Social Influence Processes and Health Outcomes in Alcoholics Anonymous
Summary and Keywords
Social influence processes play an important role in the recovery process for alcoholics who affiliate with Alcoholics Anonymous (AA). Group norms at AA emphasize the sharing of stories about past difficulties with alcohol, the circumstances that led a person to join AA, and how life has changed since achieving sobriety. These narratives serve to increase collective identity among AA members via shared experiences and to reinforce AA ideology. In discussions and interpersonal interactions at AA meetings, AA ideology is also communicated and reinforced through AA literature and the discussion of central tenets, such as the Twelve Steps and Twelve Traditions, the idea that alcoholism is a progressive disease, and the need to be active in one’s sobriety. Moreover, AA meetings provide an opportunity for recovering alcoholics to find others who share similar experiences, an opportunity for greater social comparisons to other alcoholics than are typically available in primary social networks, and group-suggested role obligations that influence commitment to AA and long-term sobriety. These social influence processes have been linked to important health outcomes, including longer abstinence from alcohol use than with other treatment options, reduced stigma associated with alcoholism, reduced stress/depression, increased self-efficacy, and the acquisition of coping skills that are important to the recovery process.
Since its creation in 1935, Alcoholics Anonymous (AA) has become, worldwide, the most widely known social support community for people facing alcohol addiction (Kaskutas, Bond, & Humphreys, 2002). There are millions of current AA members in more than 180 countries, with approximately 55,000 group meetings taking place each week (Alcoholics Anonymous, 2001; Kelly & Yeterian, 2008). The main text of AA, “the Big Book,” is one of the best-selling nonfiction books of all time, with over 28 million copies sold (Kelly & Yeterian, 2008). AA is self-supporting financially, and donations are collected at each AA group meeting to cover the expenses of meeting space, refreshments, and literature (including the Big Book) for recovering alcoholics who have limited financial means. Moreover, the influence of AA can be seen in many other social support groups and communities, both in face-to-face groups and online. For example, many other peer-support groups for other health concerns (e.g., eating disorders, cancer recovery, HIV, etc.) typically borrow and incorporate structures from AA, such as the Twelve Steps or group meeting norms, into their group norms (Kaskutas et al., 2002). AA self-help group meetings are used more frequently by people struggling with alcohol addiction than all other forms of professional alcohol treatment combined (Weisner, Greenfield, & Room, 1995). In many states in the United States, courts routinely require individuals who are convicted of alcohol-related offenses (e.g., driving under the influence) to attend AA meetings for a specified number of days (and show proof of attendance).
In addition, many hospitals and other healthcare organizations refer patients who are coping with alcohol abuse problems to recovery centers and more formal outpatient support groups that often are similar to AA in terms of structure and interpersonal communication processes (Kaskutas et al., 2002; Laudet, 2008). Most importantly, participation in AA group meetings has been found to be predictive of a variety of positive health outcomes for recovering alcoholics, including maintenance of long-term sobriety, fewer alcohol-related problems, and enhanced psychological well-being (Kelly, Stout, Zywiak, & Schneider, 2006; Kelly & Yeterian, 2008; McKellar, Stewart, & Humphreys, 2003; Moos & Moos, 2006). Rigorously conducted meta-analytic reviews of AA-focused research indicate that AA participation is helpful for a wide variety of individuals (i.e., individuals differing in SES, age, sex, etc.) for overcoming alcohol dependence (Groh, Jason, & Keys, 2008; Humphreys, 2004; Kelly & Yeterian, 2008).
However, despite the growth and popularity of AA and its influence across the healthcare landscape, relatively few social scientific studies have examined social influence processes, communication patterns, and their relationship to health outcomes within the context of AA. Studies have found that the changes recovering alcoholics experience occur via intrapersonal, behavioral, and social processes (Moos & Moos, 2006; Wright, 1997; Zemore & Kaskutas, 2008). Many of these changes are specifically tied to AA’s ideology, group communication norms, and AA prescriptions for living sober (such as working with newly recovering alcoholics once they have achieved some degree of long-term sobriety; Wright, 1997). The theoretical work in this area that does exist tends to be fragmented by academic discipline, although there is a consensus that AA members are persuaded by other members to adopt the AA ideology, and researchers from most disciplines acknowledge the key role of interpersonal and group communication in the persuasion process.
