery, then the social processes identified as critical in recovery from addiction should be evident in successful recovery group-based, peer-driven programs. In this regard, AA offers an appropriate test case as it provides the most widely available community support programme for problem drinkers (Kelly & Yeterian, 2008).

AA is a mutual aid organisation for peers to support each other to overcome an addiction to alcohol, based on 12 steps and 12 traditions that members work through over time (e.g. Step 1 requires members to admit that they are powerless over alcohol). AA is used as a case study for the current paper because, with more than 2.1 million members and 100,766 groups in 150 countries, it is the mutual aid recovery group with the largest membership and the strongest empirical evidence base.

Meta-analytic reviews report a positive association between AA participation and abstinence, as well as reductions in substance-related health care costs (Tonigan, Toscova, & Miller, 1996). The efficacy of AA involvement in supporting recovery is also evident across a diverse range of populations (Emrick, Tonigan, Montgomery, & Little, 1993; Moos & Moos, 2006). In addition, and in line with SIMOR’s theoretical analysis, higher rates of attendance at AA meetings have been associated both with greater rates of abstinence from alcohol and an increase in the number of non-drinking friends (Humphreys, Mankowski, Moos, & Finney, 1999).

Such evidence suggests that the process of categorising oneself as a member of a group that values abstinence provides a plausible explanation for the efficacy of the recovery model promoted and utilised by AA. Put simply, AA offers a positive recovery-based social identity that is accessible for members to use as a basis for self-definition. This identity is largely defined by the norms and values of AA’s prescribed social behaviours and traditions, which are laid out in the AA ‘‘Big Book’’ (Alcoholics Anonymous, 1939) and that are discussed in many AA meetings.

The frequent deployment of the AA lexicon may be indicative not only of internalisation of a recovery identity but also may imply some level of implicit identity (Frings & Albery, 2015). Indeed, 12-step fellowships may be unique in containing a range of rituals and practices that serve as warrants of membership and that, when enacted, clearly convey engagement with and adherence to, the ideology outlined in the Big Book. In serving to embed the recovery identity, such rituals and practices are likely to have significant implications for perceptions and recognition of group membership and hence for the sustainability of a recovery-based social identity. Furthermore, AA promotes meaningful and pro-social behaviour by emphasising the need to make amends and to help others as central to the recovery journey (Humphreys, 2004).

In this regard, it is noteworthy that many of AA’s prescribed practices are inherently social. New members are encouraged to seek out ‘‘sponsors’’ (people in recovery themselves who act as personal guides for the recovery journey) and to speak to as many ‘‘experienced’’ members as possible. Accepting that one is powerless over one’s use of alcohol and therefore in need of support, the sharing of one’s own story and the structure of the sponsor system all serve to generate active engagement and membership, thus binding individuals to AA on an ongoing basis. Furthermore, the principle of ‘‘keeping it by giving it away’’ speaks to a process whereby individuals protect their own ongoing recovery by helping others around them achieve this as well.

A substantial proportion of the efficacy of AA in supporting recovery is therefore achieved not merely through attendance itself but rather through active participation at meetings (Kelly, 2013), thus embedding members within the group in ways that encourage them to embody and live out the group’s norms and values. In addition, higher levels of engagement in AA-related helping activity (e.g. helping to organise meetings, taking on administrative roles and so on) have been associated with greater abstinence, and lower levels of depression, at 1 and 3 years follow-up (Pagano, Friend, Tonigan, & Stout, 2004; Zemore, 2007).

Expanding on this, Pagano, White, Kelly, Stout, and Tonigan (2013) found that active helping in AA meetings was associated with greater abstinence at 10 years follow-up compared to standard professionally delivered alcohol treatment interventions. In other words, the more members are immersed in the activities and roles of the recovery group, the more they benefit from their membership of that group.

