Effectiveness of Alcoholics Anonymous

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The effectiveness of Alcoholics Anonymous in treating alcoholism is a subject of ongoing interdisciplinary research and debate in a multitude of academic and non-academic contexts.

There are two principal ways to measure the effectiveness of Alcoholics Anonymous:

  • A Randomized controlled trial such as Ditman 1967 or Brandsma 1980. These trials tend to not show any difference in effectiveness between Alcoholics Anonymous, other treatments, and the control group. Lee Ann Kaskutas argues these can not accurately measure AA effectiveness because it's not possible to stop subjects in the control group from attending meetings, nor compel people assigned to AA to actively participate in the program.[1]
  • A number of Longitudinal studies on AA's effectiveness have been done. These studies tend to show that, the more involved subjects are with AA (usually, the more frequently the subjects go to meetings), the more likely the subjects will stay sober.[2][3] Longitudinal studies suffer from self-selection bias, but one 2014 study claims that AA's effectiveness shown in these studies does not come from self-selection.[4]

While newer studies have suggested an association between AA attendance and increased abstinence or other positive outcomes,[2][4][5][6][7] older studies and studies done outside of the United States have not.[8][9]

Experimental studies into the effectiveness of Alcoholics Anonymous (AA) have been based either on results obtained from individuals attending meetings run under the umbrella of the AA organization itself, or from similar twelve-step recovery programs based on the twelve-step approach run externally from the AA organization; generically termed, in this latter case, as twelve-step facilitation (TSF).

Studies of both implementations of the therapeutic model have not yielded conclusive evidence of effectiveness when assessed in terms of long-term prevention of problem drinking as compared with other treatments,[10][11] although limitations are widely acknowledged in obtaining acceptable data due to the difficulty in applying experimental controls to clinical analyses of AA, such as adequate placebo control and uniformity of the delivered therapy.[12]

Clinical studies[edit]

Cochrane Review[edit]

In 2006 Cochrane systematic review that reviewed studies published between 1966 and 2005 that investigated the efficacy of AA and twelve step facilitation (TSF) found no significant difference between the results of AA and twelve-step participation compared to other treatments, stating that "experimental studies have on the whole failed to demonstrate their effectiveness in reducing alcohol dependence or drinking problems when compared to other interventions." This conclusion was based on a meta-analysis of the results of eight trials involving a total of 3,417 individuals;[13] the authors note that further efficacy studies are needed, and mention the presence of flaws in one included study regarding the definition of success of interventions.[13]

John Kelly, who is working on the updated version of the Cochrane review concerning Alcoholics Anonymous, says that there are "positive results in favor of Twelve-Step Facilitation treatments that have emerged from the numerous NIH-sponsored randomized clinical trials completed since the original review published in 2006."[14]

Galanter, et al. 2016[edit]

A study published in 2016 shows that prayer helps people who have achieved sobriety in Alcoholics Anonymous reduce cravings for alcohol.[15] The study used a MRI machine to scan how subjects reacted to images of people drinking. The study randomly assigned the subjects, so that some subjects saw the images after saying prayers in the Big Book of Alcoholics Anonymous; others after reading newspaper articles. The people who had just seen the prayers reported feeling fewer cravings for alcohol; the MRI scans of their brains confirmed that there was a different reaction.

Humphreys, Blodgett, and Wagner 2014[edit]

A 2014 study by Keith Humphreys, Janet Blodgett and Todd Wagner concluded that "increasing AA attendance leads to short and long term decreases in alcohol consumption that cannot be attributed to self-selection."[4] Austin Frakt, writing for The New York Times, discusses how the study's methodology minimizes outside factors, such as how motivated the people who succeed at becoming abstinent are.[16]

Kaskutas 2009[edit]

In 2009, Lee Ann Kaskutas performed a meta-analysis of other studies looking at how effective Alcoholics Anonymous is. The article notes that "rates of abstinence are about twice as high among those who attend AA" but that whether Alcoholics Anonymous has a specific effect is unclear (a specific effect, in this context, is whether it's the actual Alcoholics Anonymous program which helps keep people sober, instead of other factors, including the fact that people more motivated to stay sober will go to more meetings, or that the group support helps alcoholics regardless of the actual program, etc.), stating that there were "2 trials finding a positive effect for AA, 1 trial finding a negative effect for AA, and 1 trial finding a null effect." [1]

Moos and Moos 2006[edit]

A 2006 study by Rudolf H. Moos and Bernice S. Moos looked at the outcome of a group of alcoholics seeking treatment over a 16-year period. The study stated that "individuals who participated in AA for 27 weeks or more had better 16-year outcomes", showing that "only 34% of individuals who did not participate in AA in the first year were abstinent at 16 years, compared to 67% of individuals who participated in AA for 27 weeks or more."[2]

Brandsma 1980[edit]

