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.