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A first description of Narcotics Anonymous and Alcoholics Anonymous members in Greece: prior treatment history and opinions about professionals.

1. Introduction

The main aim of this article is to present some of the basic findings of research intended to give a current general picture of the groups of Narcotics Anonymous (NA) and Alcoholics Anonymous (AA) in Greece. Specifically, this article presents the facts concerning the help the members receive from the group and from other sources, their unmet needs and their attitudes towards professionals in the field of addiction. Also, we compare these findings with equivalent facts from other studies. Our research was descriptive rather than testing hypotheses, since there was no similar previous research in Greece.

The concept of self-help is connected mostly or exclusively with the personal sense of responsibility, which is the activation and utilization of "your own means" towards needs relating to the handling of personal problems. The term "self-help groups" refers to groups of people with common or similar problems, as for example diabetics, alcoholics, addicted, mentally ill, or to psychotherapeutic groups that focus on personal growth through the common working-out of experiences and solution of the problems of fellow-sufferers (Bairaktaris 1994). The aim of the self-help group is not only to offer help, but to benefit from it, as well. (Riessman 1997).

There are other definitions of the basic concept of self-help and self-help groups, which may contribute to a better understanding of this field. According to the definition accepted by the World Health Organization (WHO), self-help refers to formal or informal "created social groups" in the frame of health care that find a common denominator in new forms of dealing with problems, with citizen autonomy, and with humanization of health care. Self-help groups, in this frame, are part of a wider phenomenon of alternative forms of care. The term "self-help" is used more widely than the word "mutual help," but the latter may be preferable because it put more emphasis on the mutuality than on self-interest (Kickbusch & Hatch 1983).

On the other hand, Katz and Bender formulated the most widely used definition of self-help groups: self-help groups are small, voluntary structures for the mutual help and the fulfillment of a specific purpose. They are usually created by people who unite with the purpose of offering help for the satisfaction of a common need, coping with a common difficulty or problems that threaten their lives, and to achieve desired social and/or personal change. The founders and the members of such groups believe that their needs are not satisfied or can't be satisfied by the existing social structures. Self-help groups emphasize direct social interaction and the assumption of personal responsibility by the members. They often offer material help as well as emotional support. They are often directed towards the cause of the problems and project an ideology or values through which the members may acquire a better awareness of their personal identity (Kickbusch & Hatch 1983).

Official information about the beginning of AA and NA in Greece has not previously been published. From our contact with long-term members of the groups, we collected some information. According to them, in about 1986-1987 soldiers at American bases in Greece, having experience with AA in their own country, created the first AA group in Greece. The same sources state that at the beginning of the 1980s an AA group was created in connection with the therapeutic program "18 Ano." Later, according to the same information, Greek people with problems of abuse of alcohol and illicit drugs followed their example. We should mention that the first meetings were English-speaking, until the basic core of Greek groups was created. NA and AA groups have operated occasionally in several towns in Greece. Unlike the permanent groups in Athens and Thessaloniki, the groups in smaller towns are unstable in their functioning. For that reason, we didn't involve all of them in the research, but only those which, according to available sources (members, the internet), have a more stable existence.

2. Literature review

Until the beginning of the 1970s, American social scientists' interest in research on and the theory of self-help was inadequate. With the exception of a study conducted by Bales (1944) on the therapeutic role of self-help groups of Alcoholics Anonymous, other empirical research doesn't appear in the bibliographies until 1957, when Alfred Katz published his doctoral thesis titled "Parents of disadvantaged people-Recovery Inc." Despite the important growth of self-help organizations during the 1960s, only occasional descriptive case-studies were published, studies of specific organizations or more general studies by writers from the field of social work, psychology and other clinical fields. The main exceptions are the studies of Anonymous Alcoholics (Katz 1981).

Social scientists and professionals in the mental health field were late to recognize the existence and the importance of self-help groups. A systematic research is something even more recent, following the above recognition. Today we can enumerate easily studies that cover a wide range of self-help groups that concern many problems and modern dilemmas (Lieberman & Snowden 1994).

Tracy and Gussow conducted the first research assessment that analyzed the increasing membership of self-help groups in 1976. Their study concerned the growth of six self-help organizations during a period of 30 years (1942-1972), showing a stable increase every year from 1950 onward. From 1972 to 1978 they found an increase of 50% in membership of the groups (Lieberman & Snowden 1994).