Overview of Alcoholics Anonymous
Alcoholics Anonymous was founded in 1935 by two alcoholics (Bill Wilson and a physician named Dr. Robert Smith) who both suffered horrible consequences from years of excessive drinking and drunken behavior (Alcoholics Anonymous, 2001). These men had tried to get sober by attending religious meetings, seeking medical advice, and through voluntary incarceration in mental facilities (Alcoholics Anonymous, 2001). “Bill W.” and “Dr. Bob,” as they are known to AA members, were forward thinking in their recognition that peers who are coping with similar health concerns can benefit one another through various types of social support, such as sharing information, emotional support, and tangible assistance. Seeking out a fellow alcoholic for social support in an attempt to cope with alcoholism was not a common means of treating alcoholism in 1935. In most cases, prior to AA, an alcoholic’s only options for treatment of alcoholism were admitting oneself to a mental institution or joining various religious/spiritual organizations that focused on temperance (e.g., the Oxford Group), neither of which had high success rates in terms of helping alcoholics achieve abstinence. Research on peer-group therapy for alcoholics, social support and health, and genetic/environmental influences on alcoholism was either nonexistent or in its nascent stages at the time (Wright, 1997).
The AA program consists of people in recovery “helping themselves by helping one another” (Alcoholics Anonymous, 2001). Unlike other alcohol treatment options, AA is not constrained by time limits and it is peer-led, as opposed to being led by healthcare professions. However, AA does not discourage professional therapy, and AA group meetings can often be used in conjunction with other treatment options involving professionals. According to the AA Big Book, the only prerequisite for AA membership is a desire to stop drinking. In addition to being innovators in terms of using peer social support as a means to treat alcoholism, the founders also drew upon both spiritual influences (most notably the Oxford Group) as well as psychological and medical influences from the time period. As AA has grown in size and influence over the years, it has remained open to scientific advances in the study of alcohol addiction and recovery, including the use of medications to help people cope with withdrawal symptoms as well as the acknowledgment of genetic predispositions to developing alcoholism.
The AA worldview draws upon the “disease model” of alcoholism (Jellinek, 1960), which posits that alcoholism is a physical addiction combined with a mental compulsion to consume alcohol. From this viewpoint, alcoholism is seen as a progressive illness. From this perspective, abstinence from alcohol is considered the best “cure” for alcoholism, since it is believed that any amount of alcohol consumption will trigger maladaptive physical and psychological responses from alcoholics, such as cravings and a compulsion to drink. Additionally, AA views alcoholism as a “fourfold” disease, composed of physical, emotional, spiritual, and psychological factors (Alcoholics Anonymous, 2001). The recovery components are tied to the Twelve Steps of AA, which include: (1) admitting one is powerless over alcohol; (2) the belief in a “higher power”; (3) writing and expressing a “fearless moral inventory”; (4) making amends to all those harmed by the alcoholic; and (5) the “passing on” of the AA message to other alcoholics (Alcoholics Anonymous, 2001). The Twelve Steps are promoted as the best means of recovery from alcoholism in AA group meetings (both face to face and online) and in the AA literature.
The emphasis of AA meetings is on mutual “sharing,” or communication of addiction and recovery experiences through stories. AA meetings typically involve senior members (often referred to as “old timers”), who share their story of what life was like when they were actively drinking, what circumstances led them to seek recovery through AA, and what life is like now that they are sober (Wright, 1997). These stories provide opportunities for newcomers to AA to identify with the life experiences and feelings that are conveyed in the stories of the speakers, who are invited by the meeting secretary to speak to the group (Lederman & Menegatos, 2011; Wright, 1997). The sharing of stories appears to be an important aspect of learning to live sober, and it instills a sense of empathy, belonging, and hope among recovering alcoholics (Lederman & Menegatos, 2011). In addition, most AA meetings allow audience members to discuss aspects of the speaker’s story they identify with as well as other issues or problems related to alcohol use or recovery they want to share.
New members of AA are encouraged to find a sponsor, a person in the group who has achieved a long period of sobriety (usually at least 10 years) with whom they identify. This AA norm adds a dyadic/interpersonal component, in addition to the overall group influence, that has been found to play an important role when it comes to attitudinal and behavioral change among AA members, including self-persuasion (Lederman & Menegatos, 2011).