In 1980, the book Outpatient treatment of alcoholism was published. It describes a study of 260 individuals, 184 referred by the courts and 76 self referred or referred by other agencies for 210 days. Participants were assigned randomly within five groups: AA-like meetings run by experienced non-professionals, RBT therapy administered by a non-professional, RBT therapy administered by degreed professionals, Insight Therapy administered by professionals, and a control group receiving no treatment. While the people who went to the AA-like meetings had increased binge drinking at the three-month after treatment mark, there was no increase in binge drinking for the AA-style meeting members one year after treatment.[1] According to the study, both the AA-style and the lay-RBT group were able to stop drinking more often than the control group after one or two initial drinks, and when drinking they both consumed three to four times less alcohol per day than the control group.[17]

This study had poor methodology. There was no effort to stop the people in the control group from attending Alcoholics Anonymous meetings, and the "Alcoholics Anonymous" treatment patients underwent in the Brandsma study did not use actual Alcoholics Anonymous meetings. "The control condition allowed for participation in actual AA meetings, while those in the AA condition attended a weekly AA-like meeting administered by the study (that was not an actual AA meeting)"[1][18]

Ditman, et al. 1967[edit]

A 1967 study where a judge randomly assigned (ordered) offenders to either clinical treatment, AA treatment, or to a no treatment (control) group. After one year 68% in the clinic group were rearrested, 69% in the AA group were rearrested, and 56% were rearrested in the group receiving no treatment. No statistically significant differences between the three groups were discovered in recidivism rate, in the number of subsequent rearrests or in time elapsed prior to rearrest.[19] Like the Brandsma study, the results are inaccurate since the studies did not stop people not assigned to AA treatment from going to AA meetings.[18]

Membership Retention[edit]

Results from National Longitudinal Alcohol Epidemiological Survey (NLAES)[edit]

In 1992, the United States Census Bureau and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) conducted the National Longitudinal Alcohol Epidemiologic Survey (NLAES). Direct face-to-face interviews were conducted with one randomly selected respondent, 18 years of age or older, in each of 42,862 households within the contiguous United States and the District of Columbia. NLAES respondents were asked whether they ever attended an Alcoholics Anonymous meeting for any reason related to their drinking. 1106 respondents stated they had attended an Alcoholics Anonymous meeting for their drinking prior-to-the past year. 348 respondents stated they attended an Alcoholics Anonymous meeting prior-to-the past year and continued to attend Alcoholics Anonymous during the past year, a 31% continuance rate.[20]

Results from NIAAA’s National Epidemiological Survey on Alcoholism and Related Conditions (NESARC)[edit]

In 2001-2002, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) conducted the National Epidemiological Survey on Alcoholism and Related Conditions (NESARC). Similarly structured to the NLAES, the survey conducted in-person interviews with 43,093 individuals. This time, respondents were asked if they had ever attended a 12-step meeting for an alcohol problem in their lifetime (the question was not AA-specific). 1441 (3.4%) of respondents answered the question affirmatively. Answers were further broken down into three categories: disengaged, those who started attending at some point in the past but had ceased attending at some point in the past year (988); continued engagement, those who started attending at some point in the past and continued to attend during the past year (348); and newcomers, those who started attending during the past year (105).[21] In their discussion of the findings, Kaskautas et al. (2008) state that to study disengagement, only the disengaged and continued engagement should be utilized (pg. 270).[21]

Results from Triennial Surveys[edit]

To measure the retention of members, the 1968 AA General Service Conference voted to begin surveying those participating in AA.[22] A survey was conducted beginning that year and subsequent surveys have been conducted about every three years (triennially), the latest of which was in conducted in 2011 and published in 2012.[22][23][24][25][26] The basic results of the surveys are made available in pamphlet form to AA members. Additional comments and analysis intended for academic and professional audiences were written to supplement the survey results from 1970 to 1990.[22] Non-alcoholic Board of Trustee Member, Dr. John [Jack] Norris wrote the second and third analyses. The second was presented at the North American Congress on Alcohol and Drug Problems,[27] the third was presented at the International Congress on Alcoholism and Drug Dependence.[28]

The 1990 commentary evaluated data of triennial surveys from 1977 through 1989 and found that after the first year, the rate of attrition slows. Only those in the first year were recorded by month. The survey states that the data "strongly suggests that about half those who come to A.A. are gone within three months." [29] Comments published by AA about this survey claim that 26% of people who attend AA meetings continue attending for more than one year; this is very close to the results from several independent assessments.[30] In the previous surveys, this group (those remaining active for ninety days) would be the only ones considered to have "tried AA."[22] After the first year, the rate of attrition slows. The nature of the survey questions asked did not allow a direct comparison between the twelfth month of the first year and the first month of the second year. Only those in the first year were recorded by month.[29] The necessity of an introductory period was not considered in the 1990 analysis, and the concept was not present in its analysis.[22]

The Sober Truth[edit]

Dodes, in "The Sober Truth", argues that most people who have experienced AA have not achieved long-term sobriety, making the case that research indicates that only 5 to 8 percent of the people who go to one or more AA meetings achieve sobriety for longer than one year.[30] Gabrielle Glaser used Dodes' figures to argue that AA has a low success rate in a 2015 article for The Atlantic.[31]