Research on self-help groups primarily consists of three kinds of studies: studies of effectiveness, studies evaluating the functioning of the group through ethnographic-qualitative methods, and action studies which evaluate participation in the group (Kurtz 1997). As for methodology, most of the above studies use qualitative methods based on an interview or a questionnaire. These are concerned with the essence of the process which takes place in the groups, psychological processes, abstinence from the substances, and change and spiritual maturing, as well as the micro-collective processes (Miller & McCrady 1992). The smaller number of quantitative studies examine epidemiological and demographic characteristics (Powell 1994), examining the profile of the individuals who come to these groups.

A general conclusion from this overview is that the greater part of the international research concerns AA, and not so much NA. This may reflect the great growth of AA, which was the first 12-Step self-help organization to be formed. As AA's General Service Office (GSO) informs us through its official site, the first survey of its members was conducted by the organization itself in 1977, and since then such efforts have been carried out at fixed periods, every two or three years.

The last study commissioned by the GSO of AA members (Alcoholics Anonymous 2004) showed that the 64% of the members had been in the past in some other kind of therapy--medical, psychological, counseling, or spiritual. The 74% of those who attended other therapy answered that this played an important role in their entering AA. Altogether, 65% of the participants reported that they have received other help or therapy (medical, psychological, counseling or spiritual) after they started to participate in AA. A majority of these--54%--consider this help important for their recovery. As for their relationships with professionals, 77% note that their doctor knows that they participate in AA, while 39% answer that they were sent to AA by a mental health professional.

The equivalent studies of NA do not seem to refer to similar facts, with the exception of the study of the local organization of NA in Victoria, Australia (Narcotics Anonymous 2003), where 46% of the members reported that, apart from the group, they have attended other 12 Step groups which were related to substances and addiction, such as AI-Anon, Gamblers Anonymous, Overeaters Anonymous, etc.

In the recent study by Quartini, Malandrini, Bardazzi, Tedici & Allamani (2001) in four big cities of Italy, 29% of the participants answered that before their participation in NA they were under therapy in a therapeutic community, 9% that they had therapy with naltrexone, 27% with test doses of methadone, and 11% maintenance with methadone. Otherwise, 23% tried to recover by using other psychoactive substances, 48% through psychotherapy, and 2% had gone through physical detoxification. Many of the participants used more than one of these therapies. At the same time as participating in the group, 4% of the members go to a therapeutic community, 11% take doses of methadone, 2% have maintenance therapy with methadone, 2% take other psychoactive substances, 29% have psychotherapy, and 2% go through physical detoxification.

Findings in a study of people with problems of alcohol misuse emphasized the importance of the intervention of professionals in order to facilitate the participation of these people in 12 Steps groups, as well as the effectiveness of that movement in promoting abstinence from alcohol (Humphreys 1999). The study also found that the people who attend 12 Step groups after the completion of a therapeutic program have better therapeutic results in comparison with people who do not make this choice (Hsieh & Hollister 2004).

Greek data that concern 12 Step groups do not seem to exist. That means that the only research facts related to the situation of drugs and alcohol in Greece come from official organizations as EPIPSY (Erevnitiko Panepistimiako Institouto Psychikis Ygeias) (University Research Mental Health Institute). In comparison to the figures presented here, EKTEPN (Ethniko Kentro Tekmiriosis kai Pliroforisis gia ta Narkotika kai tin Toksikomania [National Centre of Substantiation and Information for the Drugs])(2005) in its annual report notes that 51.7% of the people who come to official programs had never received therapy in the past.

3. Methodology

Participants

The individuals who participated in the research are members of AA and NA groups in Athens, Thessaloniki, Iraklio, Nafplio, Serres, or Katerini. The total number of the participants was 82. The basic selection criterion for participants was their participation in 12-Step groups related to the problem of addiction.

Research plan and methods

The main research plan was to make contact with members of the 12-Step groups and to distribute survey questionnaires to them. This kind of research collects information which can be analyzed in terms of patterns and comparisons for a sample of the population (Bell 2001).

Means of data selection

When we realized that there was not a pre-existing questionnaire which covers the aims of our study, we set out to create one. The questionnaire includes 55 items, of which 18 concern demographic facts, while 34 concern facts about the participation in the group, history of substance use and subjects related to this. The last three questions try to investigate possible subjective aspects and needs of the individuals. We should mention that, in the first page of the questionnaire, we provide a text in which we present ourselves, we mention the field which we come from and the main aims of the research. Also, we guarantee anonymity and our discretion, and we remind the recipient that participation in the research is voluntary.

