Critical Psychiatry Network

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Critical_Psychiatry_Network

The Critical Psychiatry Network (CPN) is a psychiatric organization based in the United Kingdom. It was created by a group of British psychiatrists who met in Bradford, England in January 1999 in response to proposals by the British government to amend the Mental Health Act 1983. They expressed concern about the implications of the proposed changes for human rights and the civil liberties of people with mental health illness. Most people associated with the group are practicing consultant psychiatrists in the United Kingdom's National Health Service (NHS), among them Dr Joanna Moncrieff. A number of non-consultant grade and trainee psychiatrists are also involved in the network.

Participants in the Critical Psychiatry Network share concerns about psychiatric practice where and when it is heavily dependent upon diagnostic classification and the use of psychopharmacology. These concerns reflect their recognition of poor construct validity amongst psychiatric diagnoses and scepticism about the efficacy of anti-depressants, mood stabilisers and anti-psychotic agents. According to them, these concerns have ramifications in the area of the use of psychiatric diagnosis to justify civil detention and the role of scientific knowledge in psychiatry, and an interest in promoting the study of interpersonal phenomena such as relationship, meaning and narrative in pursuit of better understanding and improved treatment.

CPN has similarities and contrasts with earlier criticisms of conventional psychiatric practice, for example those associated with David Cooper, R. D. Laing and Thomas Szasz. Features of CPN are pragmatism and full acknowledgment of the suffering commonly associated with mental health difficulties. As a result, it functions primarily as a forum within which practitioners can share experiences of practice, and provide support and encouragement in developing improvements in mainstream NHS practice where most participants are employed.

CPN maintains close links with service user or survivor led organisations such as the Hearing Voices Network, Intervoice and the Soteria Network, and with like-minded psychiatrists in other countries. It maintains its own website. The network is open to any sympathetic psychiatrist, and members meet in person, in the UK, twice a year. It is primarily intended for psychiatrists and psychiatric trainees and full participation is not available to other groups.

Coercion and social control

The other involved the introduction of community treatment orders (CTOs) to make it possible to treat people against their wishes in the community. CPN submitted evidence to the Scoping Group set up by the government under Professor Genevra Richardson. This set out ethical and practical objections to CTOs, and ethical and human rights objections to the idea of reviewable detention. It was also critical of the concept of personality disorder as a diagnosis in psychiatry. In addition, CPN's evidence called for the use of advance statements, crisis cards and a statutory right to independent advocacy as ways of helping to sustain autonomy at times of crisis. CPN also responded to government consultation on the proposed amendment, and the white paper.

The concern about these proposals caused a number of organizations to come together under the umbrella of the Mental Health Alliance to campaign in support of the protection of patients' and carers' rights, and to minimise coercion. CPN joined the Alliance's campaign, but resigned in 2005 when it became clear that the Alliance would accept those aspects of the House of Commons Scrutiny Committee's report that would result in the introduction of CTOs. Psychiatrists not identified with CPN shared the Network's concern about the more coercive aspects of the government's proposals, so CPN carried out a questionnaire survey of over two and a half thousand (2,500) consultant psychiatrists working in England seeking their views of the proposed changes. The responses (a response rate of 46%) indicated widespread concern in the profession about reviewable detention and CTOs.

The CPN was paid attention by Thomas Szasz who wrote: "Members of the CPN, like their American counterparts, criticize the proliferation of psychiatric diagnoses and 'excessive' use of psychotropic drugs, but embrace psychiatric coercions."

The role of scientific knowledge in psychiatry

There is a strong view by CPN that contemporary psychiatry relies too much on the medical model, and attaches too much importance to a narrow biomedical view of diagnosis. This can, in part, be understood as the response of an earlier generation of psychiatrists to the challenge of what has been called 'anti-psychiatry'. Psychiatrists such as David Cooper, R. D. Laing and Thomas Szasz (although the latter two rejected the term) were identified as part of a movement against psychiatry in the 1960s and 1970s. Stung by these attacks, as well as accusations that in any case psychiatrists could not even agree who was and who was not mentally ill, academic psychiatrists responded by stressing the biological and scientific basis of psychiatry through strenuous efforts to improve the reliability of psychiatric diagnosis based in a return to the traditions of one of the founding fathers of the profession, Emil Kraepelin.

The use of standardized diagnostic criteria and checklists may have improved the reliability of psychiatric diagnosis, but the problem of its validity remains. The investment of huge sums of money in Britain, America and Europe over the last half-century has failed to reveal a single, replicable difference between a person with a diagnosis of schizophrenia and someone who does not have the diagnosis. The case for the biological basis of common psychiatric disorders such as depression has also been greatly over-stated. This has a number of consequences:

First, the aggrandisement of biological research creates a false impression both inside and outside the profession of the credibility of the evidence used to justify drug treatments for disorders such as depression and schizophrenia. Reading clinical practice guidelines for the treatment of depression, for example, such as that produced for the UK National Health Service by the National Institute for Health and Clinical Excellence (NICE), one might be fooled into believing that the evidence for the efficacy of selective serotonin reuptake inhibitors (SSRIs) is established beyond question. In reality this is not the case, as re-examinations of drug trial data in meta-analyses, especially where unpublished data are included (publication bias means that researchers and drug companies do not publish negative findings for obvious commercial reasons), have revealed that most of the benefits seen in active treatment groups are also seen in the placebo groups.

As far as schizophrenia is concerned, neuroleptic drugs may have some short-term effects, but it is not the case that these drugs possess specific 'anti-psychotic' properties, and it is impossible to assess whether or not they confer advantages in long-term management of psychoses because of the severe disturbances that occur when people on long-term active treatment are withdrawn to placebos. These disturbances are traditionally interpreted as a 'relapse' of schizophrenia when in fact there are several possible interpretations for the phenomenon.

Another consequence of the domination of psychiatry by biological science is that the importance of contexts in understanding distress and madness is played down. This has a number of consequences. First, it obscures the true nature of what in fact are extremely complex problems. For example, if we consider depression to be a biological disorder remediable through the use of antidepressant tablets, then we may be excused from having to delve into the tragic circumstances that so often lie at the heart the experience. This is so in adults and children.

Meaning and experience in psychiatry

There is a common theme, here, with the work of David Ingleby whose chapter in Critical Psychiatry: The Politics of Mental Health sets out a detailed critique of positivism (the view that epistemology, or knowledge about the world is best served by empiricism and the scientific method rather than metaphysics). A common theme running through Laingian antipsychiatry, Ingleby's critical psychiatry, contemporary critical psychiatry and postpsychiatry is the view that social, political and cultural realities play a vital role in helping us to understand the suffering and experience of madness. Like Laing, Ingleby stressed the importance of hermeneutics and interpretation in inquiries about the meaning of experience in psychiatry, and (like Laing) he drew on psychoanalysis as an interpretative aid, but his work was also heavily influenced by the critical theory of the Frankfurt School.

