Mind the gap-a European viewpoint on Alcoholics Anonymous.

It is believed commonly that mutual help groups (MHGs) achieve results through a cluster of social– psychological processes, including mutual identification and altruism [1,2]. This view is affirmed in Kelly’s review of recent research on Alcoholics Anonymous (AA), which suggests further that AA-related change is based on more than the main purported view of the mutual movement itself [3]. In addiction treatment, events during the aftercare phase are of vital importance, as a patient’s return to a network that supports drinking is a well-known significant negative prognostic factor [4,5]. The abstinence-supportive environment of addiction-related MHGs is an essential factor promoting their positive influence on the ongoing recovery process [6]. Accordingly, Kelly’s review highlights the influence of AA on social network changes. Here I discuss an important issue related to the representativeness of MHG research outside the United States, which is not a focus of Kelly’s review. Much of the research on AA has been performed in the United States, as is reflected by the observation that only one of 57 references in Kelly’s review is from outside the United States. AA defines itself as a spiritual, rather than a religious, organization. However, the religious language in AA’s 12 Steps (e.g. references to God and a Higher Power) has been noted as an obstacle to participation [7], even in the United States where AA’s position on its religious/spiritual aspect is quite well known by the treatment system and in society. Research is much sparser in Europe, where AA is less commonly considered a standard element of a continuing-care system and practice. The few existing crosscultural studies [1,8] indicate that the religious/spiritual aspect of AA may be more problematic in Europe than in the United States. For example, in a study conducted in the United Kingdom, the majority of patients stated that it was ‘off-putting’ to find references to God and a Higher Power in the 12-Step programme [9]. In a cross-cultural study among addiction professionals, 70% of Norwegian clinicians considered the religious connotations in AA’s 12 Steps to be an obstacle for many patients, compared to only 29% of US clinicians [8]. AA is the most widespread and available MHG for addiction in both the United States and Europe [1]. To increase utilization of these peer-based recovery resources in European contexts, researchers and clinicians should engage themselves and attempt to ‘bridge the gap’ to these organizations [10,11]. In this sense, Kelly’s review admirably provides professionals with comprehensive and evidence-based information regarding the behaviour change mechanism at work in AA, which may minimize some of the existing ambivalence and enhance the potential of making referrals. In a review about addiction and spirituality, 60% of the included papers were related to the 12-Step philosophy, indicating permeation of this theme in the addiction field [12]. In contrast to trends observed in the United States, institutionalized religion has become less popular in Europe during the post-war period, with both religious practice and belief declining in the 20th century [13]. However, this does not mean that people no longer search for a sense of transcendence and/or spiritual fulfilment, at least in the sense that people need something to live for. As Victor Frankl states, man strives to find meaning in life, and this will to meaning is the primary and most powerful motivating and driving force in humans [14]. A study comparing Norwegian and US social workers found that the theme of spirituality was integrated in both the education and practice of social workers in the United States, but was barely mentioned in Norwegian curricula, nor did the Norwegian workers consider this theme relevant to their practice [15,16]. It is unsurprising that clinicians feel uneasy about and are unfamiliar with how to approach existential issues with patients, when their education does not prepare them to do so adequately. Addiction seems to be linked to distinctly existential issues. Even the diagnostic criteria mention the value shift that occurs during the evolution of a substance use disorder—as increasing focus is placed on the addictive substance, with correspondingly reduced focus on other important values the individual may have had, e.g. spending time with and caring for family and/or friends. The professional community should not ignore AA’s position that spirituality and spiritual virtues (e.g. honesty, gratitude and altruism) can potentially counter the desire to use alcohol/drugs and encourage a new way of living. AA’s open and ‘non-denominational’ framework, in which people of varying spiritual persuasions can find direction and assistance with the existential issues involved in