Social Influence Processes and Mechanisms of Behavior Change within Alcoholics Anonymous
In examining social influence and effects on attitude, belief, and behavior change in AA, one must refer to what the larger alcohol treatment and recovery field has embraced as the “mechanisms of behavior change” framework (Morgenstern & McKay, 2007; Willenbring, 2007). From this perspective, it is believed that no single factor is likely to account for the entire effects of the AA group’s influence on abstinence and other important health outcomes. Moreover, the change mechanisms are also likely to vary over time, and the aspects of AA that may help individuals achieve sobriety may not be the same as the processes that sustain it. According to Kelly, Magill, and Stout (2009), AA facilitates attitudinal and behavioral change through two broad components: the AA “program,” which includes the Twelve Steps; and AA “fellowship,” or the relationships that develop among the network of formal and informal social gatherings and interpersonal communications between AA meetings (e.g., such as getting coffee or dessert after an AA meeting).
Although the language that AA members use and their specific experiences may differ on the surface, the same (common) processes appear to operate for most members. The common experiences with alcoholism and alcohol-related behaviors often resonate with newcomers to AA meetings. Even if the particulars of one person’s story about his or her alcoholism differ from the newcomer’s experience, AA members report identifying with common emotions, such as the fears and sense of demoralization that often accompany alcoholism.
As Berkman, Glass, Brissette, and Seeman (2000) have observed, social influence/social comparison is an important set of perceptions that appear to influence the relationship between participation in support groups like AA and health outcomes. People obtain both normative and behavioral guidance through the social comparisons they make with others in their reference groups (Festinger, 1954; Groh et al., 2008), and social comparisons appear to be an important part of the AA recovery process (Wright, 1997), as well as in support groups in general (Rains & Wright, 2016). Individuals in AA assess their own attitudes, beliefs, and behaviors against the behaviors modeled by other AA members. These attitudes, beliefs, and behaviors are usually revealed at AA group meetings through the stories shared by AA members.
Helgeson and Gottlieb (2000) argue that lateral comparisons, or comparisons to similar others, may normalize people’s experiences and reduce uncertainty and stress for those dealing with health concerns, including alcoholism. According to Wright (2016), social comparisons to others and self-assessments can be either positive or negative. For example, if a struggling alcoholic feels that he or she is coping with problems less effectively than others in the AA group, this may lead to upward comparisons, which could either produce feelings of frustration or serve as a source of inspiration to the person to cope more effectively by emulating the successful behaviors of the other members. On the other hand, downward comparisons, such as when an AA member who has achieved long-term sobriety hears a newcomer talk about all the drinking-related problems he or she is dealing with due, may help reinforce the wisdom of adhering to the AA way of thinking (to avoid having similar problems).
In other words, AA members see around them others who have been successful in recovering from alcohol addiction and who enriched their lives in a multitude of ways, as well as those who have relapsed and have suffered negative consequences. AA members hear stories from individuals who have relapsed and returned to AA and who are enjoying new success in recovery. The sharing of experience, both past and present, by AA members is also believed to serve a persuasive function for the speaker as well as for the audience (Kassel & Wagner, 1993). Findings from the field of social psychology suggest that persuasive processes are most powerful in those who are trying to persuade others (Festinger, 1954). So, the “telling of one's story” in AA meetings may lead to the acceptance of new values and ways of understanding for the speakers as they recast their experience within the newly accepted group ideology (Kassel & Wagner, 1993). AA members often reinterpret their experiences with alcoholism in the ideological framework offered by AA, and share “what it was like, what happened, and what it is like now” with the group (Alcoholics Anonymous, 2001).
However, there may be a downside to social comparisons in online support groups/communities like AA. For example, hearing about the difficulties experienced by other community members can lead to increased stress (Holbrey & Coulson, 2013; Malik & Coulson, 2008), which may undermine a person’s confidence or self-efficacy in terms of their perceived ability to maintain long-term sobriety.