The most forceful critic of this view was R. D. Laing, who famously attacked the approach enshrined by Jaspers' and Kraepelin's work in chapter two of The Divided Self, proposing instead an existential-phenomenological basis for understanding psychosis. Laing always insisted that schizophrenia is more understandable than is commonly supposed. Mainstream psychiatry has never accepted Laing's ideas, but many in CPN regard The Divided Self as central to twentieth century psychiatry. Laing's influence continued in America through the work of the late Loren Mosher, who worked at the Tavistock Clinic in the mid-1960s, when he also spent time in Kingsley Hall witnessing Laing's work. Shortly after his return to the US, Loren Mosher was appointed Director of Schizophrenia Research at the National Institute of Mental Health, and also the founding editor of the journal Schizophrenia Bulletin.

One of his most notable contributions to this area was setting up and evaluating the first Soteria House, an environment modeled on Kingsley Hall in which people experiencing acute psychoses could be helped with minimal drug use and a form of interpersonal phenomenology influenced by Heidegger. He also conducted evaluation studies of the effectiveness of Soteria. A recent systematic review of the Soteria model found that it achieved as good, and in some areas, better, clinical outcomes with much lower levels of medication (Soteria House was not anti-medication) than conventional approaches to drug treatment.

Efficacy

One comparison study showed 34% of patients of a 'medical model' team were still being treated after two years, compared with only 9% of patients of a team using a 'non-diagnostic' approach (less medication, little diagnosis, individual treatment plans tailored to the person's unique needs). However the study comments that cases may have left the system in the 'non-diagnostic' approach, not because treatment had worked, but because (1) multi-agency involvement meant long-term work may have been continued by a different agency, (2) the starting question of 'Do we think our service can make a positive difference to this young person's life?' rather than 'What is wrong with this young person?' may have led to treatment not being continued, and (3) the attitude of viewing a case as problematic when no improvement has occurred after five sessions may have led to treatment not being continued (rather than the case 'drifting' on in the system).

Critical Psychiatry and Postpsychiatry

Peter Campbell first used the term 'postpsychiatry' in the anthology Speaking Our Minds, which imagines what would happen in a world after psychiatry. Independently, Patrick Bracken and Philip Thomas coined the word later and used it as the title of a series of articles written for Openmind. This was followed by a key paper in the British Medical Journal and a book of the same name. This culminated with the publication by Bradley Lewis, a psychiatrist based in New York, of Moving Beyond Prozac, DSM, and the New Psychiatry: The Birth of Postpsychiatry.

According to Bracken, progress in the field of mental health is presented in terms of 'breakthrough drugs', 'wonders of neuroscience', 'the Decade of the Brain' and 'molecular genetics'. These developments suited the interests of a relatively small number of academic psychiatrists, many of whom have interests in the pharmaceutical industry, although so far the promised insights into psychosis and madness were yet to be realized. Some psychiatrists have turned to another form of technology, Cognitive Behavioural Therapy, although this does draw attention to the person's relationship with their experiences (such as voices or unusual beliefs), and focuses on helping them to find different ways of coping, it however, it is based on a particular set of assumptions about the nature of the self, the nature of thought, and how reality is constructed. The pros and cons of this have been explored in some detail in a recent publication.

Framing mental health problems as 'technical' in nature involves prioritising technology and expertise over values, relationships and meanings, the very things that emerge as important for service users, both in their narratives, and in service user-led research. For many service users these issues are of primary importance. Recent meta-analyses into the effectiveness of antidepressants and cognitive therapy in depression confirm that non-specific, non-technical factors (such as the quality of the therapeutic relationship as seen by the patient, and the placebo effect in medication) are more important than the specific factors.

Postpsychiatry tries to move beyond the view that we can only help people through technologies and expertise. Instead, it prioritises values, meanings and relationships and sees progress in terms of engaging creatively with the service user movement, and communities. This is especially important given the considerable evidence that in Britain, Black and Minority Ethnic (BME) communities are particularly poorly served by mental health services. For this reason an important practical aspect of postpsychiatry is the use of community development in order to engage with these communities. The community development project Sharing Voices Bradford is an excellent example of such an approach.

There are many commonalities between critical psychiatry and postpsychiatry, but it is probably fair to say that whereas postpsychiatry would broadly endorse most aspects of the work of critical psychiatry, the obverse does not necessarily hold. In identifying the modernist privileging of technical responses to madness and distress as a primary problem, postpsychiatry has looked to postmodernist thought for insights. Its conceptual critique of traditional psychiatry draws on ideas from philosophers such as Heidegger, Merleau-Ponty, Foucault and Wittgenstein.

Anti-psychiatry and Critical Psychiatry

Main article: Anti-psychiatry

The word anti-psychiatry is associated with the South African psychiatrist David Cooper, who used it to refer to the ending of the 'game' the psychiatrist plays with his or her victim (patient). It has been widely used to refer to the writings and activities of a small group of psychiatrists, most notably R.D. Laing, Aaron Esterson, Cooper, and Thomas Szasz (although he rejects the use of the label in relation to his own work, as did Laing and Esterson), and sociologists (Thomas Scheff). Szasz discards even more what he calls the quackery of 'antipsychiatry' than the quackery of psychiatry.

Anti-psychiatry can best be understood against the counter-cultural context in which it arose. The decade of the 1960s was a potent mix of student rebellion, anti-establishment sentiment and anti-war (Vietnam) demonstrations. It saw the rise to prominence of feminism and the American civil rights movement and the Northern Ireland civil rights movement. Across the world, formerly colonised peoples were throwing off the shackles of colonialism. Some of these themes emerged in the Dialectics of Liberation, a conference organized by Laing and others in the Round House in London in 1968.

Critical Psychiatry Network - Activities

CPN is involved in four main areas of work, writing and the publication of academic and other papers, organizing and participating in conferences, activism and support. A glance at the members' publication page on the CPN website reveals in excess of a hundred papers, books and other articles published by people associated with the network over the last twelve years or so. These cover a wide range of topics, from child psychiatry, psychotherapy, the role of diagnosis in psychiatry, critical psychiatry, philosophy and postpsychiatry, to globalization and psychiatry. CPN has also organized a number of conferences in the past, and continues to do so in collaboration with other groups and bodies. It has run workshops for psychiatrists and offers peer supervision face to face and via videolink. It also supports service user and survivor activists who campaign against the role of the pharmaceutical industry in psychiatry, and the campaign for the abolition of the schizophrenia label. The CPN has published a statement in support.

Recovery model

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Recovery_model

The recovery model, recovery approach or psychological recovery is an approach to mental disorder or substance dependence that emphasizes and supports a person's potential for recovery. Recovery is generally seen in this model as a personal journey rather than a set outcome, and one that may involve developing hope, a secure base and sense of self, supportive relationships, empowerment, social inclusion, coping skills, and meaning. Recovery sees symptoms as a continuum of the norm rather than an aberration and rejects sane-insane dichotomy.

William Anthony, Director of the Boston Centre for Psychiatric Rehabilitation developed a quaint cornerstone definition of mental health recovery in 1993. "Recovery is a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness."

The use of the concept in mental health emerged as deinstitutionalization resulted in more individuals living in the community. It gained impetus as a social movement due to a perceived failure by services or wider society to adequately support social inclusion, and to studies demonstrating that many people do recover. A recovery approach has now been explicitly adopted as the guiding principle of the mental health or substance dependency policies of a number of countries and states. In many cases practical steps are being taken to base services on a recovery model, although a range of obstacles, concerns and criticisms have been raised both by service providers and by recipients of services. A number of standardized measures have been developed to assess aspects of recovery, although there is some variation between professionalized models and those originating in the psychiatric survivors movement.

