Chapter 34. Psychological Mechanisms in Alcoholics Anonymous

J. Scott Tonigan, Ph.D.; Gerard J. Connors, Ph.D.
DOI: 10.1176/appi.books.9781585623440.354343



Alcoholics Anonymous (AA) is the most popular self-help program for alcohol-related problems, and 12-step therapy, based on AA doctrine and practice, is the prevailing alcohol treatment model in the United States (Morgenstern et al. 2002). Studies of 12-step therapy indicate that it is as effective as therapies that are more research supported, such as cognitive-behavioral approaches, and that it may actually be superior when total abstinence is the goal (Ouimette et al. 1997; Project MATCH Research Group 1997, 1998). A primary objective of 12-step therapy is to facilitate AA participation, and evidence suggests that this aim contributes to its overall success (e.g., Moos and Moos 2005; Tonigan 2005). To date, significant gains have been made both in identifying the individual characteristics predictive of AA affiliation (e.g., Emrick et al. 1993; Tonigan et al. 1996, 2006) and in developing effective clinical strategies to promote AA affiliation (e.g., Nowinski 2006; Nowinski et al. 1992). Furthermore, we now have a clearer picture regarding the nature and magnitude of benefits associated with AA attendance (e.g., Gossop et al. 2003; Kelly et al. 2006; Tonigan 2001). Understandably, then, high priority now has been assigned to investigation of what actually occurs in AA, with a special focus on identifying how prescribed AA behaviors and beliefs mobilize drinking reduction. This chapter focuses on the psychological mechanisms explaining how and why AA is beneficial for many substance abusers. Our goal is to provide readers with an evidence-based review of what is currently understood about AA-related change and to highlight some associated clinical recommendations.

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FIGURE 34–1. Four conditions to establish statistical mediation in identifying processes of psychological change.Note. AA = Alcoholics Anonymous.

FIGURE 34–2. Comparison of three Alcoholics Anonymous (AA)–exposed groups of treatment-seeking individuals on religious practices and God consciousness over a 10-year period.Source. From Connors et al. 1996.
Table Reference Number
TABLE 34–1. Summary of self-efficacy and Alcoholics Anonymous (AA) meta-analysis
Table Reference Number

Alcoholics Anonymous (AA) is the most popular self-help program for alcohol-related problems. Much is known about the nature and magnitude of benefits associated with participation in AA attendance and participation, and researchers are focusing now on identifying and understanding the mechanisms of AA behavior.

AA participation is associated with increases in self-efficacy, which is a consistent predictor of subsequent clinical improvement.

Spirituality is a cornerstone of the philosophy and practice of AA, and many AA-exposed individuals report increases in their religious beliefs and practices. However, the evidence is mixed on the importance of such changes for later abstinence.

It is important that practitioners be familiar with the core AA literature and experience the environment and fellowship of AA by attending several meetings.

In the clinical setting, practitioners should routinely assess patients'€™ prior experiences with AA and/or other self-help groups, which will be helpful in determining whether, how, and to what extent subsequent attendance can or should be recommended, encouraged, and/or facilitated.


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Sample questions:
There are four conditions that must be met before declaring that a psychological process explains why a prescribed behavior produces a desired outcome. Which of the following is not one of these conditions?
In a study by Morgenstern et al. (2002), which of the following 12-step cognitions at treatment discharge significantly predicted increased abstinence at both 6- and 12-month follow-up?
Which of the following is an important causal mechanism that explains substance use behavior change?
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