Perceived Similarity Among AA Participants
In past research, perceptions of source characteristics have been found to be an important aspect of social influence (Chaiken, 1980; McPherson, Smith-Lovin, & Cook, 2001). One important source characteristic in AA is perceived similarity among members, especially between long-time recovering alcoholics and newcomers to AA. Perceived similarity among AA members (and support group members in general) has been found to increase satisfaction with the group and a sense of belonging. In addition, similarity between a sender and receiver appears to increase the persuasiveness of the messages that are exchanged in support groups/communities (Bond, Kaskutas, & Weisner, 2003; Wright, 2000). Moreover, perceived similarity among support group members appears to influence perceptions of the credibility of information people receive from other members. Wang, Walther, Pingree, and Hawkins (2008) found that perceived similarity of support group members influenced perceptions of their credibility and, in turn, the evaluation of health information they provided. Other studies have found that perceived similarity was associated with social support satisfaction with support providers in online AA support groups (Campbell & Wright, 2002; Kelly, Magill, & Stout, 2009), which may be a strong motivation to participate.
Support groups/communities (both face-to-face and online groups) facilitate the process of bringing people with similar circumstances together, and the collective experience of the many people who make up these groups/communities, along with the information they pass along, is often perceived as more credible than the experience of, and information received from, healthcare providers (Coulson, Buchanan, & Aubeeluck, 2007; Hu & Sundar, 2009). In the larger recovery literature, this psychotherapeutic process is often referred to as a “talking cure,” or communication that promotes behavior change by facilitating the development of introspection and insight about one’s drinking experience. Sharing of addiction and recovery experiences appears to teach newcomers important technical aspects of living sober and evokes a sense of empathy and belonging.
Role Obligations, Relational Commitment, and Reinforcement of AA Ideology Through Helping Others
Other aspects of social influence are embedded in AA’s Twelve Steps, group communication norms, and the development of interpersonal relationships within AA meetings (Bond, Kaskutas, & Weisner, 2003; Groh et al., 2008). These aspects include role obligations, relational commitment, and reinforcement of AA ideology through “working” the Twelve Steps. Role obligations can influence attitudes and behaviors in a variety of ways. For example, commitments and responsibilities to role partners exert implicit pressures on persons to avoid risky or deviant behaviors and to engage in self-care (Rook & Underwood, 2000; Umberson, 1987). Role obligations and commitment within the interpersonal relationships that are developed in AA can strengthen connections to other people and foster of a sense of belonging (Barrera, 2000; Cutrona & Russell, 1990; Thoits, 2011; Uchino, 2004), which can be conceptualized as acceptance and inclusion by members of the AA group. Acceptance and inclusion are not necessarily guaranteed for everyone who affiliates with AA. However, AA group norms and 12th Step (carrying the AA message to other alcoholics) both foster an environment where AA members seek out newcomers to AA, and members share common experiences and feelings that can lead to an environment of acceptance, understanding, and empathy. The Big Book mentions that the sense of comradery among recovering alcoholics is based on the common experiences they have had with alcohol addiction and the negative experiences that come with it. Greater acceptance tends to reinforce the belief that one belongs in AA, and this can provide security that a person’s needs will be met by the group (Pagano, Phillips, Stout, Menard, & Piliavin, 2007; Wright, 1997; Zemore & Kaskutas, 2008).
Once an AA member achieves long-term sobriety, AA ideology is reinforced by “working the Twelve Steps” of AA (Bond et al., 2003). A central goal of 12-step organizations invokes what has been called the “helper principle” (Riessman, 1965), or the idea that helping another person can benefit the helper. The 12th Step of AA involves carrying the message of AA to suffering alcoholics, and being willing to help them by sharing one’s experience as an alcoholic who made the transformation from actively drinking alcohol to achieving long-term sobriety. In other words, the 12th Step asks AA members to help newcomers to the group who may still be living with many negative effects of actively drinking alcohol, such as being arrested for driving under the influence, damaged relationships, etc. The Big Book mentions “practical experience shows that nothing will so much insure immunity against drinking as intensive work with other alcoholics” (Alcoholics Anonymous, 2001, p. 89). So, the Twelve Steps and interaction norms at group meetings influence the processes of mutual sharing and helping others (Pagano et al., 2007; Zemore & Kaskutas, 2008). In addition, AA encourages long-time sober members to voluntarily talk about AA to prisoners who are incarcerated for alcohol-related crimes as well as to individuals in mental institutions who have a history of alcoholic behavior.
