Does AA Work?

As long as AA has existed, mental health professionals have had a queasy feeling about it. Some mocked it; some dismissed it; some embraced it, grudgingly. (See my earlier post.)

After all, what good was all of their advanced scientific training when a couple of drunks from Akron, Ohio could cobble together an effective treatment for alcoholism… not based on science but based on religion.

Wasn’t science supposed to replace religious superstition?

Worse yet, AA was free.

The debate has been raging for many years, but it now appears that psychiatry is ready to give AA its due.

Stanford psychiatrist Keith Humphreys explains in the Washington Post:

AA is the most commonly-sought source of help for problem drinking in the United States and many millions of people have participated in it and the other 12-step organizations it inspired around the world.

Still, is AA effective? Does it work?

Humphreys explains:

For most of the 12-step fellowship’s existence, professionals in the addiction field held widely varying opinions of its value.  Some praised AA as an extremely valuable resource for people seeking recovery, but others viewed it as unsophisticated folk medicine and even a bit cultish.  Other tensions emerged from turf issues: Medical professionals can be dismissive of – at times even hostile to – those they consider well-intentioned amateurs.  Just as some obstetricians resent midwives, some addiction treatment professionals looked down on the non-professional AA members in their midst.

To be fair, many psychiatrists are less than pleased to see patients with mental health problems treated by amateurs. One also suspects that they see AA as their competition: a comparable service offered for free.

Those who questioned AA observed that those who profited from the program were those who worked the program. Since they were the most motivated, perhaps they would have gotten better on their own, without AA.

Then again, when reputable professionals denounce AA as superstitious nonsense, this fact, in and of itself, must entice some people to drop out of it.

Humphreys writes:

To be sure, a large number of studies conducted from the 1950s through the 1980s showed that AA participation was correlated with decreases in problem drinking as well as improvements in mental health and quality of life.   But because these studies were of individuals who had chosen on their own to attend AA, many suspected that the putatively positive findings were actually due to “selection bias.”  In this case, selection bias would be present if only the most motivated and organized problem drinkers attended AA.  This would undermine the case for AA’s effectiveness because such individuals might well have recovered without the organization’s help.

As other therapies were developed scientifically, the battle lines were drawn. It is worth underscoring, if only in passing, that many of these alternative therapies—the ones that did not involve medication-- borrowed significantly from AA.

Eventually, someone decided to do a comparative study. Professionally-developed, probably cognitive-behavioral therapies were studied against 12 step programs.

The results surprised the physicians:

Two well-validated professionally-developed psychotherapies were evaluated head to head against “twelve-step facilitation counselling.”  This counselling approach adapted AA ideas and goals into a 3-month long psychotherapist-delivered outpatient treatment protocol and also strongly encouraged involvement in community-based AA groups.

AA skeptics were confident that by putting AA up against the best professional psychotherapies in a highly rigorous study, Project MATCH would prove beyond doubt that the 12-steps were mumbo jumbo.  The skeptics were humbled: Twelve-step facilitation was as effective as the best psychotherapies professionals had developed.

Next, the researchers compared the individual counseling and studied people who merely attended AA meetings.

The results were surprising:

A subsequent randomized clinical trial eliminated the twelve-step counselling component and simply evaluated the effect of a brief, structured introduction to AA (as well as Narcotics Anonymous, if appropriate).  Those connected by researchers to 12-step groups had substantially lower rates of using alcohol and other drugs over time.  This proved that the groups themselves have a positive impact, even when they are not coupled with extended professionally-provided twelve-step facilitation counselling.

This means that going to AA meetings can be effective even when the alcoholic does not undergo individual counseling.

Clearly, AA is not the only effective treatment for addiction, but the fact that it has proven its worth scientifically should give us pause.