Maria E. Pagano, PhD

Case Western Reserve University School of Medicine

Alcohol Medical Scholars Program

June 15, 2007

Giving Service in Alcohol Abuse/Dependence Treatment


I. Introduction

A. Giving service is an important topic because:

1. The process is important to recovery from problems

2. Everyone is able to give service in one way or another

3.  The process is not well understood

B. Therefore, this lecture will cover:

1. Definition of giving service

2. Health benefits of service in general

3. Background on alcohol abuse/dependency treatments

4. Role of service in Alcoholics Anonymous

5. Clinical implications of service overall

II. Overview

A. Review definition of service

B. Health benefits of service

C. Current alcohol abuse/dependence treatment approaches

D. Research: Alcoholics Anonymous and service

E. Clinical implications

III. Definition of service

A.  Synonyms for service: helping behaviors, prosocial behaviors, other-oriented behaviors, caring for others, altruism

B.  Review of altruism definitions found 5 common elements (Bar-Tal, 1986)

            1. Must benefit another person

            2. Must be performed voluntarily

            3. Must be performed intentionally

            4. Benefit to another must be the primary goal

            5. Must be performed without expecting any external reward

IV. Health benefits of giving service in general

A. Physical/mental health benefits (Post, 2005)

1. Physical benefits

a. Fewer duodenal ulcers

b. Longevity

c. Lower coronary heart disease rates

d. Lower blood pressure

2. Mental benefits

a. Lower depression

b. Lower anxiety

c. Less somatization

d. Higher self-esteem

e. Displacement of negative emotional states

f. Overall benefits

            1. Greatest for isolated individuals (Music and Wilson, 2003)

            2. Alcoholism is socially isolating (Brown et al., 2003)

  B. Social benefits (Barber et al., 2001)

1. Fewer arrests

2. Fewer delinquent acts

3. Lower pregnancy rates

4. Less alcohol/marijuana abuse

  C. Adverse health conditions associated with opposite end of giving service: self-pre-occupation

1. More bodily pain

2. More depression

3. Lower functioning and quality of life

V. Current alcohol abuse/dependency treatment approaches

                        A. Core of treatment is the same as for all chronic relapsing disorders


B. Most treatment efforts are cognitive behavioral to:    

1. Enhance motivation (for abstinence)

            a. Strengthening patient commitment to change

b. Motivate patients to use their resources to change behavior

2. Help people rebuild their lives

a. Restoration of physical health

b. Restoration of psychosocial functioning

3. Relapse prevention

            a. Cognitive-behavioral coping skills to cope with relapse precipitants

b. Lifestyle changes for disease prevention

4. Same three steps are used in helping “recovery” from diabetes and hypertension

C. Examples of each of these steps related to alcoholism include:

1. Motivational interviewing (Miller & Rollnick, 2002)

            a. Express empathy

            b. Develop discrepancy

            c. Roll with resistance

            d. Support self-efficacy

2. Help people rebuild their lives

a. Restoration of organs damaged by alcoholism

b. Development/restoration of social functioning

3. Relapse prevention (Marlatt et al., 1999)

            a. Cognitive-behavioral coping skills to cope with relapse precipitants

i. intrapersonal (negative and positive emotional states)

ii. interpersonal (relationship conflict, social pressure to drink)

b. Lifestyle changes to decrease need for substances

D. Medications can be helpful

1. Useful in detox

            a. Management of withdrawal symptoms

            b. Pre-existing mental health conditions

2. Two medications appear helpful in maintaining abstinence

            a. Naltrexone

                        i. Blocking the reward: opiate atagonists

                        ii. how much it helps: improves outcome by 20%

                        iii. several good outcome studies

            b. Acamprosate

i. Restores normal activity in two neurotransmitter systems:glutamate and gamma-aminobutyric acid

                        ii. how much it helps

                        iii. several good outcome studies

3. Other medications have less empirical support

E. Common psychological treatment elements seen in AA

1. Enhance motivation (for abstinence)

a. Positive elements of recovery/negative consequences of relapse routinely highlighted, witnessed

b. Self-efficacy strengthened - individual makes main contribution to change process (Leon, 1999)