Over time, AA newcomers often discover that they have something to offer to more recent newcomers, and this appears to increase self-esteem and self-worth, both of which have been found to influence psychological and physical health as well as quality of life. Moreover, helping other alcoholics within the context of AA appears to invoke a type of self-persuasion that reinforces the AA ideology in the mind of the AA member who is helping a newcomer. Interacting with an AA newcomer reminds the long-term AA member of the types of problems he or she once faced when actively drinking, and in persuading the newcomer to accept the tenets of AA ideology, the sober AA member has the tenets reinforced in his or her own mind—as he or she presents the AA message to the newcomer, he or she reflects on how the same messages influenced his or her ability to achieve sobriety.
AA Ideology and Resistance to Counterpersuasion
One function of the language of AA (in the AA literature as well as what is said in AA meetings) is to reinforce the AA ideology (Bond, Kaskutas, & Weisner, 2003). However, another important function of AA language may lie in its ability to provide resistance to negative persuasive messages for recovering alcoholics (e.g., pro-drinking messages the recovering alcoholic might receive from friends) or resistance to situations, feelings, and other negative triggers that can lead a recovering alcoholic back to drinking (Bond et al., 2003; Groh et al., 2008). As a person progresses through the Twelve Steps, AA literature (e.g., the Big Book) is regularly used to guide, reinforce, or challenge behavior (Bond et al., 2003). AA slogans that are commonly communicated at AA meetings, such as “Easy does it,” and “HALT” (hungry, angry, lonely, and tired), can remind recovering alcoholics about feelings or physiological conditions that may trigger a relapse into drinking. For example, the HALT acronym is frequently mentioned at AA meetings, and it reminds recovering alcoholics to be aware of when they are hungry, angry, lonely, and tired, since these physical/mental states often produce negative feelings that can trigger alcohol use. Accordingly, the HALT acronym can remind a recovering alcoholic when he or she is experiencing one of these states to call another AA member before reaching for the bottle.
The Twelve Steps of AA also present counterarguments to former ways of thinking about one’s alcohol problem. Most alcoholics attempt to control or monitor the amount of alcohol they consume, only to find that they are unable to control their drinking. Step 1 requires the alcoholic to admit that he or she has no control over alcohol in terms of the amount he or she consumes as well as the drunken behaviors that may result from drinking alcohol. This runs counter to what an alcoholic may encounter from a member of his or her social network, who says “One drink won’t hurt you.” Step 1 also involves reconstruction of the sequence of negative life events and associating these events with alcohol use. In other words, the goal is to associate drinking with the trouble it has caused in the past. The second step emphasizes that there is something more powerful than the self that can work in the fight against alcoholism (e.g., a “higher power” a person can turn to during times when the temptation to drink alcohol is overwhelming). AA members are exposed to other group members who have successfully achieved sobriety by not relying exclusively on their own resources. In the third step, the alcoholic “makes a decision” to rely upon others for help. Newly recovering AA members are also encouraged to “think the drink through” at meetings, which involves replacing thoughts like “drinking will relax me,” with thoughts about the negative consequences that have followed after taking a drink (e.g., “I fought with my spouse after drinking,” “I was arrested for a DUI after drinking,” etc.).
The idea of resistance to persuasion is consistent with inoculation theory (Compton & Pfau, 2005; McGuire, 1964), which posits that arming people with persuasive arguments to counter persuasive threats to their beliefs in the environment can help them become more resistant to the threats. Within the context of AA, reading AA literature and attendance at group meetings increase alcoholics’ exposure to AA slogans and other messages that remind them to be aware, every day and outside of AA meetings, of pro-drinking messages or states of mind that can trigger drinking. As recovering alcoholics achieve months or years of sobriety, they often repress memories of past painful alcohol-related negative experiences. The ongoing reminders of the pain of active drinking, in conjunction with positive (sober) experience and observable examples of recovery witnessed through the stories of others at AA meetings, can serve to continually motivate individuals to take steps toward ongoing recovery and AA participation (Kelly, Magill, & Stout, 2009). For AA members who relapse, the AA slogans reportedly create some degree of cognitive dissonance and discomfort. In other words, people who have been exposed to AA slogans remember the slogans even while drinking, and this causes discomfort due to the inconsistency between one’s behavior and the AA message. AA members have a saying for this situation: “A belly full of booze and head full of AA makes you miserable.” So, the language that AA members learn through AA literature and at group meetings appears to influence their cognitions and behaviors.