According to a study, a combined social and physical environment intervention has the potential to improve the need for recovery. However, the study's general healthy and well-functioning population made it challenging to have a significant impact. The researchers recommended implementing the intervention among a population with higher baseline values on need for recovery and providing physical activity opportunities, such as organizing lunch walking or yoga classes at work. Additionally, integrating a social media platform strategically with incentives for regular use, linking to other platforms such as Facebook, and implementing more drastic physical interventions, such as restructuring an entire department floor, may be necessary for improving the intervention's effectiveness. The study concluded that the relatively simple environment modifications used, such as placing signs to promote stair use, did not result in changes in need for recovery.

History

In general medicine and psychiatry, recovery has long been used to refer to the end of a particular experience or episode of illness. The broader concept of "recovery" as a general philosophy and model was first popularized in regard to recovery from substance abuse/drug addiction, for example within twelve-step programs.

Mental health recovery emerged in Geel, Belgium in the 13th century. Saint Dymphna—the patron saint of mental illness—was martyred there by her father in the 7th century. The Church of Saint Dymphna (built in 1349) became a pilgrimage destination for those seeking help with their psychiatric conditions. By the late 1400s, so many pilgrims were coming to Geel that the townspeople began hosting them as guests in their homes. This tradition of community recovery continues to this day. 

More widespread application of recovery models to psychiatric disorders is comparatively recent. The concept of recovery can be traced back as far as 1840, when John Thomas Perceval, son of Prime Minister Spencer Perceval, wrote of his personal recovery from the psychosis that he experienced from 1830 until 1832, a recovery that he obtained despite the "treatment" he received from the "lunatic" doctors who attended him. But by consensus the main impetus for the development came from within the consumer/survivor/ex-patient movement, a grassroots self-help and advocacy initiative, particularly within the United States during the late 1980s and early 1990s. The professional literature, starting with the psychiatric rehabilitation movement in particular, began to incorporate the concept from the early 1990s in the United States, followed by New Zealand and more recently across nearly all countries within the "First World". Similar approaches developed around the same time, without necessarily using the term recovery, in Italy, the Netherlands and the UK.

Developments were fueled by a number of long-term outcome studies of people with "major mental illnesses" in populations from virtually every continent, including landmark cross-national studies by the World Health Organization from the 1970s and 1990s, showing unexpectedly high rates of complete or partial recovery, with exact statistics varying by region and the criteria used. The cumulative impact of personal stories or testimony of recovery has also been a powerful force behind the development of recovery approaches and policies. A key issue became how service consumers could maintain the ownership and authenticity of recovery concepts while also supporting them in professional policy and practice.

Increasingly, recovery became both a subject of mental health services research and a term emblematic of many of the goals of the Consumer/Survivor/Ex-Patient Movement. The concept of recovery was often defined and applied differently by consumers/survivors and professionals. Specific policy and clinical strategies were developed to implement recovery principles although key questions remained.

Elements of recovery

It has been emphasized that each individual's journey to recovery is a deeply personal process, as well as being related to an individual's community and society. A number of features or signs of recovery have been proposed as often core elements and comprehensively they have been categorized under the concept of CHIME. CHIME is a mnemonic of connectedness, hope & optimism, identity, meaning & purpose and empowerment.

Connectedness and supportive relationships

A common aspect of recovery is said to be the presence of others who believe in the person's potential to recover and who stand by them. According to Relational Cultural Theory as developed by Jean Baker Miller, recovery requires mutuality and empathy in relationships. The theory states this requires relationships that embody respect, authenticity, and emotional availability. Supportive relationships can also be made safer through predictability and avoiding shaming and violence. While mental health professionals can offer a particular limited kind of relationship and help foster hope, relationships with friends, family and the community are said to often be of wider and longer-term importance. Case managers can play the role of connecting recovering persons to services that the recovering person may have limited access to, such as food stamps and medical care. Others who have experienced similar difficulties and are on a journey of recovery can also play a role in establishing community and combating a recovering person's feelings of isolation. An example of a recovery approach that fosters a sense of community to combat feelings of isolation is the safe house or transitional housing model of rehabilitation. This approach supports victims of trauma through a community-centered, transitional housing method that provides social services, healthcare, and psychological support to navigate through and past experiences. Safe houses aim to support survivors on account of their individual needs and can effectively rehabilitate those recovering from issues such as sexual violence and drug addiction without criminalization. Additionally, safe houses provide a comfortable space where survivors can be listened to and uplifted through compassion. In practice, this can be accomplished through one on one interviews with other recovering persons, engaging in communal story circles, or peer-led support groups. Those who share the same values and outlooks more generally (not just in the area of mental health) may also be particularly important. It is said that one-way relationships based on being helped can actually be devaluing and potentially re-traumatizing, and that reciprocal relationships and mutual support networks can be of more value to self-esteem and recovery.

Hope

Finding and nurturing hope has been described as a key to recovery. It is said to include not just optimism but a sustainable belief in oneself and a willingness to persevere through uncertainty and setbacks. Hope may start at a certain turning point, or emerge gradually as a small and fragile feeling, and may fluctuate with despair. It is said to involve trusting, and risking disappointment, failure and further hurt.

Identity

Recovery of a durable sense of self (if it had been lost or taken away) has been proposed as an important element. A research review suggested that people sometimes achieve this by "positive withdrawal"—regulating social involvement and negotiating public space in order to only move towards others in a way that feels safe yet meaningful; and nurturing personal psychological space that allows room for developing understanding and a broad sense of self, interests, spirituality, etc. It was suggested that the process is usually greatly facilitated by experiences of interpersonal acceptance, mutuality, and a sense of social belonging; and is often challenging in the face of the typical barrage of overt and covert negative messages that come from the broader social context. Being able to move on can mean having to cope with feelings of loss, which may include despair and anger. When an individual is ready for change, a process of grieving is initiated. It may require accepting past suffering and lost opportunities or lost time.

Formation of healthy coping strategies and meaningful internal schema

The development of personal coping strategies (including self-management or self-help) is said to be an important element. This can involve making use of medication or psychotherapy if the patient is fully informed and listened to, including about adverse effects and about which methods fit with the consumer's life and their journey of recovery. Developing coping and problem solving skills to manage individual traits and problem issues (which may or may not be seen as symptoms of mental disorder) may require a person becoming their own expert, in order to identify key stress points and possible crisis points, and to understand and develop personal ways of responding and coping. Developing a sense of meaning and overall purpose is said to be important for sustaining the recovery process. This may involve recovering or developing a social or work role. It may also involve renewing, finding or developing a guiding philosophy, religion, politics or culture. From a postmodern perspective, this can be seen as developing a narrative.