For the form and the content of the questions and the answers, we consulted the results of studies conducted by the EPIPSY (Research Academic Institute of Mental Health), so that the results will be as comparable as possible. Specifically, we use the annual statistics from EKTEPN (National Centre of Substantiation and Information for the Drugs) of 2004 for the situation concerning drugs and alcohol in Greece. Useful guides for the construction of the questionnaire were the research efforts by AA and NA groups (e.g. Victoria, Australia in 2003, New Zealand in 2005), as well as by the central organization in other countries, as we mentioned above.

Process

Our first step was to contact the central organizations or collective organs of the groups (World Service, General Service Office, Intergroup), to get some useful information for the research. Their correspondence was limited but positive. At the same time we met some key persons who were willing to give us advice on our effort and some information on the groups and their functioning. These persons were usually ordinary members of the groups or individuals responsible for the public information of these groups. After we had collected the essential facts through the bibliography and the above contacts, we progressed to the pilot study, which investigated possible deficits or failings of the questionnaire and clarified the way to approach members of the groups.

The group we chose for the pilot study was the AA group in Serres, because of its small number of members and of one member whom we knew and who helped us with the first stage of the research. We visited the group in an open meeting and, after the member we knew introduced us, we explained to the members the aims of our study. We administered the questionnaires and discussed with members possible questions they had. From the discussion we learned that we should change some points in the introductory text of the questionnaire that could cause confusion.

Data collection

Success in collecting the data proved to have a direct relation with the way of approaching the groups. We should mention that in most cases the contact was feasible only with members of the groups and rarely with the whole group, as the formal Traditions of the groups include a rule against outside affiliations or interventions. Bibliographic reports by Wilson (1995) of earlier research gave us some useful and practical information and guidance.

Our daily contact and development of relationships with people attending the Self-Help Promoting Program in Thessaloniki helped in the creation of confidence, which, as we saw later, was an essential prerequisite for the continuance of the research. These first contacts opened the way for contacts with the members of other groups in Greece. Some members of the groups in Thessaloniki helped us by giving information about which groups existed at that time in Greece and, most importantly, they sent us to members of the groups they personally knew. This ensured positive responses from people we tried to meet in other towns. This was the main way to make connection with the other groups, and the relationship we created each time with the reference persons determined our way of approach, the duration of the contact, the frequency of the visits in each group and, as it was proved, the proportion of the questionnaires which were returned.

Depending on the circumstances, we used various ways of approaching the members of the groups. The simplest way was meeting one by one with different members of the groups, with them filling out the questionnaire on the spot. Experience showed that this way was the most effective, as with this we collected the most questionnaires.

In meeting with members individually or as a group, we had decided in advance that we would pay the expenses of the meeting, since we had invited them. But in some cases, the members wanted to make us feel comfortable, so they paid the expenses and sometimes our transportation.

Method of data analysis

The method of analysis we followed is the simple analysis of percentages with the help of Statistical Package for the Social Sciences (SPSS) 12. While the majority of the questions can be analyzed quantitatively, there are some open-type questions, and for them we used qualitative analysis, and specifically the thematic analysis described in Smith's book "Qualitative Psychology" (2003). The aim of both quantitative and qualitative analysis of the findings is to present a profile of the people who come to 12-Step groups, and their possible needs.

In the discussion which follows, the facts we collected are compared with those of official programs (e.g. EKTEPN), and we discuss issues and possible correlations raised by the findings.

4. Findings

Alcoholics Anonymous

During the study, we gave 40 questionnaires to AA group members, from which 22 were returned to us.

Findings related to efforts for recovery and the opinions of the members about the unmet needs and professionals

Altogether, 82% of the participants had made previous efforts for recovery. Among these, 67% had tried to recover on their own; after they had tried this, 22% went to a professional. Another 11% had from the beginning used another way, such as specialized clinics for alcoholics situated abroad. Only 22% of the respondents report accepting help from some other source besides the group; most of these (80%) accepted help from a supportive program, and the rest from a professional. All refer to the group helping them to abstain from substances, and some report help also from their family, their interpersonal relationships and their profession. Some believe that the groups also helps them beyond maintaining abstinence, e.g., in changing their view of life.

