Thursday, May 6, 2010

One Tequila, Two Tequila, Three Tequila, Floor: A Critique of the Use of Transtheoretical Model in Alcoholics- Anonymous - Jenn Johnson

Alcoholism is a major problem facing both adults and adolescents in the United States. In 2008, fifty percent of all the adults, aged 18 and over, in the United States were classified as regular drinkers (at least 12 drinks in the last 12 months) (1). More stringent analyses have found that only five percent of all adults report that they are heavy drinkers (more than two drinks per day for men and more than one drink per day for women) (2). The transtheoretical model relies on a set path of thoughts and actions to accomplish the action of quitting a certain health behavior and as a result it cannot be used successfully by an alcoholic, who has spontaneous behavior, to become sober. Many interventions targeted toward quitting alcohol consumption focus on the transtheoretical model of behavior change but alcoholism is defined by the inability of the drinker to control the urge to drink despite knowing that drinking is harmful to his or her health (3). It is this inability to control the compulsion to drink that makes the transtheoretical model approach inappropriate.
Many interventions use the transtheoretical model of behavior change to address alcoholism in the United Stated. This health behavior model focuses on the idea that people go through stages while changing from one behavior to another. These stages are precontemplation, contemplation, preparation, action and maintenance (4). Each stage is defined as follows: precontemplation – the recipient has no intention of taking action in the next six months; contemplation – the recipient has the intention to take action within the next six months; preparation – the recipient is intending to take action in the next month; action – the recipient has made life style modifications in the past six months; and maintenance – the recipient is working to prevent relapse (4). The model is based around an individual’s ability to weigh the pros and cons of changing (4). If the individual relapses, he or she must return to the beginning and start the process over again. If a person cannot control how much or when he or she drinks, how can that person be expected to successfully follow a set path of thoughts and actions in order to arrive at the destination of sobriety.
Alcoholics Anonymous (AA) was developed in 1935 and is based on the Oxford Group religious movement (5). This movement was founded on a formula of self-improvement that is based on performing self-inventory, admitting wrongs, making amends, using prayer and meditation, and telling the message to others (5). Today, AA is a recovery program that is based on twelve steps and twelve traditions focused on the concept that alcoholics are sick people who will recover if they follow AA’s simple program (5). The twelve step program is grounded in the transtheoretical model of health behavior change as it is based on moving from one stage of action or understanding to the next stage. The Alcoholics Anonymous program has flaws; many of these flaws can be attributed to the fact that the program is grounded in the transtheoretical model.
The transtheoretical model of health behavior change has flaws that result from the model’s reliance on individual behavior, vague stage definitions and planned behavior. The lack of set definitions for the behavior that the intervention recipient should be carrying out at a certain stage and how to progress to the subsequent stages is a problem because the person receiving the intervention has no way of positively identifying the correct thoughts and behavior that coincide with each stage. Also, the model only tells you that you should plan on moving from one stage to another but not how the recipient actual moves to a different stage; this is a problem because neither the clinician nor the intervention participant fully know or understand how one is supposed to move through the program. The transtheoretical model is an individual level model while drinking is a social behavior. In order to develop and use an effective intervention for alcohol abuse, these problems need to be addressed and fixed. Since the structure of the transtheoretical model is not always conducive to treating alcoholism; an improved model needs to be the basis for the future interventions against alcohol abuse.
Planned Behavior
The transtheoretical model only allows recipients to go forward through the model in a rigid stage by stage progression until they reach the maintenance stage (4). This model incorporates reasoned or planned behavior in the way that a participant must travel from one stage to another. The problem with using planned behavior is that the actual behavior of a person attempting to quit a strong behavior or drug is irrational and often spontaneous (8). The fact that alcoholism is complex and there are many factors that contribute to recovery shows that the use of planned behavior in the model will not appropriately handle the problem. Currently, this fluidity between stages is frowned upon as it is seen as a regression, or relapse, and not a progression.
If an AA member relapses or “slips,” the view of AA is that the member deliberately forgot the steps and let the relapse happen (5). This means that AA sees a relapse as a deliberate action, and as a result the member who experienced the relapse must start at the beginning of the twelve step program again in order to get back on track with the program. Because alcoholism is defined to be an uncontrollable, spontaneous affliction, the member cannot truly be blamed if he or she relapses. Instead, the intervention should focus on how to help the member to move past the relapse and help to ensure fewer and eventually no relapses in the future. This can be done by allowing for members to move fluidly throughout the stages and not frown upon those members who have a relapse.
Lack of Stage Definitions
There are no definitions of behavior for the stages of the transtheoretical model; as a result, there is no way for the clinician assessing the intervention, or the participant in the intervention, to know exactly in which stage to start the recipient. The only set definitions that are available for the stages is the definition of the intention to act and the change of this intention to move from one stage to another (4). These definitions, however, do not define actual behaviors that should be done or should have been done at each stage.
The stages, or steps, of the AA program are based on the experiences of the first AA members and these experiences are translated to the members through simple sentences about the individual. The steps outline attitudes and activities that the founders and first members thought were important in order to achieve sobriety (6). These attitudes and activities are left to the member to define and interpret, though the member must complete the previous step in order to move on the next one. The problem with this idea is that without a clear and concrete definition of each step the AA member can never be certain that he or she has successfully completed a stage. Without knowledge of whether or not the member has completed a certain step, he or she can never be certain whether or not to truly move onto the following step.