2. Help people rebuild their lives

            a. Repair social costs of alcoholism through moral inventory, confession,


b. Development of social network

3. Relapse prevention (Marlatt et al., 1999)

            a. Cognitive-behavioral skills to identify and cope with negative thinking

b. Encouragement to pursue activities incompatible with drinking

VI. Alcoholics Anonymous (AA)

A. AA involvement associated with decreases in substance use (Mcintire, 2000) talk about actual data

B. Most commonly sought source of help for alcohol use disorders ;60% of men and 80% of women seeking help for a alcohol problems went to AA (Weisner et al., 1995)

C. The majority of alcohol treatment programs encourage AA attendance (Miller, Wilbourne, & Hettema, 2003).

D. More than 100,000 groups and over 2,000,000 members in 150 countries

E. 77% of AA members’ doctors know that they are in AA (AA, 2004)

F. 39% of AA members referred by health care professional (AA, 2004)

G. However, while involvement in AA has determined to be a multidimensional construct (Allen, 2000), poor understanding of the “active ingredients” of AA

VII. Unique to AA’s intervention strategy: service

A. A general overview

            1. Primary purpose: to stay sober and help others

            2. Roots in Oxford group: four necessary absolutes

                        a. Honesty: is it true or is it false?

                        b. Unselfishness: how will this affect the other fellow?

                        c. Love: is it ugly or is it beautiful?

                        d. Purity: is it right or is it wrong?

B. Service in the context of AA

1. Defined as: anything that helps fellow sufferers (AA, 1985)

2. Forms of service include:

a. Formal roles at AA meeting (e.g. coffee maker, door greeter)

b. Helping newcomers

c. Sharing experience, strength, and hope

d. Being a sponsor

3. Sponsor: an alcoholic who has made some progress in the recovery program shares that experience on a continuous, individual basis with another alcoholic who is attempting to attain or maintain sobriety through AA (AA, 1983) 

a). A good sponsor probably should be a year or more away from the last drink and should seem to be enjoying sobriety

                  b). Helps another alcoholic solve one problem: how to stay sober

B. AA’s primary purpose: to stay sober and to help the alcoholic who still suffers  (AA, 2001) 

C. AA traces its roots to the Oxford Group, which espoused four necessary “Absolutes” – one of which is unselfishness (AA, 1985)

D. Symbol for AA: equilateral triangle with each side representing one of AA’s three legacies: Service, Recovery, Unity

E. AA originally consisted of 6 steps: the 6th step “help other alcoholics”

F. Developed into the 12 steps

G. Step 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"

VIII. Research: AA and service

A. Correlational research: service and alcohol use disorders

1. Review of AA participation and alcohol use disorders (Emrick, 1993)

a. modest and positive correlations:

1). Having a sponsor

2). Engaging in twelfth-step work

3). Leading a meeting

4). Increasing one’s degree of participation in the organization compared to a previous time

2. Conclusions:

      a. 2 out of these 4 summary findings are service related

B. Longitudinal research: service and alcohol use disorders

1. Project MATCH: largest prospective randomized clinical trial of 3 behavioral treatments (Longabough & Wirtz, 2001)

a. Cognitive-behavioral skill training, motivational enhancement therapy, 12-step facilitated therapy (TFT)

1). TFT: designed to help clients to engage in AA and complete initial steps of the 12-steps of AA

b. Those engaged in service during treatment period (3 months) were significantly less likely to relapse in the year following treatment (Pagano et al., 2004)

1). Benefit of service to maintained sobriety found independent of number of AA meetings           

2). Service measured as being a sponsor, endorsement of step 12 completion

      3). Modest effect may be greater if other forms of service are measured

2. Conclusion: clinicians treating alcoholics should encourage clients to engage in service as a method to stay sober

IX. Future research

A. Protective mechanisms underlying the benefits of service poorly understood

1. Stress reduction – service may help individuals cope with the leading stress reasons for relapse by Marlatt’s taxonomy (Marlatt, Barrett, & Daley, 1999)

a. Intra-individual negative affect, interpersonal conflict, interpersonal pressure

b. Negative physical affect, negative physical states, urges

c. Enhancement of positive states

B. Stages of change – service may promote individuals to highest stage (action), which is associated with drinking reductions (Prochaska et al., 1994)