A minority of 9% considered that there are things in which the group does not meet their needs. The most important of these are education, entertainment and social abilities. About one-third (36%) gave suggestions for how these needs might be met. The suggestions included giving parental information (18%), setting up specialized programs for alcohol users (18%), and providing medical and educational support (9.1% each). Smaller percentages of respondents (4%) gave suggestions about social acceptance, nonstigmatization of alcoholics as well as banning the advertisement of alcoholic drinks.

About three-quarters (77%) of the respondents answered the question on their opinion of professionals in the addictions field. Thirty-two percent felt that, to a great extent, professionals have no knowledge of the subject of addiction, 27% were of the opinion that professionals mainly prescribe medicines to alcoholics, and 27% gave a general negative opinion about professionals, without mentioning details. Fourteen percent were of the opinion that the fact that the professionals did not have personal experience of substance use limits the help they can offer. Smaller numbers (9% for each) criticized professionals' self-interest, felt that professionals can help only in a more peripheral way, and felt that professionals were sometime helpful and sometimes not. Finally, 4% felt that professionals treat alcoholics in a nonhumanistic way (e.g. as "guinea-pigs").

Narcotics Anonymous

The questionnaires that were given to members of the groups of NA totaled 96, from which 60 were returned.

Findings related to efforts for recovery and opinions about the unmet needs and professionals

One or more previous efforts to recover are referred to by 97% of the participants. Eighty-one percent (of those who referred previous efforts) had tried on their own at some time, 24% said that they had attended some open dry therapeutic program, 17% some therapeutic community, and 14% had tried all the above ways. Fourteen percent refer to some other ways, while only 3% have gone to an opiate maintenance program. We should mention that the 47% have tried to recover with one of the above ways, while 50% have tried two to five of the ways before coming to NA.

Of those who report receiving help from somewhere else besides the group (47%), 43% report receiving help from a mental health professional, 21% from a supportive program, and 11% from a priest. The rest declared that they receive some other kind of help (family, private therapeutic program, etc). Fully 97% believe that the group helps them. Most of them (62%) say that the group helps them in more than one field, such as abstinence from the substances, relationships with family, partner and friends, and their profession. One third (33%) refer to some combination of the above answers or give some other answer.

Thirty-eight percent think that there are things in which the group does not meet all their needs. The main things lacking are help with personal development (50%), health (50%), professional settlement (50%), social reenrollment (41%), and educational and legal assistance (28% and 23% respectively). To a smaller extent, they referred to family matters, fiscal matters and facts related to abstinence from the substances and the functioning of the group. To the question about suggestions for meeting the above needs, 51% of the participants answered. The main suggestions are: general care by the state (22%), support in legal problems (12%), medical (12%) and educational (7%) subjects, better information (12%), specific suggestions about matters of recovery (12%) and more social acceptance (10%). To a smaller extent the respondents cited issues concerning financial help, nonexploitation of the problem of drugs, help from the church, the need for places for the meetings of the groups and official recognition of the NA.

Ninety percent answered the question concerning their opinion of professionals in the addiction field. Thirty-five percent (of those who answered the question) had mixed opinions, reflecting the diversity in professional views, 33% consider that professionals have no knowledge of addiction, and 22% that lack of experience effects the extent to which the professionals can help. Opinions concerning overprescription of medicines, that professionals act too much their own self-interest, and general negative opinions towards professionals appear in 15% of the cases. Finally, some respondents have positive opinions about professionals; some others believe that the professionals can help in personal subjects or as additional help at the same time as the group, while others consider that professionals should adopt a different attitude and style of interaction with NA groups.

5. Discussion

Alcoholics Anonymous

The fact that most of these who have made previous efforts for recovery made it mainly by themselves shows the usual route followed prior to coming to an AA group. This route involves, in the main, seeking help from a professional or in another way. There is thus a need for professionals to be informed about AA groups, and addiction generally. In AA's GSO's research, a substantial percentage (64%) of members had attended some kind of therapy in the past, something that agrees with our findings.

From the question on the help receiving from somewhere else outside the group, it was found that 22% receive some kind of help at the same time as their participation in the group. It is pointed out that some members have the need of getting support in things the group probably does not offer them. Despite this, most members do not receive help from another source, either because they feel their needs are covered or because there are not any suitable and available places offering help. The finding that some of them come to a supportive program is maybe related to the fact that some of the participants of our sample take part in the actions of the Self-Help Promoting Program, which means that they have contact with this type of supportive program. In the findings of GSO we see that a much greater percentage of members receive some other kind of help while they participate in the AA. This may be explained by the fact that in other countries there are suitable places which can support the members and/or there is a network to offer the members choices of places to approach for different services.