Empowerment and building a secure base

Building a positive culture of healing is essential in the recovery approach. Since recovering is a long process, a strong supportive network can be helpful. Appropriate housing, a sufficient income, freedom from violence, and adequate access to health care have also been proposed as important tools to empowering someone and increasing her/his self-sufficiency. Empowerment and self-determination are said to be important to recovery for reducing the social and psychological effects of stress and trauma. Women's Empowerment Theory suggests that recovery from mental illness, substance abuse, and trauma requires helping survivors understand their rights so they can increase their capacity to make autonomous choices. This can mean develop the confidence for independent assertive decision making and help-seeking which translates into proper medication and active self care practices. Achieving social inclusion and overcoming challenging social stigma and prejudice about mental distress/disorder/difference is also an important part of empowerment. Advocates of Women's Empowerment Theory argue it is important to recognize that a recovering person's view of self is perpetuated by stereotypes and combating those narratives. Empowerment according to this logic requires reframing a survivor's view of self and the world. In practice, empowerment and building a secure base require mutually supportive relationships between survivors and service providers, identifying a survivor's existing strengths, and an awareness of the survivor's trauma and cultural context.

Concepts of recovery

Varied definitions

What constitutes 'recovery', or a recovery model, is a matter of ongoing debate both in theory and in practice. In general, professionalized clinical models tend to focus on improvement in particular symptoms and functions, and on the role of treatments, while consumer/survivor models tend to put more emphasis on peer support, empowerment and real-world personal experience."Recovery from", the medical approach, is defined by a dwindling of symptoms, whereas "recovery in", the peer approach, may still involve symptoms, but the person feels they are gaining more control over their life. Similarly, recovery may be viewed in terms of a social model of disability rather than a medical model of disability, and there may be differences in the acceptance of diagnostic "labels" and treatments.

A review of research suggested that writers on recovery are rarely explicit about which of the various concepts they are employing. The reviewers classified the approaches they found in to broadly "rehabilitation" perspectives, which they defined as being focused on life and meaning within the context of enduring disability, and "clinical" perspectives which focused on observable remission of symptoms and restoration of functioning. From a psychiatric rehabilitation perspective, a number of additional qualities of the recovery process have been suggested, including that it: can occur without professional intervention, but requires people who believe in and stand by the person in recovery; does not depend on believing certain theories about the cause of conditions; can be said to occur even if symptoms later re-occur, but does change the frequency and duration of symptoms; requires recovery from the consequences of a psychiatric condition as well as the condition itself; is not linear but does tend to take place as a series of small steps; does not mean the person was never really psychiatrically disabled; focuses on wellness not illness, and on consumer choice.

A consensus statement on mental health recovery from US agencies, that involved some consumer input, defined recovery as a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential. Ten fundamental components were elucidated, all assuming that the person continues to be a "consumer" or to have a "mental disability". Conferences have been held on the importance of the "elusive" concept from the perspectives of consumers and psychiatrists.

One approach to recovery known as the Tidal Model focuses on the continuous process of change inherent in all people, conveying the meaning of experiences through water metaphors. Crisis is seen as involving opportunity; creativity is valued; and different domains are explored such as sense of security, personal narrative and relationships. Initially developed by mental health nurses along with service users, Tidal is a particular model that has been specifically researched. Based on a discrete set of values (the Ten Commitments), it emphasizes the importance of each person's own voice, resourcefulness and wisdom. Since 1999, projects based on the Tidal Model have been established in several countries.

For many, recovery has a political as well as personal implication—where to recover is to: find meaning; challenge prejudice (including diagnostic "labels" in some cases); perhaps to be a "bad" non-compliant patient and refuse to accept the indoctrination of the system; to reclaim a chosen life and place within society; and to validate the self. Recovery can thus be viewed as one manifestation of empowerment. Such an empowerment model may emphasize that conditions are not necessarily permanent; that other people have recovered who can be role models and share experiences; and that "symptoms" can be understood as expressions of distress related to emotions and other people. One such model from the US National Empowerment Center proposes a number of principles of how people recover and seeks to identify the characteristics of people in recovery.

In general, recovery may be seen as more of a philosophy or attitude than a specific model, requiring fundamentally that "we regain personal power and a valued place in our communities. Sometimes we need services to support us to get there".

Recovery from substance dependence

Particular kinds of recovery models have been adopted in drug rehabilitation services. While interventions in this area have tended to focus on harm reduction, particularly through substitute prescribing (or alternatively requiring total abstinence) recovery approaches have emphasized the need to simultaneously address the whole of people's lives, and to encourage aspirations while promoting equal access and opportunities within society. Some examples of harm reduction services include overdose reversal medications (such as Narcan), substance testing kits, supplies for sterile injections, HIV, HBV, and HCV at-home testing equipment– and trauma-informed care in the form of group therapy, community building/events, case management, and rental assistance services. The purpose of this model is to rehabilitate those experiencing addiction in a holistic way rather than through law enforcement and criminal justice-based intervention which can fail to address victims’ circumstances on a need-by-need basis. From the perspective of services the work may include helping people with "developing the skills to prevent relapse into further illegal drug taking, rebuilding broken relationships or forging new ones, actively engaging in meaningful activities and taking steps to build a home and provide for themselves and their families. Milestones could be as simple as gaining weight, re-establishing relationships with friends, or building self-esteem. What is key is that recovery is sustained.". Key to the philosophy of the recovery movement is the aim for an equal relationship between "Experts by Profession" and "Experts by Experience".

Trauma-Informed Recovery

Trauma-Informed care is a philosophy for recovery that combines the conditions and needs of people recovering from mental illness and/or substance abuse into one framework. This framework combines all of the elements of the Recovery Approach and adds an awareness of trauma. Advocates of trauma-informed care argue the principles and strategies should be applied to individuals experiencing mental illness, substance dependence, and trauma as these three often occur simultaneously or as result of each other. The paradigms surrounding trauma-informed care began to shift in 1998 and 1999. In 1998, the Center for Mental Health Services, the Center for Substance Abuse Treatment, and the Center for Substance Abuse Prevention collaborated to fund 14 sites to develop integrated services in order to address the interrelated effects of violence, mental health, and substance abuse. In 1999, the National Association of State Mental Health Program Directors passed a resolution recognizing the impact of violence and trauma and developed a toolkit of resources for the implementation of trauma services in state mental health agencies. Trauma-informed care has been supported in academia as well. Scholars claim that neglecting the role of trauma in a person's story can interfere with recovery in the form of misdiagnosis, inaccurate treatment, or retraumatization. Some principles of trauma-informed care include validating survivor experiences and resiliency, aiming to increase a survivor's control over her/his/their recovery, creating atmospheres for recovery that embody consistency and confidentiality, minimizing the possibilities of triggering past trauma, and integrating survivors/recovering persons in service evaluation. In practice, trauma-informed care has shown to be most effective when every participant in a service providing context to be committed to following these principles. In addition, these principles can apply to all steps of the recovery process within a service providing context, including outreach and engagement, screening, advocacy, crisis intervention, and resource coordination. The overall goal in trauma-informed care is facilitating healing and empowerment using strengths-based empowerment practices and a comprehensive array of services that integrate co-occurring disorders and the multitude of needs a recovering person might have, such as drug treatment, housing, relationship building, and parenting support.

These approaches are in contrast to traditional care systems. Advocates of trauma-informed care critique traditional service delivery systems, such as standard hospitals, for failing to understand the role of trauma in a patients life. Traditional service delivery systems are also critiqued for isolating the conditions of a recovering person and not addressing conditions such as substance abuse and mental illness simultaneously as part of one source. Specific practices in traditional service delivery systems, such as unnecessary procedures, undressing for examinations, involuntary hospitalizations, crowded emergency rooms, and limited time for providers to meet with patients, have all been critiqued as insensitive to persons recovering from trauma and consequential mental illness or substance abuse. Limited resources and time in the United States healthcare system can make the implementation of trauma-informed care difficult.