SIMOR as a basis for understanding AA efficacy

The impact and effectiveness of AA can readily be explained from a social identity perspective. To recap, the principal tenet of the social identity approach is that individuals internalise group characteristics as elements of the self (Turner et al., 1987) and that social identities become increasingly salient as a function of their meaningfulness and successful application in everyday situations and activities. In these terms, it is the perception of the self as belonging to a group that provides the foundations for self-definition in social terms (Turner et al., 1994). In AA, new members’ initial attendance is said to be precipitated by ‘‘hitting rock bottom’’ (Alcoholics Anonymous, 1939). As Best et al. (2008) note, this is typically understood as a culmination of the adverse effects of their drinking reaching a crisis point, and it is this understanding that provokes early engagement with recovery groups.

When first attending AA, new members are greeted by existing members, who encourage them to commit time and energy to active engagement in the group. New members actively engage by attending 90 meetings in 90 days, by finding a sponsor to guide them through the 12-step program, by ‘‘working’’ the 12 steps, and by speaking to established members (recovery elders) both during and after meetings. In this way, the efficacy of AA for new members can be seen to result partly from the availability and support of recovery role models who are established members and who provide identity-based leadership by seeking to exemplify the norms and values of AA (Haslam, Reicher, & Platow, 2011).

Established members are encouraged to ‘‘keep it [their sobriety] by giving it away’’ and do so by engaging with and encouraging new members through formal and informal mentoring, assisting them to actively engage in AA meetings and support. By having a sponsor and identifying a ‘‘home group’’, new members are incorporated into the social world of AA. This facilitates the internalisation of the norms and values of the 12-step fellowship and the adoption of an AA-based social identity.

The foregoing analysis is consistent with the work of Moos (2007), who has argued that one of the effective elements of mutual aid groups like AA is the availability of opportunities for social learning provided by the observation of group members who are further into their recovery journeys.

Moos goes further to argue that it is not just role models that AA offers but also an implicit expectation that new members will learn and conform to the group’s norms to achieve and maintain membership, a process he refers to as ‘‘social control’’. In addition, opportunities for social learning by observing and imitating the recovery behaviours of more experienced peers in recovery promotes the development of coping skills, and positive attitudes, beliefs and expectations, that support sustained recovery

In line with SIMOR’s emphasis on the changing structure of identity-based networks, Kelly, Hoeppner, Stout, and Pagano (2012) also found that it was the influence of AA engagement on social network change, together with increases in abstinence self-efficacy, that were crucial to recovery from alcohol addiction.

As the individual cultivates their recoverybased social identity through immersion in AA activities and internalisation of AA values, so the social identity associated with their using group is diminished (Buckingham et al., 2013). The established importance of social network support for long-term recovery (Best et al., 2012; Dobkin et al., 2002; Litt et al., 2009; Longabaugh et al., 2010; Pagano et al., 2004) speaks to the underlying effect of social influence and social control on the transmission of recovery behaviours (Best & Lubman, 2012).

More specifically, individuals are only likely to take on board the values, goals, messages and support from networks of people with whom they can already identify. Without a basis for shared identification, there is little motivation to engage with well-intentioned others, a point that underscores the central role of social identification in achieving such influence.

Conclusion: recovery as a socially embedded process

Rather than locating recovery solely in individual processes, we argue that recovery is more usefully framed as a social process, underpinned by transitions in social network composition that includes the addition of new recovery-oriented groups, where such groups are perceived as attractive, beneficial and relevant (Jetten et al., 2014), and involves the concurrent emergence of a new recovery-based social identity. These changes are sustained and supported through group processes of social influence, through the transmission of recoveryoriented norms and values, and through the social control that comes from internalising these norms and values (Moos, 2007).

The social processes embedded in Alcoholics Anonymous, an enduring and successful peer-based mutual aid group, provide an effective and tangible case study through which to examine the role of group-based social influence on social identity change in recovery. To better understand recovery, we need to move away from the view that it is simply an individualised personal journey and see it instead as a socially embedded process of successful social identity transition

Reference

1. Overcoming alcohol and other drug addiction as a process of social identity transition: the Social Identity Model Of Recovery (SIMOR). Available from:https://www.researchgate.net/publication/281643200_Overcoming_alcohol_and_other_drug_addiction_as_a_process_of_social_identity_transition_the_Social_Identity_Model_Of_Recovery_%28SIMOR%29[accessed Sep 14, 2015].