Why the empty seats at the free public health lunch?

September 30, 2022
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A few years back in my first few months of working full time in addictions, I attended a seminar on mutual aid. Facilitated by an addiction psychiatrist, the meeting was packed with a variety of addiction treatment professionals.

The facilitator laid out the evidence base for mutual aid as it was at the time and discussed how assertively referring to mutual aid organisations could result in high take-up rates with benefits to patients. This was in the days when most groups were 12-step – SMART and other groups were still to be launched locally.

At the interactive part of the presentation the audience was asked ‘what objections might your patient have to attending mutual aid groups’? There were a variety of responses to this: people don’t like AA; many don’t want abstinence; people don’t like speaking groups; it makes people want to drink and use; they are too religious; everyone goes to the pub after an AA meeting; the groups are cult-like; it’s not safe for women etc.

As each objection came up the facilitator gave evidence from literature and from his experience to allay concerns in a robust manner. A curious thing began to happen, as he gave reasonable and, to my mind, fairly convincing reassurances to each objection, many of the participants began to double down, argue, find new objections and the heat in the room went up. Some got irritable and short.

I began to realise what was going on. The professionals were no longer relaying the concerns of their patients, they were relaying their own concerns, or to be frank, they were relaying their own prejudices. This of course, did not apply to some who hold open or positive views.

Some of the reasons for resistance to mutual aid have little to do with mutual aid, but to do with our own reasons for being in the caring professions. For some of us, the prospect of the client leaving our care and managing on their own is a bridge too far. When this is the case it is rarely in consciousness.

What else is going on when some of those who work with people with alcohol and other substance use disorders are antagonistic to mutual aid and lived experience organisations? In the last while I’ve heard a very senior medic dismiss lived experience as ‘fake news’ and assert that recovery communities are unlikely to prevent drug deaths. Recovery discrimination and stigma can be just as potent as addiction stigma.

On Twitter someone who is well respected and works in the field asserted, ‘the biggest risk to drug users is… recovery orgs… bound by a belief system handed down, full of holes, and not fit for now’. So not only not helping, but making things worse?

There are other less ostensibly antagonistic views out there which may be even more damaging. ‘It doesn’t suit everyone’ is often a starting point in discussions with colleagues about mutual aid (this happened in a meeting yesterday incidentally). This approach is a subtle way to remove any enthusiasm or motivation to get serious about connecting people to mutual aid. 

When patients have serious medical conditions that need intensive treatments like radiotherapy or IV antibiotics, we don’t initiate the conversation by saying ‘this doesn’t suit everyone’. If the evidence base is good that an intervention is more likely than not to provide benefits we usually come at it with a recommendation to try it, not to immediately stick a flag up that says ‘may not work’.

And does it work? Mutual aid, I mean. Well, yes.

A Cochrane review which examined evidence from 27 published studies involving 10,000 people found AA performed as well as established treatments like cognitive behavioural therapy (CBT) and motivational enhancement (and was free) but better than these when twelve-step facilitation was employed. Abstinence rates where people participated in AA were 42% one year later compared to 35% with other treatments including CBT. The time for confusion about the efficacy of mutual aid is over.

John Kelly, a Professor of Addiction Psychiatry at Harvard University, one of the researchers who co-authored the Cochrane review, has just published a further paper on mutual help organisations,[1] in which he says, “AA and similar freely available community-based 12-step and non-12-step (eg, SMART Recovery) MHOs [mutual help organisations] may be the closest thing public health has to a “free lunch.”

AA is without doubt the most studied mutual aid group with many robust studies now published. Although the same quality of evidence is not available for other mutual aid groups, Kelly writes, “Emerging evidence from statistically controlled prospective observational studies do show positive salubrious relationships between NA participation and better opioid use disorder outcomes, particularly increased abstinence and enhanced adherence to medications for the treatment of opioid use disorder.”

He also reports, “NA mutual-help attendance was associated with twice the rate of abstinence independent of buprenorphine or methadone engagement more than 3 years after entering the trial. Professionally delivered behavioural treatment in that study, on the other hand, was not associated with opioid abstinence.” It is likely that non-12-step mutual aid confers benefits too.

The problem with this free lunch is lack of access. The table is set, the dishes are served, the plates are bountiful and healthy, but relatively few are turning up – though it does not have to be that way. In England, recognising the public health benefits of a free lunch, PHE published a suite of documents to improve uptake.

While we have acknowledgement of the value of mutual aid in policy documents here in Scotland, we still have a blind spot in terms of the emphasis we place on it. If you want evidence, look at the research output on mutual aid from the academic community in Scotland. (I’ll save you time, there is next to none). In Edinburgh in 2010, less than 1% of individuals attending treatment services had ever been to AA. For NA, it was less than half a percent. Think back to those professionals and their views on mutual aid at that seminar I attended. We ought not to be surprised.. I think things are better now than they were then, but not nearly as good as they might be.

Unless you have a drugs or alcohol worker or social or healthcare professional who is aware of the evidence base, who is not carrying conscious or unconscious bias against mutual aid and who knows how to get you to the free lunch then your chance of getting to lift your knife and fork and feast at the recovery table is limited. That’s not okay and it’s got to change.

Continue the discussion on Twitter @DocDavidM

[1] Kelly JF. The Protective Wall of Human Community: The New Evidence on the Clinical and Public Health Utility of Twelve-Step Mutual-Help Organizations and Related Treatments. Psychiatr Clin North Am. 2022 Sep;45(3):557-575. doi: 10.1016/j.psc.2022.05.007. Epub 2022 Aug 1. PMID: 36055739.

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