There are other challenges to trauma-informed care besides limits in the United States healthcare system that can make trauma-informed care ineffective for treating persons recovering from mental illness or substance dependence. Advocates of trauma-informed care argue implementation requires a strong commitment from leadership in an agency to train staff members to be trauma-aware, but this training can be costly and time-consuming. "Trauma-informed care" and "trauma" also have contested definitions and can be hard to measure in a real world service setting. Another barrier to trauma-informed care is the necessity of screening for histories of trauma. While agencies need to screen for histories of trauma in order to give the best care, there can be feelings of shame and fear of being invalidated that can prevent a recovering person from disclosing their personal experiences.

Concerns

Some concerns have been raised about a recovery approach in theory and in practice. These include suggestions that it: is an old concept; only happens to very few people; represents an irresponsible fad; happens only as a result of active treatment; implies a cure; can only be implemented with new resources; adds to the burden of already stretched providers; is neither reimbursable nor evidence based; devalues the role of professional intervention; and increases providers' exposure to risk and liability.

Other criticisms focused on practical implementation by service providers include that: the recovery model can be manipulated by officials to serve various political and financial interests including withdrawing services and pushing people out before they're ready; that it is becoming a new orthodoxy or bandwagon that neglects the empowerment aspects and structural problems of societies and primarily represents a middle class experience; that it hides the continued dominance of a medical model; and that it potentially increases social exclusion and marginalizes those who don't fit into a recovery narrative.

There have been specific tensions between recovery models and "evidence-based practice" models in the transformation of US mental health services based on the recommendations of the New Freedom Commission on Mental Health. The commission's emphasis on recovery has been interpreted by some critics as saying that everyone can fully recover through sheer will power and therefore as giving false hope and implicitly blaming those who may be unable to recover. However, the critics have themselves been charged with undermining consumer rights and failing to recognize that the model is intended to support a person in their personal journey rather than expecting a given outcome, and that it relates to social and political support and empowerment as well as the individual.

Various stages of resistance to recovery approaches have been identified amongst staff in traditional services, starting with "Our people are much sicker than yours. They won't be able to recover" and ending in "Our doctors will never agree to this". However, ways to harness the energy of this perceived resistance and use it to move forward have been proposed. In addition, staff training materials have been developed by various organisations, for example by the National Empowerment Center.

Some positives and negatives of recovery models were highlighted in a study of a community mental health service for people diagnosed with schizophrenia. It was concluded that while the approach may be a useful corrective to the usual style of case management - at least when genuinely chosen and shaped by each unique individual on the ground - serious social, institutional and personal difficulties made it essential that there be sufficient ongoing effective support with stress management and coping in daily life. Cultural biases and uncertainties were also noted in the 'North American' model of recovery in practice, reflecting views about the sorts of contributions and lifestyles that should be considered valuable or acceptable.

Assessment

A number of standardized questionnaires and assessments have been developed to try to assess aspects of an individual's recovery journey. These include the Milestones of Recovery (MOR) Scale, Recovery Enhancing Environment (REE) measure, Recovery Measurement Tool (RMT), Recovery Oriented System Indicators (ROSI) Measure, Stages of Recovery Instrument (STORI), and numerous related instruments.

The data-collection systems and terminology used by services and funders are said to be typically incompatible with recovery frameworks, so methods of adapting them have been developed. It has also been argued that the Diagnostic and Statistical Manual of Mental Disorders (and to some extent any system of categorical classification of mental disorders) uses definitions and terminology that are inconsistent with a recovery model, leading to suggestions that the next version, the DSM-V, requires: greater sensitivity to cultural issues and gender; to recognize the need for others to change as well as just those singled out for a diagnosis of disorder; and to adopt a dimensional approach to assessment that better captures individuality and does not erroneously imply excess psychopathology or chronicity.

National policies and implementation

United States and Canada

The New Freedom Commission on Mental Health has proposed to transform the mental health system in the US by shifting the paradigm of care from traditional medical psychiatric treatment toward the concept of recovery, and the American Psychiatric Association has endorsed a recovery model from a psychiatric services perspective.

The US Department of Health and Human Services reports developing national and state initiatives to empower consumers and support recovery, with specific committees planning to launch nationwide pro-recovery, anti-stigma education campaigns; develop and synthesize recovery policies; train consumers in carrying out evaluations of mental health systems; and help further the development of peer-run services. Mental Health service directors and planners are providing guidance to help state services implement recovery approaches.

Some US states, such as California (see the California Mental Health Services Act), Wisconsin and Ohio, already report redesigning their mental health systems to stress recovery model values like hope, healing, empowerment, social connectedness, human rights, and recovery-oriented services.

At least some parts of the Canadian Mental Health Association, such as the Ontario region, have adopted recovery as a guiding principle for reforming and developing the mental health system.

New Zealand and Australia

Since 1998, all mental health services in New Zealand have been required by government policy to use a recovery approach and mental health professionals are expected to demonstrate competence in the recovery model. Australia's National Mental Health Plan 2003-2008 states that services should adopt a recovery orientation although there is variation between Australian states and territories in the level of knowledge, commitment and implementation.

UK and Ireland

In 2005, the National Institute for Mental Health in England (NIMHE) endorsed a recovery model as a possible guiding principle of mental health service provision and public education. The National Health Service is implementing a recovery approach in at least some regions, and has developed a new professional role of Support Time and Recovery Worker. Centre for Mental Health issued a 2008 policy paper proposing that the recovery approach is an idea "whose time has come" and, in partnership with the NHS Confederation Mental Health Network, and support and funding from the Department of Health, manages the Implementing Recovery through Organisational Change (ImROC) nationwide project that aims to put recovery at the heart of mental health services in the UK. The Scottish Executive has included the promotion and support of recovery as one of its four key mental health aims and funded a Scottish Recovery Network to facilitate this. A 2006 review of nursing in Scotland recommended a recovery approach as the model for mental health nursing care and intervention. The Mental Health Commission of Ireland reports that its guiding documents place the service user at the core and emphasize an individual's personal journey towards recovery.

Twelve-step program

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Twelve-step_program

Twelve-step programs are international mutual aid programs supporting recovery from substance addictions, behavioral addictions and compulsions. Developed in the 1930s, the first twelve-step program, Alcoholics Anonymous (AA), founded by Bill Wilson and Bob Smith, aided its membership to overcome alcoholism. Since that time dozens of other organizations have been derived from AA's approach to address problems as varied as drug addiction, compulsive gambling, sex, and overeating. All twelve-step programs utilize a version of AA's suggested twelve steps first published in the 1939 book Alcoholics Anonymous: The Story of How More Than One Hundred Men Have Recovered from Alcoholism.

As summarized by the American Psychological Association (APA), the process involves the following:

• admitting that one cannot control one's alcoholism, addiction, or compulsion;
• coming to believe in a Higher Power that can give strength;
• examining past errors with the help of a sponsor (experienced member);
• making amends for these errors;
• learning to live a new life with a new code of behavior;
• helping others who suffer from the same alcoholism, addictions, or compulsions.