C. Service among individuals with long-term sobriety

1. Preliminary evidence that service is very important to sobriety among individuals with long-term sobriety (Pagano et al., 2006)

D. Personality traits – service may treat personality traits associated with alcohol use disorders   

1. Correlations between neuroticism, low conscientiousness and alcohol use disorders (Chassin, Flora, & King, 2004)

2. Self centeredness as the root problem of alcoholism (AA, 2001)

3. Getting out of self through service is antidote to egotism (AA, 2001)

X. Clinical implications: fact and fiction

A. Issue: length of sobriety

1. Fiction: alcoholics are too new to sobriety to help others (National Center on Addiction and Substance Abuse, 2000)

2. Fact: Bill Wilson, co-founder of AA, located another alcoholic to help (Dr. Bob, co-founder of AA) within a few months of his sobriety (AA, 2001).  He did this because he wanted to drink.

3. Fact: AA literature encourages newcomers to get involved in service immediately (AA, 1981)

4. Fact: service, measured as time spent sharing experiences about staying sober and locating resources, following 4 days of intensive outpatient treatment benefits those with substance use disorders (Zemore & Kaskutas, 2004)

B. Issue: personality differences 

1. Fiction: one has to have an altruistic personality to engage in service (National Center on Addiction and Substance Abuse, 2000)

2. Fact: humans are psychologically and biologically hard-wired to care for others (Post, 2005)

3. Fact: reviews of experimental psychology research find no consistent associations between personality characteristics and service (Piliavin, 1990)

C. Issue: applicability

1. Fiction: alcoholics are too self-centered to engage in service (National Center on Addiction and Substance Abuse, 2000)

2. Fact: members of AA go against the tide of national decline in community involvement and charity contributions (Putnam, 2000)

3. Fact: William Silkworth, MD, founder of AA knowledge of the nature of alcoholism “physical allergy plus mental obsession”, observed a great altruistic movement arising among recovered alcoholics (AA, 2001). 

XI. Summary

A. Service has an important role in promoting health of patients

B. Short term efficacy of current treatment approaches

C. AA, the most widely relied upon source of non-professional treatment for alcoholics, advocates service as one of its three legacies

D. Benefits of service to sobriety, recommended in AA literature since 1939, is supported empirically

E. Many of the arguments against encouraging service are myths

F. Alcoholics should be encouraged to engage in service as a method to stay sober


Alcoholics Anonymous World Service, Inc. Alcoholics comes of Age, New York:

Alcoholics Anonymous Publishing, Inc., 1985. 


Alcoholics Anonymous World Service, Inc.  Alcoholics Anonymous, 4th Edition, New York:

Alcoholics Anonymous Publishing, Inc., 2001. 


Alcoholics Anonymous World Service, Inc.  The twelve steps and twelve traditions, New York:

Alcoholics Anonymous Publishing, Inc., 1981. 


Alcoholics Anonymous World Service, Inc.  Questions and answers on sponsorship.  New York:

Alcoholics Anonymous Publishing, Inc., 1983.


Alcoholics Anonymous World Services. (2005).  Alcoholics Anonymous 2004 membership

survey.  Retrieved January 15, 2007, from


Allen JP.  Measuring treatment process variables in Alcoholics Anonymous. 

Journal of Substance Abuse Treatment.  2000;18:227-230.


Barber BL, Eccles JS, Stone MR. Whatever happened to the jock, the brain, and the princess? 

Young adult pathways linked to adolescent activity involvement and social identity.  J. Adoles. Res. 2001;16: 429-55.


Bar-Tal D.  Altruistic motivation to help: Definition, utility and operationalization. Humboldt

Journal of Social Relations. 1986;13:3-14.


Brown SL, Nesse RM, Vinokur AD, Smith DM.  Providing social support may be more

beneficial than receiving it.  Psychological Science.  2003;14: 320-327.


Calabrese SK, Lyness JM, Sorensen S, Duberstein PR.  Personality and the association of pain

            and depression.  American Journal of Geriatric Psychiatry. 2006;14:546-549.


