Tuesday, June 10, 2014

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:

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.


Anonymous said...

I read the report. Skimmed, in truth. Not being a Psychometrician, conversant with the acronyms, please forgive my ignorant question ...

In sum, what is the percentage of people in the studies who maintain full abstinence for a year of more?

I happened to be in treatment at Lutheran General about the same time as Elton John. I'm very happy about his success.

I was there due to a rather serious lifelong problem w/Depression. I've had 2 breakdowns, but managed to climb my way back.

ETOH had nothing to do w/it. But the money was lavish for that back then, so I was shoveled in.

As a patient, I developed a warm friendship with a young Resident Psychiatrist. He said the real Success Rate was about 5%.

Can that really be true? -- Rich Lara

Lastango said...

Most of the objections to AA that I've seen lately come from the Marxist/academic left and their political/cultural allies.

They are undermining AA because it has an overtly religious core -- something they associate with their political enemies.

Especially, they want to drive AA references and language out of public and state-funded institutions. Marxism will not tolerate competing centers of cultural gravity, and religion has always been a stubborn obstacle to progressivist social engineering.

And they are sly. Because strategically-minded and tactically-aware Leftists play the long game, they prefer to attack obliquely in order to conceal their power-driven agenda. So they pretend to object on technical grounds, or claim competing approaches are more effective. Only the short-term thinkers on the Left are unsophisticated enough to throw around rhetoric about an AA meeting being a bunch of bible-thumping, patriarchal, creepy neanderthals.


For anyone not familiar with AA's 12 steps, here they are. You'll immediately see why the Left wants to wipe them out.

1: We admitted we were powerless over alcohol--that our lives had become unmanageable.

2: Came to believe that a Power greater than ourselves could restore us to sanity.

3: Made a decision to turn our will and our lives over to the care of God as we understood Him.

4: Made a searching and fearless moral inventory of ourselves.

5: Admitted to God, to ourselves and to another human being the exact nature of our wrongs.

6: Were entirely ready to have God remove all these defects of character.

7: Humbly asked Him to remove our shortcomings.

8: Made a list of all persons we had harmed, and became willing to make amends to them all.

9: Made direct amends to such people wherever possible, except when to do so would injure them or others.

10: Continued to take personal inventory and when we were wrong promptly admitted it.

11: Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

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.

David S. said...

I've been a sober member of AA for twenty-five years, and a data-scientist working with substance abuse treatment researchers for twenty-two, by way of qualification.

There is no question that there has been suspicion bordering on hostility toward AA on the part of some, and possibly many, researchers and other "treatment professionals," at least since my involvement began in 1992.

There are many reasons why that could be the case - jealousy of a successful competitor, dislike of AA's spiritual nature, and frustration with the way that AA won't compromise anonymity to play the academic research game are only a few.

My experience has been that there has been a substantial reduction of overt hostility toward 12-step programs in the research community in the past decade or so. I'd like to think that this is at least in part due to the growth of "Big Data" that unambiguously shows that the single best predictor of long-term sobriety is the degree of involvement with 12-step programs. It's really hard to argue with success. The "scientifically developed" treatment methodologies that aren't primarily AA-based simply don't demonstrate the long-term success rate that real 12-step involvement offers.

Selection bias? Only the most motivated drunks go to AA on their own, work the program, and stay sober. Can't deny that. If we're looking for a methodology that can force any random drunk or druggie to get and stay clean, AA ain't it. But then, neither are any of the scientifically respectably techniques. If you hold a pneumonia sufferer down and pump him full of antibiotics long enough, he'll be cured. The same just isn't true of addiction.