Individual Level Model
The transtheoretical model of behavior focuses on an individual and intervenes on the level of that individual but alcohol abuse is often a social activity, or at least begins as such. With this in mind, an effective intervention against alcohol abuse needs to consider the group dynamic when attacking the behavior in question.
AA is founded on the idea that the program will not work until the alcoholic personally admits that he or she is not in control and is powerless against alcohol (7). Each of the steps and traditions in AA are based on the idea that the individual, not the group, is responsible for completing the attitudes and activities found in the founding principles. The problem with this view is that alcoholism is a social problem; this means that an individual level approach will not work in an intervention for it. If an individual’s social network changes its alcohol consumption behavior, it significantly changes that person’s alcohol consumption behavior (9). This shows that the best way to intervene in an alcoholic’s consumption behavior is to either target his or her social network or include them in the intervention.
Proposed Intervention
The best way to improve the Alcoholics Anonymous program is to make several important changes that coincide with the flaws based on the transtheoretical model. The transtheoretical model of health behavior was developed in 1977, so it is out of date in dealing with alcoholism. These changes are to allow for irrational behavior, allow for fluidity between the steps, and to take into account the society in which the individual resides. By implementing these changes, Alcoholics Anonymous would be able to help more people from a wider variety of backgrounds to not only become sober but also to stay sober for the rest of their lives.
Unplanned/ Irrational Behavior
In order to allow for the irrational behavior which is a part of human behavior and is brought out more with alcoholism, the AA intervention program needs to allow for fluidity between the stages of change. This means that a relapse will not be seen as a failure to comply with the program but as just another step in the intervention. With this idea as an integral part of the program, members who experience a relapse will not have to feel guilty about having said relapse. Fewer people who have a relapse feel guilty or become depressed because they experienced a relapse, would result in fewer people turning back to alcohol to feel better after relapsing. This lack of people turning to alcohol to feel better would result in fewer temptations to fall back into the addictive actions that these people are trying to overcome. With fewer temptations the members would have a smaller pull toward drinking behavior and would have an easier time staying on the program for the long run.
Allowing for fluidity between the steps of the program, AA would end up being more understanding of alcoholism and would be able to help more people from different backgrounds. Because allowing for the ability to move in more than just a straight line along the steps will not only help the members feel better about themselves but it will also help the AA program appeal to a more broad population of drinkers. This will be possible as AA only currently appeals to and truly works for people with large support systems that can move in a linear direction along the steps of the program; by including the ability to move around through the stages of the program, AA will be able to work for people who have a large support system but cannot move in a linear direction (10). As a result, the AA program will be able to increase its interest in populations of alcoholics who may not think that they can move easily from one step to another.
Set Definitions of Behavior/Personalized Model
In order to allow people to know when they have reached a certain stage, AA needs to better define what it means to reach that particular stage and how the members can know when it is time to move onto the next stage in the intervention. Currently, the AA program uses past experiences and stories to help the new members figure out what each step means and what situations may occur during each step (6). These materials may be helpful to a certain degree but the lack of specific definitions could result in confusion among the members in understanding which step they are on at any given time. Without these specific definitions, it would be impossible for the member to know specifically what to think about and how to act, or how to strive to act, during each specific stage and between stages.
Strict definitions for each step of the intervention should be made on a personalized level for each individual when he or she enters the program. The individualization of the steps will help each person know where he or she is in the intervention process as well as help to ensure that if/ when they move between steps they will know exactly what to be thinking about and how to be acting at each step of the intervention.
Group Level Model
Alcohol is a social activity which means that alcoholism is a social problem, as previously noted. As a result, the AA intervention program needs to include a social/ group factor in their intervention. By including the immediate social network of the AA member in the intervention, AA would be able to make more of a difference than by just targeting the alcoholic alone. The best way to make a permanent change in the alcoholics’ behavior since the changes in consumption will be passed into the member’s social network in addition to the member (9). In order to accomplish this change in behavior, Alcoholics Anonymous should allow members to include people of major influence to him or her in the group meetings. As an organization AA does not allow this, though some individual groups may allow it (6). Consequently, AA makes a small change in the member’s immediate network of friends, but not the individual’s family network (10).
The problem with this approach is that the intervention needs to change both the member’s network of friends and the member’s network of family to make the biggest impact on eradicating drinking behavior from the member’s life. This spreading of change will eventually result in fewer people drinking in the members’ social group which will also decrease the likelihood that the AA member will be tempted to go out and drink.
Alcoholism is a serious problem affecting numerous individuals the United States and an effective intervention to deal with it is needed. Alcoholics Anonymous is used in many interventions and is helpful but only to a certain type of alcoholic. In order for the intervention to reach out and help more alcoholics, changes need to be made to the Alcoholics Anonymous intervention program. The program is based on the transtheoretical model of behavior change, which is flawed in several ways but has the potential to still be useful. Instead, the program needs to change the definitions of the stages, the exclusion of family and immediate social network, and allow for the irrational behavior within the intervention. After making these changes, Alcoholics Anonymous will be able to reach more people and, as a result, AA will be able to help more people successfully complete the intervention program and become sober.