Chassin L, Flora DB, King KM.  Trajectories of alcohol and drug use and dependence from

adolescence to adulthood: The effects of family alcoholism and personality. Journal of Abnormal Psychology.  2004;113:483-498.


Emrick CD, Tonigan JS, Montogomery H, Little L.  Alcoholics Anonymous: what is currently

known?  In: McCrady BS, Miller WR. eds.  Research on Alcoholics Anonymous: Opportunities and Alternatives.  New Brunswick, NJ: Rutgers Center of Alcohol Studies; 1993:41-78


Gendolla GH, Abele AE, Andrei A, Spurk D, Richter M.  Negative mood, self-focused attention,

and the experience of physical symptoms: the joint impact hypothesis.  Emotion.  2005; 5:131-144.


Leon, G.  (1999). The therapeutic community treatment model.  In B.S. McGrady & E.E. Epstein

(Eds.), Addictions: A comprehensive guidebook (pp. 306-324).  Oxford University Press, New York.


Longabough R, Wirtz PW.  Project MATCH hypotheses: results and causal chain analyses. 

NIAAA Project MATCH Monograph series, volume 8, NIH Publication no. 01-4238, Washington: Government Printing Office, 2001.


Marlatt GA, Barrett K, Daley DC.  Relapse Prevention.  In M Galanter & HD Kleber (eds.)

Textbook of Substance Abuse, 2nd edition.  Washington, DC: American Psychiatric Press, 1999: 353-365.


McIntire D.  How well does AA work?  An analysis of published AA surveys (1968-96) and

related analyses/comments.  Alcoholism Treatment Quarterly.  2000:18:1-18.


Miller W. Researching the spiritual dimensions of alcohol and other drug problems.

            Addiction. 1988;93:979-990.


Miller WR, Wilbourne PL, Hetterma JE.  What works?  A summary of alcohol treatment

outcome research. In: Hester RK, Miller WR, eds. Handbook of Alcoholism Treatment Approaches, Effective Alternatives. 3rd ed. Needham Heights, MA: Allen & Bacon; 2003:



Miller WR, Sanchez-Craig M.  How to have a high success rate in treatment: Advice for

evaluators of alcoholism programs.  Addiction.  1996:91:779-785.


Musick MA, Wilson J.  Volunteering and depression: The role of psychological and social

            resources in different age groups. Soc. Sci. Med. 2003;56:259-269.


National Center on Addiction and Substance Abuse at Columbia University: Missed

Opportunity: National Survey of Primary Care Physicians and patients on substance abuse.  New York, National Center on Addiction and Substance Abuse at Columbia University, 2000.


Pagano ME, Jaber J, Kotz M, Zywiak WH, & Dean R. (2006, June).  Helping behaviors in

alcoholics with long-term sobriety.  Poster presentation at the 29th annual meeting of the Research Society on Alcoholism, Baltimore, Maryland.


Pagano ME, Friend KB.  Helping others in Alcoholics Anonymous and drinking outcomes:

            Findings from Project MATCH.  Journal of Studies on Alcohol. 2004;65:766-773.


Piliavin JA, Charng HW.  Altruism: A review of recent theory and research. Annu. Rev. Sociol.



Post SG.  Altruism, happiness, and health: it’s good to be good.  International Journal of

Behavioral Medicine.  2005;12:66-77.


Prochaska JO, Velicer WF, Rossi JS, et al. Stages of change and decisional balance for twelve

problem behaviors.  Health Psychology. 1994;13:39-46.


Putnam, R.D.  Civic Participation.  In: Putnam RD (Ed.) Bowling alone: the collapse and

revival of American community.  New York: Simon & Schuster; 2000: 48-64.


Weisner C, Greenfield TK, Room R.  Trends in the treatment of alcohol problems in the U.S.

general population, 1979-1990.  American Journal of Public Health.  1995;85:55-60.


Zemore SE, Kaskutas LA.  Helping, spirituality, and Alcoholics Anonymous in recovery. 

Journal of Studies on Alcohol.  2004;65:383-392.