Overview

Twelve-step methods have been adapted to address a wide range of alcoholism, substance abuse, and dependency problems. Over 200 mutual aid organizations—often known as fellowships—with a worldwide membership of millions have adopted and adapted AA’s 12 Steps and 12 Traditions for recovery. Narcotics Anonymous was formed by addicts who did not relate to the specifics of alcohol dependency.

Demographic preferences related to the addicts' drug of choice has led to the creation of Cocaine Anonymous, Crystal Meth Anonymous and Marijuana Anonymous. Behavioral issues such as compulsion for or addiction to gambling, crime, food, sex, hoarding, getting into debt and work are addressed in fellowships such as Gamblers Anonymous, Overeaters Anonymous, Sexaholics Anonymous and Debtors Anonymous.

Auxiliary groups such as Al-Anon and Nar-Anon, for friends and family members of alcoholics and addicts, respectively, are part of a response to treating addiction as a disease that is enabled by family systems. Adult Children of Alcoholics (ACA or ACOA) addresses the effects of growing up in an alcoholic or otherwise dysfunctional family. Co-Dependents Anonymous (CoDA) addresses compulsions related to relationships, referred to as codependency.

History

Further information: History of Alcoholics Anonymous

Alcoholics Anonymous (AA), the first twelve-step fellowship, was founded in 1935 by Bill Wilson and Dr. Robert Holbrook Smith, known to AA members as "Bill W." and "Dr. Bob", in Akron, Ohio. In 1946 they formally established the twelve traditions to help deal with the issues of how various groups could relate and function as membership grew. The practice of remaining anonymous (using only one's first names) when interacting with the general public was published in the first edition of the AA Big Book.

As AA chapters were increasing in number during the 1930s and 1940s, the guiding principles were gradually defined as the Twelve Traditions. A singleness of purpose emerged as Tradition Five: "Each group has but one primary purpose—to carry its message to the alcoholic who still suffers". Consequently, drug addicts who do not suffer from the specifics of alcoholism involved in AA hoping for recovery technically are not welcome in "closed" meetings unless they have a desire to stop drinking alcohol.

The principles of AA have been used to form numerous other fellowships specifically designed for those recovering from various pathologies; each emphasizes recovery from the specific malady which brought the sufferer into the fellowship.

Twelve Steps

Several terms ending in "step" redirect here. For other uses, see Scale (music), Eighth Step Coffee House, and Ninth Step Station.

 

Further information: List of Twelve Step alternate wordings

See also: The Fifth Step

The following are the original twelve steps as published by Alcoholics Anonymous:

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory, and when we were wrong, promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

Where other twelve-step groups have adapted the AA steps as guiding principles, step one is generally updated to reflect the focus of recovery. For example, in Overeaters Anonymous, the first step reads, "We admitted we were powerless over compulsive overeating—that our lives had become unmanageable." The third step is also sometimes altered to remove gender-specific pronouns.

Twelve Traditions

Main article: Twelve Traditions

The Twelve Traditions accompany the Twelve Steps. The Traditions provide guidelines for group governance. They were developed in AA in order to help resolve conflicts in the areas of publicity, politics, religion, and finances. Alcoholics Anonymous' Twelve Traditions are:

1. Our common welfare should come first; personal recovery depends upon AA unity.
2. For our group purpose there is but one ultimate authority—a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants; they do not govern.
3. The only requirement for AA membership is a desire to stop drinking.
4. Each group should be autonomous except in matters affecting other groups or AA as a whole.
5. Each group has but one primary purpose—to carry its message to the alcoholic who still suffers.
6. An AA group ought never endorse, finance, or lend the AA name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose.
7. Every AA group ought to be fully self-supporting, declining outside contributions.
8. Alcoholics Anonymous should remain forever non-professional, but our service centers may employ special workers.
9. AA, as such, ought never be organized; but we may create service boards or committees directly responsible to those they serve.
10. Alcoholics Anonymous has no opinion on outside issues; hence the AA name ought never be drawn into public controversy.
11. Our public relations policy is based on attraction rather than promotion; we need always to maintain personal anonymity at the level of press, radio, and films.
12. Anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities.

Process

In the twelve-step program, the human structure is symbolically represented in three dimensions: physical, mental, and spiritual. The problems the groups deal with are understood to manifest themselves in each dimension. For addicts and alcoholics, the physical dimension is best described by the allergy-like bodily reaction resulting in the compulsion to continue using substances even when it's harmful or wanting to quit. The statement in the First Step that the individual is "powerless" over the substance-abuse related behavior at issue refers to the lack of control over this compulsion, which persists despite any negative consequences that may be endured as a result.

The mental obsession is described as the cognitive processes that cause the individual to repeat the compulsive behavior after some period of abstinence, either knowing that the result will be an inability to stop or operating under the delusion that the result will be different. The description in the First Step of the life of the alcoholic or addict as "unmanageable" refers to the lack of choice that the mind of the addict or alcoholic affords concerning whether to drink or use again. The illness of the spiritual dimension, or "spiritual malady," is considered in all twelve-step groups to be self-centeredness. The process of working the steps is intended to replace self-centeredness with a growing moral consciousness and a willingness for self-sacrifice and unselfish constructive action. In twelve-step groups, this is known as a "spiritual awakening." This should not be confused with abreaction, which produces dramatic, but temporary, changes. As a rule, in twelve-step fellowships, spiritual awakening occurs slowly over a period of time, although there are exceptions where members experience a sudden spiritual awakening.

In accordance with the First Step, twelve-step groups emphasize self-admission by members of the problem they are recovering from. It is in this spirit that members often identify themselves along with an admission of their problem, often as "Hi, I’m [first name only], and I’m an alcoholic".

Sponsorship

A sponsor is a more experienced person in recovery who guides the less-experienced aspirant ("sponsee") through the program's twelve steps. New members in twelve-step programs are encouraged to secure a relationship with at least one sponsor who both has a sponsor and has taken the twelve steps themselves. Publications from twelve-step fellowships emphasize that sponsorship is a "one on one" nonhierarchical relationship of shared experiences focused on working the Twelve Steps. According to Narcotics Anonymous:

Sponsors share their experience, strength, and hope with their sponsees... A sponsor's role is not that of a legal adviser, a banker, a parent, a marriage counselor, or a social worker. Nor is a sponsor a therapist offering some sort of professional advice. A sponsor is simply another addict in recovery who is willing to share his or her journey through the Twelve Steps.

Sponsors and sponsees participate in activities that lead to spiritual growth. Experiences in the program are often shared by outgoing members with incoming members. This rotation of experience is often considered to have a great spiritual reward. These may include practices such as literature discussion and study, meditation, and writing. Completing the program usually implies competency to guide newcomers which is often encouraged. Sponsees typically do their Fifth Step, review their moral inventory written as part of the Fourth Step, with their sponsor. The Fifth Step, as well as the Ninth Step, have been compared to confession and penitence. Michel Foucault, a French philosopher, noted such practices produce intrinsic modifications in the person—exonerating, redeeming and purifying them; relieves them of their burden of wrong, liberating them and promising salvation.