Social control also appears to be a key mechanism through which social network ties within AA (and to some extent, within non-AA social networks) affect health and longevity, primarily through its effects on health behaviors. A number of psychological processes underlie the building of relationships in AA, such as how a person entering into the AA context connects with other members. Each person must be able to identify with other AA members’ experiences that resonate in some way with the person’s own life experience (especially as it applies to drinking), and the ability to understand one’s own mental state and its relation to that of another person. Social control refers to the overt attempts of social network members to monitor, encourage, or persuade a person to adopt or to adhere to positive health practice (Hughes & Gove, 1981). Social control efforts can discourage risky health behaviors, but they can also backfire if they are perceived as overly intrusive or dominating, which can lead to feelings of resentment and/or resistance to behavior change (Hughes & Gove, 1981; Lewis and Rook, 1999). So, social control effects can be beneficial or harmful, depending on the strategies employed. In some cases, AA members may interpret the recovering alcoholic’s psychological symptoms as being serious enough to require professional treatment and may press him or her to seek help (Pescosolido, Gardner, & Lubell, 1998; Thoits, 2011)
AA Participation, Behavioral Modification Outcomes, and Mediating Variables
Previous research has found statistically significant relationships between AA group participation and positive drinking outcomes, although the relationship between AA participation and these outcomes appears to be mediated by a several variables, including coping ability, perceived quality of social support within the AA group, and the use of an AA sponsor, as well as the quality of the sponsor-newcomer relationship (Humphreys et al., 1999; Morgenstern et al., 1997).
AA Participation and Health Outcomes
Studies have found that greater AA participation is associated with less alcohol consumption and fewer alcohol-related problems (see Morgenstern, Labouvie, McCrady, Kahler, & Frey, 1997; Thoits, 2011; Tonigan, Miller, & Connors, 2000), although this body of research is mostly based on cross-sectional study designs. However, some longitudinal research on AA has also found a link between AA group meeting participation and fewer alcohol-related problems (Kaskutas et al., 2002; McKellar, Stewart, & Humphreys, 2003), lower drinking intensity levels (Kelly, Stout, Zywiak, & Schneider, 2006), and increased abstinence (Kelly & Yeterian, 2008; Moos & Moos, 2006). Several meta-analyses of AA effectiveness studies have found that AA participation is linked to positive drinking outcomes and modestly related to better psychological health, better social functioning, more secure employment, and improved legal situations (Emrick et al., 1993; Tonigan, Toscova, & Miller, 1996).
Two large-scale studies of AA (Project Match) revealed that, during the first year, AA alone was as effective as the two most effective professional alternatives: cognitive behavioral therapy and motivational enhancement therapy (Project MATCH Research Group, 1998a). A Project Match follow-up study showed that, regardless of the original treatment condition (cognitive behavioral, motivational, or Twelve Steps), the more AA meetings attended, the better the outcome for recovering alcoholics (Project MATCH Research Group, 1998b). Rains and Young (2009) conducted a meta-analysis of 28 published studies of online support groups, including online AA groups, and found that greater participation in online support groups was related to increased perceived support, reduced depression, increased quality of life, and increased self-efficacy in terms of managing health problems.
Quality of Social Support
Social support within AA has been found to be an important factor in accounting for increased abstinence (Groh, Jason, & Keys, 2008). The benefits of social support have been demonstrated across a wide variety of contexts and populations in terms of helping individuals cope better with health-related problems and leading to positive psychological and physical health outcomes (Burleson, Albrecht, & Sarason, 1994; Goldsmith, 2004; Goldsmith & Albrecht, 2011; Thoits, 2011). However, individuals vary in their ability to mobilize social support from their social networks as well as in their perceptions of what constitutes adequate social support (Cutrona & Russell, 1990; Thoits, 2011). For example, AA participants can obtain many different types of social support from other AA members, including informational support (i.e., advice on living sober), emotional support and empathy, and even tangible support (e.g., AA members often volunteer to help newcomers who may need a ride to a meeting, etc.). However, AA members may desire one type of support over another, and so it is important for AA members to find other AA members who can optimally match their support needs (Goldsmith, 2004). The literature suggests individuals who do not receive what they perceive to be helpful support from other AA members are less likely to achieve long-term sobriety and other important health outcomes via AA (Humphreys, Huebsch, Finney, & Moos, 1999). Specifically, Humphreys et al. (1999) found that both AA friendship quality and network support for abstinence partially mediated the relationship between AA participation and a variety of 12-month substance use outcomes.
