There are patients who leave lasting impressions on us in one way or another throughout our training. I had never expected an angry, alcoholic patient who left against medical advice (AMA) to be one of those patients for me. I had always anticipated the sweet old lady with colon cancer or the cystic fibrosis patient status-post lung transplant to leave a lasting impact on my practice. However, this particular patient is the one who led me to spend a week at Alcoholics Anonymous (AA) meetings, which opened my eyes to a unique population that we regularly treat in medicine.
The last I had seen of Mr. Larson (pseudonym) was during morning surgical rounds. The team stood awkwardly around the bed, and each of us was staring at him while he trembled uncontrollably in an attempt to spread butter on his toast. We recognized his early signs of alcohol withdrawal, and after a calm conversation with Mr. Larson, we made plans for appropriate management.
Three hours later, our plans were squashed when he left AMA claiming that he needed to find his stolen wheelchair. As an immature, third-year medical student, I was completely shocked and dumbfounded. Two hours ago, this patient was agreeing to treatment, and now he was agitated, angry and absent. My shock turned into curiosity over the following days which ultimately led me to learn about Alcoholics Anonymous and attempt to better understand a community I knew absolutely nothing about regardless of my medical training.
In the span of one week, I attended multiple AA meetings, which all began the same way. The first ten minutes consisted of reading the Twelve Traditions of Alcoholics Anonymous and the Twelve Steps to Recovery. The rest of the meeting was open to sharing stories of drinking, relapsing, and sobriety. Members would introduce themselves and share high points and low points of the week which were all pertaining to alcoholism. During the week I attended meetings, I encountered participants who attended two AA meetings each day: one before and after work. They emphasized the accountability they had by going to multiple meetings in one day.
Throughout the meetings, AA elders who had been sober for as long as forty years described how their lives had been changed since they had chosen sobriety. These stories were juxtaposed with younger alcoholics who expressed their struggles during their second week of sobriety when they lost friends and sometimes, their homes. Beyond attendance, AA offers sponsors for alcoholics. A sponsor is a person to whom an AA member can turn for daily encouragement and support. A sponsor acts like a mentor, and many alcoholics at the meetings I attended had or were sponsors. Multiple participants told me in passing how sponsoring others gave them meaning in their day-to-day lives.
Regardless of the varying themes of stories shared, I gathered strong senses of bravery and hope within the AA community which led me to conclude that it must work. However, I knew I could not accept my feelings as scientific evidence. Soon, I found myself deep in medical literature, determined to evaluate the efficacy of the famous Twelve Steps to Recovery.
Founded in 1935 by William “Bill” Griffeth Wilson and Robert Holbrook Smith, MD in Akron, Ohio, Alcoholics Anonymous was a novel community that allowed alcoholics to avoid judgement and criticism in their search for sobriety. The group’s popularity grew quickly, and within fifteen years, it expanded internationally. Currently, it is present in over 170 countries. Despite its popularity, AA has remained questioned by scientific research for decades. Multiple studies have evaluated the long-term success rates of maintaining sobriety through the program, likelihood of relapse and even the organization’s emphasis on spirituality.
Beyond the success of the organization, clinicians remain puzzled as to whether or not they should recommend AA to patients. These questions clinicians wrestle with include: whether it is successful to start with medical management or a twelve-step program, and whether it is inappropriate to recommend AA to non-Christian patients. Yet, there are no suggested guidelines regarding endorsing AA or similar twelve-step programs.
Despite the debate, multiple research studies have shown that increased attendance at AA meetings is associated with higher rates of prolonged sobriety. A small longitudinal study evaluated the frequency of AA attendance during a two-year period and concluded that abstinence rates were higher in those who attended more than seventy percent of meetings. In fact, attending less than seventy percent of meetings was equivalent to never attending an AA meeting in terms of attaining abstinence.
A different study conducted in the Veterans Affairs system also determined that higher rates of alcohol sobriety were attained with increased frequency of AA attendance. It is evident that the community and meetings can provide a healthy routine for alcoholic patients. It is a place that holds them accountable for their actions and surrounds them with like-minded people who experience similar struggles. From the research, it also appears as though increased attendance and participation in AA are keys to achieving sobriety.
Previous studies have shown that large social networks are associated with higher rates of long-term sobriety. A longitudinal study of 654 patients who attended AA meetings determined that increased size of the AA network was associated with longer abstinence from alcohol compared to non-AA network support. In fact, the size of the alcoholic’s non-AA network was not associated with prolonged abstinence. This study’s results included possible factors of having a community of people who abstained from alcohol ingestion. For example, participants in AA have been shown to be less likely to be actively drinking compared to non-AA community members attempting to achieve sobriety with whom alcoholics may be associated.
These studies illustrate the importance of having a community that supports and enables one attempting sobriety. Evidently, attending AA meetings alone is not enough to achieve sobriety. It is heavily dependent on personal factors such as non-AA support, ability to attend multiple meetings in a week and having a sponsor.
Part of our jobs as clinicians and medical professionals is to educate patients regarding our recommendations for their health, For example, it would be ineffective to tell a patient to eat healthier without providing examples of nutritious foods, medically-approved diets and research that support our recommendations. The same is true of suggesting AA meetings to our patients. It is important to discuss factors related to AA that will help patients be successful in their journeys toward sobriety. Being surrounded by AA members, having sponsors and attending multiple AA meetings each week have been proven to increase sobriety rates. These are wonderful examples to share with patients to encourage them and provide concrete goals for their challenging tasks.
Furthermore, it is useful for clinicians to attend and observe AA meetings at some point during their careers to better understand how this community functions. Knowing the research is helpful, but experiencing it provides an intimate view of the program that may be helpful when patients ask about the meetings. Not only will this allow clinicians to better educate patients, but it will also help them understand the challenges that alcoholic patients experience on their paths to sobriety.