The personal nature of the behavioral issues that lead to seeking help in twelve-step fellowships results in a strong relationship between sponsee and sponsor. As the relationship is based on spiritual principles, it is unique and not generally characterized as "friendship". Fundamentally, the sponsor has the single purpose of helping the sponsee recover from the behavioral problem that brought the sufferer into twelve-step work, which reflexively helps the sponsor recover.

A study of sponsorship as practiced in Alcoholics Anonymous and Narcotics Anonymous found that providing direction and support to other alcoholics and addicts is associated with sustained abstinence for the sponsor, but suggested that there were few short-term benefits for the sponsee's one-year sustained abstinence rate.

Effectiveness

See also: Effectiveness of Alcoholics Anonymous, Effectiveness of Crystal Meth Anonymous, Effectiveness of Gamblers Anonymous, Effectiveness of Narcotics Anonymous, Effectiveness of Neurotics Anonymous, Effectiveness of Nicotine Anonymous, and Effectiveness of self-help groups for mental health

Alcoholics Anonymous is the largest of all of the twelve-step programs (from which all other twelve-step programs are derived), followed by Narcotics Anonymous; the majority of twelve-step members are recovering from addiction to alcohol or other drugs. The majority of twelve-step programs, however, address illnesses other than substance addiction. For example, the third-largest twelve-step program, Al-Anon, assists family members and friends of people who have alcoholism and other addictions. About twenty percent of twelve-step programs are for substance addiction recovery, the other eighty percent address a variety of problems from debt to depression. It would be an error to assume the effectiveness of twelve-step methods at treating problems in one domain translates to all or to another domain.

A 2020 Cochrane review of Alcoholics Anonymous showed that participation in AA resulted in more alcoholics being abstinent from alcohol and for longer periods of time than cognitive behavioral therapy and motivational enhancement therapy, and as effective as these in other measures. The 2020 review did not compare twelve step programs to the use of disulfiram or naltrexone, though some patients did receive these medications. These medications are considered the standard of care in alcohol use disorder treatment among medical experts and have demonstrated efficacy in randomized-controlled trials in promoting alcohol abstinence. A systematic review published in 2017 found that twelve-step programs for reducing illicit drug use are neither better nor worse than other interventions.

Criticism

See also: Alcoholics Anonymous: Criticism, Gamblers Anonymous: Criticism, Narcotics Anonymous: Controversies, Overeaters Anonymous: Criticism, Self-help groups for mental health: Criticism, and Sexaholics Anonymous: Criticism

In the past, some medical professionals have criticized 12-step programs as "a cult that relies on God as the mechanism of action" and as lacking any experimental evidence in favor of its efficacy. Ethical and operational issues had prevented robust randomized controlled trials from being conducted comparing 12-step programs directly to other approaches. More recent studies employing non-randomized and quasi-experimental studies have shown 12-step programs provide similar benefit compared to motivational enhancement therapy (MET) and cognitive behavioral therapy (CBT), and were more effective in producing continuous abstinence and remission compared to these approaches.

Confidentiality

The Twelve Traditions encourage members to practice the spiritual principle of anonymity in the public media and members are also asked to respect each other's confidentiality. This is a group norm, however, and not legally mandated; there are no legal consequences to discourage those attending twelve-step groups from revealing information disclosed during meetings. Statutes on group therapy do not encompass those associations that lack a professional therapist or clergyman to whom confidentiality and privilege might apply. Professionals and paraprofessionals who refer patients to these groups, to avoid both civil liability and licensure problems, have been advised that they should alert their patients that, at any time, their statements made in meetings may be disclosed.

Cultural identity

One review warned of detrimental iatrogenic effects of twelve-step philosophy and labeled the organizations as cults, while another review asserts that these programs bore little semblance to religious cults and that the techniques used appeared beneficial to some. Another study found that a twelve-step program's focus on self-admission of having a problem increases deviant stigma and strips members of their previous cultural identity, replacing it with the deviant identity. Another study asserts that the prior cultural identity may not be replaced entirely, but rather members found adapted a bicultural identity.

Nicotine Anonymous

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Nicotine_Anonymous

Nicotine Anonymous (NicA) is a twelve-step program founded in 1982 for people desiring to quit smoking and live free of nicotine. As of July 2017, there are over 700 face-to-face meetings in 32 countries worldwide with the majority of these meetings occurring in the United States, Iran, India, Canada, Brazil, the United Kingdom, Australia, Russia and in various online community and social media platforms. NicA maintains that total abstinence from nicotine is necessary for recovery. NicA defines abstinence as “a state that begins when all use of nicotine ceases.

History

See also: Twelve-step program: History

The first meetings began in February 1982 one on one meetings between a group of Southern California AA members to focus specifically on smoking cessation. These meetings began under the name Smokers Anonymous in Los Angeles. In June 1982 the founders, Rodger F, Robert K, Stephanie S, Dan H, began holding group meetings in Santa Monica California. Shortly thereafter another group independently started in San Francisco.

In 1983, a Manhattan, New York group of meetings formed independently, also formed by recovering AA members, specifically to address their smoking addiction. They called themselves "AA for Non-Smokers". During the same period, two groups started in Cleveland, Ohio.

Then in May 1985, Maurice Z., a California member, authored an article for Reader’s Digest. Thousands of letters poured in from people wanting to know more about this new Twelve-Step fellowship. That year Smokers Anonymous groups started independently in Woodstock, NY and in Islip, NY. Within a year there were a hundred meetings identified.

In 1986 the group members met for their first conference in Bakersfield, California to form a fellowship, originally known as Smokers Anonymous.

These groups met again in 1987 in Monterey, California. In April 1988, the fellowship’s first official World Services Conference was held in San Francisco.

The fellowship was renamed Nicotine Anonymous in Phoenix, Arizona at the 1990 World Services Conference because the Smokers Anonymous trademark was not available, but also, importantly, the delegates decided the focus of recovery should be on the drug nicotine rather than any single nicotine delivery system.

In 2000, "NicA" was selected to abbreviate Nicotine Anonymous at the annual World Service Conference.

Structure

Adapted with permission of Alcoholics Anonymous World Services, Inc., the Twelve Traditions are utilized by Nicotine Anonymous as fundamental guiding principles. Nicotine Anonymous operates with an elected, all volunteer, nine member board of officers and a set of by-laws. The board meets regularly to discuss how to be of service to the organization including organizing its annual World Service Conference and monitoring a number of appointed committee coordinators and the Nicotine Anonymous World Service home office located in Dallas, TX. The office keeps regularly updated meeting lists, manages the website and its online store, distributes NicA literature and free Meeting Starter Kits, and serves as a resource for members or any interested nicotine user. There are no dues or fees for NicA membership, as stated in Tradition Three: "the only requirement for Nicotine Anonymous membership is a desire to stop using nicotine."

Comparison

There are several commercial and nonprofit programs supporting smoking cessation programs in the United States. Low-cost options, in addition to Nicotine Anonymous, are sponsored by groups such as The American Cancer Society, The American Lung Association, The American Heart Association and The Seventh-day Adventist Church. Commercial programs include cognitive-behavioral group therapy, nicotine replacement therapies and bupropion. Combinations of these approaches, marketed in commercial packages such as Smokeless and Smoke Stoppers, are licensed to treatment providers and conducted on an inpatient or outpatient basis. These are in addition to local programs ran by regional treatment facilities.