In addition to offering specific types of social support, AA participation appears to influence social network composition or structure, which has been linked to positive behavioral change and improved health outcomes. For example, AA appears to help individuals reduce social network erosion throughout the recovery process (Humphreys & Noke, 1997). Social network erosion can take place when a recovering alcoholic stops spending time with previous social network members (e.g., old drinking buddies, etc.). Moreover, AA involvement may even increase the size of the alcoholic’s friendship networks through the inclusion of new friendships that are developed at AA meetings and social events outside of meetings (Humphreys & Noke, 1997). In a mixed sample of inpatients and outpatients, Kaskutas et al. (2002) found that social network influences among AA members were important mediators of 12-month abstinence. Specifically, the researchers found that a larger social network and greater network support for abstinence due to affiliation with AA partially explained the relationship between greater AA involvement and improved health outcomes.
Since alcoholism is a stigmatized health problem, people who affiliate with AA may feel more supported by fellow alcoholics, who understand what it is like to struggle with alcoholism, than by other people in their social network (e.g., friends and family members) who are not alcoholics. People who share mutual experiences with health problems appear to be less likely to judge one another (Bond et al., 2003; Wright & Bell, 2003; Wright & Miller, 2010). Individuals living with stigmatized health issues (including alcoholism) report increased stress and depression (Riggs, Vosvick, & Stallings, 2007; Wolitski, Pals, Kidder, Courtenay-Quick, & Holtgrave, 2008), both of which have been linked to a multitude of other health problems. Within the context of AA, studies have shown that effective social support statistically mediates the positive and significant relationship between AA involvement and substance use reductions (Humphreys et al., 1999; Laudet, Cleland, Magura, Vogel, & Knight, 2004). Obtaining advice from long-term members of AA or from members who have relapsed and returned to the group can also boost participants’ confidence in their perceived ability to handle common relapse-related situations or circumstances (Kelly et al., 2009).
Influence of Sponsorship
Social influence within AA can be enhanced at the dyadic level through the formation and influence of sponsor-newcomer relationships (Tonigan & Rice, 2010; Wright, 1997). Within the sponsor-newcomer relationship, the two AA members usually have frequent social contact outside of AA meetings, and it is commonly recommended in the AA literature and at group meetings that AA members contact a sponsor when abstinence is at risk. The sponsor-newcomer relationship serves to expose the AA newcomer to persuasive messages about the benefits of sobriety and the pitfalls of continued drinking outside of regular AA meetings. Slogans like “Pick up the phone before you pick up the bottle” are commonly heard at AA meetings, and they are often enmeshed in AA member stories at meetings. Access to a sponsor outside of regular AA meeting provides additional opportunities for emotional, informational, and tangible social support. A sponsor is a long-term AA member who has learned the Twelve Steps and their application to daily life, which allows him or her to guide a more junior member through the Twelve Steps and others aspects of AA (Tonigan & Rice, 2010). The sponsor’s role is similar to that of a teacher/therapist role in which the student is taught by modeling.
Studies have found that AA sponsorship is positively associated with other AA-related prescribed behaviors and practices. Kelly and Moos (2003), for example, reported that acquiring an AA sponsor during treatment was a significant predictor of continued AA attendance at 1-year follow-up. Thomassen (2002) found positive associations between having a sponsor, reading aloud at AA meetings, and using the phone to talk with other AA members outside of meetings. Moreover, Pagano et al. (2004) reported that having an AA sponsor was predictive of later helping behaviors, such as willingness to help newcomers or to sponsor them. Majer, Jason, Ferrari, Venable, and Olson (2002) and Tonigan and Rice (2010) found that having a sponsor was significantly predictive of perceptions of increased social and personal social support. Bond et al. (2003) found that relapse was significantly more likely to occur when AA members did not have a sponsor and/or when they reported accessing their sponsor less often.