1. Centers for Disease Control and Prevention. Pleis JR, Lucas JW, Ward BW. Summary health statistics for U.S. adults: National Health Interview Survey, 2008. National Center for Health Statistics. Vital Health Stat 10(242). 2009.

2. National Institute on Alcohol Abuse and Alcoholism. NIAAA Percentage of Adults who Reported Heavy Drinking by State and Gender, 1984-2008. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism

3. Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association. 31 July 1994.

4. Prochaska, J. The Transtheoretical Model of Health Behavior Change. American Journal of Health Promotion, 1997; 12(1):38-48

5. Alcoholics Anonymous. A.A. Timeline. Alcoholics Anonymous World Services, Inc.

6. Alcoholics Anonymous. Frequently Asked Questions about A.A. New York, NY: Alcoholics Anonymous World Services, Inc, 1952.

7. Alcoholics Anonymous. This is A.A.: An Introduction to the A.A. Recovery Program. New York, NY: Alcoholics Anonymous World Services, Inc, 1952

8. National Institute on Alcohol Abuse and Alcoholism. Alcohol Alert: National Epidemiologic Survey on Alcohol and Related Conditions. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism: of the National Institutes of Health, 2006.

9. Rosenquist, J. N. et al. The Spread of Consumption Behavior in a Large Social Network. Annals of Internal Medicine 2010; 152: 426-433.

10. Groh, D. R. et al. Social Network Variables in Alcoholics Anonymous: A Literature Review. Clinical Psychology Review 2008; 28(3): 430-450.

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