The AA group was found by the respondents to help its members in abstaining from substances as well as in such fields as family, friends, and profession. Some declare that this additional help comes as a consequence of abstinence from the substances. What is more, they emphasize the philosophy of change in one's life contributed to by participation in the group. Additionally, we can say that such changes help in maintaining abstinence from substances.

Although 22% receive some other kind of help, too, only 9% of the participants answer that there are things in which the group does not meet their needs. The main unmet needs things concern education, entertainment, and social abilities, along with the process of social reintegration and the handling of time spent away from drugs.

Many more respondents answered the question about the efficacy of professionals in the addiction field than answered the other open-ended questions in the questionnaire. This specific question seems to have motivated considerable interest, and for us it is a substantial part of our study. The negative opinion that most members display seems to be mostly because these people were helped by nonprofessionals, and some have unpleasant experiences from their contact with the health system. After such an experience some of them were led to seeking help from the group.

Despite this, we can say that the general way of thinking in the groups seems to develop a negative attitude towards professionals in the field of addiction, as for them the important thing is personal experience and not theoretical knowledge. The negative attitude toward professionals is much less visible in the GSO samples, where 2/5 of AA members reported that they were sent to the group by a specialized professional. The importance of the positive role that professionals can play has been emphasized by studies looking in a broader frame than just AA (e.g. Humphreys 1999). Findings such as ours in Greece could show the need for communication and information among the interested sides, so that there are better therapeutic results.

Narcotics Anonymous

Ninety-seven percent of the participants in our study have made a previous effort at recovery, while EKTEPN finds that about half of its sample (52%) had never tried therapy in the past. This finding may be explained by the different coding schemes, e.g. we treat as an effort for recovery the effort someone makes on his/her own, which EKTEPN does not do. It is remarkable that in our findings there are many ways of recovery one uses before his/her participation in the group of NA. This demands a further study as to what kind of people go to which mode of recovery and for what reason. It shows, anyway, a deficiency of public information about the groups, the result of which is that the addicts go first to places which are not suitable for them. The quest for many other ways of therapy before participation in NA is confirmed by Quartini et al. (2001), as well. In this study each person had tried 1.8 ways of therapy on average. Our experience showed that even if there is information about the existence of the NA group available to the interested people and those around them, most of the time they do not believe in the effectiveness of such a solution.

About half of the NA participants in our study received help from somewhere else, and it is observed that 1/5 at the same time receive help from a professional and 1/10 from a supportive program. These facts suggest a need for other kinds of help, apart from the group, or that some members do not consider the group as the only place which can offer them help. The need for help simultaneously with participation in the NA is something that the study of Quartini et al. (2001) shows clearly, with each of the participants using 0.52 ways on average--a proportion which is less than that for help received before their participation in the group. Quartini et al. (2001) show the use of other substances (methadone, other psychoactive substances) at the same time as the participation in NA, as a form of simultaneous help. This is not found in our study, which merits further attention, since the main program of NA supports abstinence from all the substances, although the group is open to all if they have the wish to stop the use of such substances. However, it is possible that the nature and the formulation of the questions were different in the two studies.

As for the help that the members of the groups receive, it is worth mentioning that this concerns other domains of personal and social life, beyond the group's core concern with abstinence from the substances. We note that there is a two-way relation between abstinence and the other domains, with the attainment of one contributing to the improvement of the other. This is reflected in the indicators of quality of life in several phases of recovery (family, profession, love, relationships, economics, law problems) referred to in the study of Quartini et al. (2001).

Although all the participants in the study commented negatively on what the group promised and what was finally given to them, more than 1/3 indicate the need for meeting needs that are mainly related to deficiencies and unresolved issues (education, health, law problems) that were created during the period of substance abuse and impede their social reintegration. It is interesting that a number of people refer to the need for personal development and psychotherapy, things that are probably mainly available in the form of professional help.

Finally, almost all the participants gave some opinion about professionals in the field of addiction. Although almost all expressed a negative opinion about the professionals--possibly because of their direct experience--it is interesting that a great proportion of them are positively disposed towards them. This probably reflects their intensive needs, which are often not met, as we have seen, by professionals.

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Author:Flora, Katerina; Raftopoulos, Antonis
Publication:Contemporary Drug Problems
Date:Mar 22, 2007
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