However, a number of mediating variables appear to influence the relationship between AA sponsorship and abstinence. Witbrodt and Kaskutas (2005) identified several covariates that appear to coincide with sponsorship and abstinence, such as reading AA literature. In this case, reading AA literature may expose newcomers to additional persuasive arguments for abstinence and sobriety and counterarguments against drinking alcohol beyond what they encounter in group meetings and within the sponsor-newcomer relationship. Another important variable that appears to influence the relationship between sponsorship and abstinence is how quickly newcomers acquire sponsors. Tonigan and Rice (2010) found that newcomers who acquire sponsors early in their affiliation with AA were more likely to achieve long-term abstinence from alcohol.
Conclusion and Directions for Research
Alcoholics Anonymous incorporates a number of social influence mechanisms within its ideology that appear to influence important health outcomes, such as reduced alcohol-related problems, increased ability to remain sober, and improved quality of life. Group norms at AA meetings include sharing mutual experiences with alcohol addiction and recovery, communication of social support, and AA slogans that remind alcoholics to engage in certain behaviors to avoid relapse. In addition, the Twelve Steps of AA require members to engage in practices that reinforce the AA ideology, such as Step 12, which encourages members to work with AA newcomers. While a variety of positive health outcomes are associated with AA participation, mediating variables appear to influence to degree to which recovering alcoholics are successful at achieving these outcomes.
Future research on AA participation, behavioral modification mechanisms, and health outcomes would benefit from more theoretically framed studies that draw specifically upon frameworks that make specific predictions about social influence processes and messages and their relationships to specific behavioral health outcomes. While much of the existing work acknowledges social influence theory and research, most of the research in this area has been largely descriptive, as opposed to using theoretically derived hypotheses from the social influence literature.
As the Internet and social media have become more popular in recent years, many AA meetings have evolved from traditional face-to-face meetings to Facebook groups, online bulletin board communities, and AA chat rooms. While several scholars have examined online social support groups/communities for a variety of health problems (see Rains, Peterson, & Wright, 2015; Rains & Young, 2009; Wright, 2000), few studies have examined online AA meetings specifically. The research on online support groups (see Rains & Wright, 2016; Wright & Bell, 2003) has identified a number of benefits of online support groups that are tied to channel characteristics of the Internet and social media—including the ability to conveniently talk to others 24 hours a day/7 days a week, an expanded network of peers who are living with similar health concerns (compared to face-to-face support networks) who can provide greater diversity in terms of informational support, and lower risk in terms of communicating about a stigmatized health issue (compared to face-to-face support)—as well as limitations of these groups. Future research should examine how characteristics of online AA groups and meetings may enhance or undermine the important AA social influence processes that have been identified in research on face-to-face AA meetings.
Finally, the findings of previous research on social influences and mechanisms of change, and their implications for health behavioral change within the context of AA, have implications for support groups/communities for people with health concerns other than alcoholism or alcohol abuse. Many social support organizations and groups model their norms after the AA model. Al-Anon (for helping friends and family members of recovering alcoholics) and Narcotics Anonymous both evolved out of Alcoholics Anonymous, and the group norms and practices of these organizations are essentially the same as those of AA. However, fewer studies have examined social influence, change mechanisms, and health outcomes within the context of these sister organizations. These organizations present researchers with new contexts to test and refine more general theories and models of social influence, social support, and behavior change. Moreover, many other types of support groups/communities for other diseases and health conditions meet daily in the U.S. and around the world (both face to face and online). Research is needed to assess social influence, social support, and behavioral change across a variety of health-related social support groups/communities to look for commonalities between contexts as well as unique features of specific groups/communities that may influence these processes.
In short, more research is needed to better understand social influence processes and how they affect communication patterns and health outcomes among people who use health-related support groups/communities, including those that are AA-based. Given the rising cost of traditional provider-based health care, AA and other health-related support groups/communities serve as an important network of peers who are living with the same health issues. These groups/communities are capable of drawing upon their collective experience with a health issue, and they can often offer people who are coping with health problems higher-quality health information and support for health behavior change than other sources. Given the number of people in the United States alone who have turned to AA and similar organizations for social support, it is important that health communication scholars continue to research this area.
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