A weekly NicA meeting is ongoing and therefore unique among the array of treatment options because nicotine users and ex-nicotine users can enter and leave the process as they please. Most other treatment programs are structured as limited duration programs, with only a certain number of sessions, making it difficult for members to pick it up midway through or begin when a program is not being offered.

In 1996, NicA ranked twelfth in size among the thirteen twelve-step organizations studied by Klaus Makela. Sponsorship and lifetime attendance is not emphasized as much as in other twelve-step programs. The average meeting size is about seven people.

Although both drinking and smoking are recognized by many respondents as imposing burdens on the family, there are no auxiliary support groups for friends and family of smokers related to NicA; as Al-Anon meetings were created for friends and family members of alcoholics. Nicotine Anonymous World Services does, however, offer a pamphlet, Are You Concerned About Someone Who Smokes or Chews Tobacco? with information for friends and family of nicotine users.

Effectiveness

See also: Twelve-step program: Effectiveness

Success in achieving smoking abstinence using current smoking therapies such as Nicotine Anonymous, cognitive-behavioral group therapy, nicotine replacement therapies and bupropion (Zyban) ranges from 9% to 40% in different studies. Alcoholics and drug addicts have better smoking cessation success rates when attempting to quit smoking early in recovery. Combining psychosocial and pharmacological treatments increases smoking cessation success rates. Acupuncture, hypnosis, inpatient treatment, and Nicotine Anonymous have not been shown effective thus far.

In a controlled study 205 alcoholics, with heavy tobacco dependence (an average of 26.8 cigarettes per day) and three months or more of continuous abstinence from drugs and alcohol, were placed at random in one of three treatment groups: an American Lung Association Quit Program plus Nicotine Anonymous meetings group, a behavioral counseling plus physical exercise group, or a behavioral counseling plus nicotine gum group. The effectiveness of the treatment programs was measured at post-treatment, six months, and twelve-months following post-treatment based on self-reports confirmed by confirmed biochemical and informant reports. Immediately following treatment the behavior counseling and exercise group had the highest quit percentage (60%) followed by the behavioral counseling plus nicotine gum group, with the ALA quit program plus NicA group at 31%. At the six-month follow up all groups had similar percentages of members maintaining abstinence from tobacco (29%, 27%, and 21%, respectively) and also at twelve-months (27%, 27%, and 26%, respectively). Out of all the participants, only 4% relapsed on alcohol or drugs. The alcohol relapse rate did not differ by treatment group.

Demographics

In a survey of 104 smokers (ages 18 and older) 78% reported they believed spiritual resources could be helpful in an attempt to quit smoking. In the same survey, male smokers, ages 31 and over, and females were found to be significantly more open to using spiritual resources in the smoking cessation process than controls. Heavy smokers, those smoking more than fifteen cigarettes per day, were also significantly more receptive to encouragement of spiritual resources in an attempt to quit.

Alcoholics may have experienced twelve-step approaches to recovery and therefore may be more open to the possibility that same approach can be used to initiate and maintain abstinence from tobacco use. The first edition of Nicotine Anonymous: The Book published results of an internal survey of members showing that 25% of members responding to a survey on the topic reported they had prior twelve-step experience. Many smokers do not see group treatment as a potentially useful.

Literature

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Nicotine Anonymous publishes eight books, sixteen pamphlets, two CDs, and one newsletter. Nicotine Anonymous: The Book explains the various principles of the Twelve Steps as they apply to nicotine addiction and includes testimonials from NicA members. Nicotine Anonymous Newcomer’s Booklet is a pocket sized booklet that answers common questions about the program and includes helpful tips. Nicotine Anonymous Step Study Workbook briefly discusses aspects of each Step and is followed by questions for the member to answer. Our Path to Freedom: Twelve Stories of Recovery includes testimonials from NicA members. 90 Days, 90 Ways has 90 daily meditations on topics related to recovery from nicotine addiction. A Year of Miracles has 366 daily meditations further expanding on topics related to recovery from nicotine addiction. The Twelve Traditions of Nicotine Anonymous (Extended Version) includes a complete copy of the explanations for all Twelve Traditions. Bylaws of Nicotine Anonymous has the rules and regulations for how Nicotine Anonymous World Services operates.

The pamphlets provide information to new and prospective members, and include titles as follows: Introducing Nicotine Anonymous; To the Newcomer and Sponsorship in Nicotine Anonymous; Out Policy of Openness; How Nicotine Anonymous Works; Nicotine Anonymous the Program and the Tools; A Nicotine User's View of the Twelve Steps; The Serenity Prayer for Nicotine Users; Slogans to Help Us be Happy, Joyous, and Free Living Without Nicotine; Abstinence: What is it?; Tips for Gaining Freedom From Nicotine; Facing the Fatal Attraction; To the Dipper and Chewer; Our Promises; World Services, My intergroup, and Me; Introducing Nicotine Anonymous to the Medical Profession; Are You Concerned About Someone Who Smokes or Chews Tobacco? For the Friends and Family of Nicotine Addicts. Voices of NicA is a CD that has audio shares from members covering their experience, strength and hope in their nicotine recovery. There is also a CD with an audio content of Nicotine Anonymous: The Book and Our Path to Freedom. Seven Minutes is a quarterly newsletter used to keep members informed about developments within the organization and members’ recovery contributions.

• Nicotine Anonymous World Services (September 2004). Nicotine Anonymous: The Book (3rd ed.). Huntington Beach, CA: Nicotine Anonymous World Services. ISBN 978-0-9770115-0-6. OCLC 32687553.
• Nicotine Anonymous World Services (August 2003). Our Path to Freedom: Twelve Stories of Recovery. Huntington Beach, CA: Nicotine Anonymous World Services. ISBN 978-0-9770115-1-3.
• Nicotine Anonymous World Services (October 2004). 90 Days, 90 Ways. Huntington Beach, CA: Nicotine Anonymous World Services. ISBN 978-0-9770115-2-0.
• Nicotine Anonymous World Services (April 2008). A Year of Miracles (1st ed.). Huntington Beach, CA: Nicotine Anonymous World Services. ISBN 978-0-9770115-4-4.
• Nicotine Anonymous World Services (2012). Nicotine Anonymous Newcomer's Booklet. Dallas, TX: Nicotine Anonymous World Services.

Analysis

A NicA pamphlet, Tips for Gaining Freedom from Nicotine, was reviewed in 1999 by a convenience sample of twelve professional colleagues of psychologist Edward Lichtenstein. These professionals were asked to review the cessation tips from the pamphlet and rate them on whether they were cognitive, behavioral, or neither. To that extent, they also rated how consistent the tips were with current cognitive-behavioral cessation techniques. It was found that many of the tips were very consistent with modern cognitive-behavioral smoking cessation treatment programs. The cognitive behavioral tips included setting dates, making commitments, planning things to keep one's mind off smoking, having something to fidget with, having something to put in one's mouth, rewarding oneself when goals have been met, remembering that discomfort associated with withdrawal will subside within two weeks. One tip was found to be spiritual, "Pray instead of puff". Since 1999 many of the NicA pamphlets have been updated and current versions may not contain the information analyzed.