The 5 to 8 percent figure put forward by Dodes is controversial; Thomas Beresford, MD., writing for the National Council on Alcoholism and Drug Dependence, says that the book uses "three separate, questionable, calculations that arrive at the 5-8% figure."[32] This is not the only criticism the book has received; The New York Times calls The Sober Truth a "polemical and deeply flawed book" [33] and John F. Kelly, an associate professor at Harvard, as well as Gene Beresin, a professor at Harvard, feel that the book's conclusion that "[12-step] approaches are almost completely ineffective and even harmful in treating substance use disorders" is wrong (Dodes responded by pointing out that "I have never said that AA is harmful in general"), noting that "studies published in prestigious peer-reviewed scientific journals have found that 12-step treatments that facilitate engagement with AA post-discharge [...] produce about one third higher continuous abstinence rates" [34][35]

Sobriety of AA members[edit]

According to AA World Services, about 40% of all AA members who have already been sober for less than a year will remain both sober and active in AA another year; 60 percent of this group will either lose sobriety or stop participating in AA during the next year, or both. About 80% of those participants who have been sober between one and five years will remain both sober and active in the fellowship another year. About 90% of the members who have been sober five years or more will remain both sober and active in the fellowship another year. (AA's survey could not determine the number of people who remain sober but discontinue participation in AA groups.) These figures have been repeated within a few percentage points using the same calculations since 1974.[29] While AA has continued to publish member surveys, they have not published any parallel commentary or analysis of the surveys since 1990.[22]

See also[edit]

References[edit]

  1. ^ a b c d Kaskutas, Lee Ann (2009). "Alcoholics Anonymous Effectiveness: Faith Meets Science". Journal of Addictive Diseases 28 (2): 145–157. doi:10.1080/10550880902772464. PMC 2746426. PMID 19340677. 
  2. ^ a b c Moos, Rudolf H.; Moos, BS (June 2006). "Participation in Treatment and Alcoholics Anonymous: A 16-Year Follow-Up of Initially Untreated Individuals". Journal of Clinical Psychology 62 (6): 735–750. doi:10.1002/jclp.20259. PMC 2220012. PMID 16538654. 
  3. ^ The Natural History of Alcoholism Revisited by George E. Vaillant shows much higher success among alcoholics who attended 300 or more meetings over a 10-year period
  4. ^ a b c Humphreys, Blodgett, Wagner (2014). "Estimating the efficacy of Alcoholics Anonymous without self-selection bias: an instrumental variables re-analysis of randomized clinical trials". Alcoholism: Clinical and Experimental Research 38 (11): 2688–94. doi:10.1111/acer.12557. PMC 4285560. PMID 25421504. 
  5. ^ Walitzer, Dermen, Barrick (2009). "Facilitating involvement in Alcoholics Anonymous during out-patient treatment: a randomized clinical trial". Addiction 104 (3): 391–401. doi:10.1111/j.1360-0443.2008.02467.x. PMC 2802221. PMID 19207347. 
  6. ^ Litt, Kadden; Kabela-Cormier, Petry (2009). "Changing network support for drinking: network support project 2-year follow-up". J Consult Clin Psychol. 77 (2): 229–42. doi:10.1037/a0015252. PMC 2661035. PMID 19309183. 
  7. ^ Moos, Rudolf H.; Moos, BS (February 2006). "Rates and predictors of relapse after natural and treated remission from alcohol use disorders". Addiction 101 (2): 212–222. doi:10.1111/j.1360-0443.2006.01310.x. PMC 1976118. PMID 16445550. 
  8. ^ Ståhlbrandt, Henriettæ; Johnsson, Kent O.; Berglund, Mats (2007). "Two-Year Outcome of Alcohol Interventions in Swedish University Halls of Residence: A Cluster Randomized Trial of a Brief Skills Training Program, Twelve-Step Influenced Intervention, and Controls". Alcoholism: Clinical and Experimental Research 31 (3): 458–66. doi:10.1111/j.1530-0277.2006.00327.x. PMID 17295731. 
  9. ^ Terra, Mauro Barbosa; Barros, Helena Maria Tannhauser; Stein, Airton Tetelbom; Figueira, Ivan; Palermo, Luiz Henrique; Athayde, Luciana Dias; Gonçalves, Marcelo de Souza; Da Silveira, Dartiu Xavier (2008). "Do Alcoholics Anonymous Groups Really Work? Factors of Adherence in a Brazilian Sample of Hospitalized Alcohol Dependents". American Journal on Addictions 17 (1): 48–53. doi:10.1080/10550490701756393. PMID 18214722. 
  10. ^ Ferri, Marica; Amato, Laura; Davoli, Marina (2006). "Alcoholics Anonymous and other 12-step programmes for alcohol dependence". Cochrane Database Syst Rev (3): CD005032. doi:10.1002/14651858.CD005032.pub2. PMID 16856072. 
  11. ^ Emrick, C. (1989). "Alcoholics Anonymous: Membership characteristics and effectiveness as treatment" in Recent developments in alcoholism, Vol. 7: Treatment research M. Galanter, ed. (1989) New York: Plenum Press, pp. 37-53.
  12. ^ Bebbington, PE (1976). "The efficacy of Alcoholics Anonymous: The elusiveness of hard data". The British Journal of Psychiatry 128 (6): 572–80. doi:10.1192/bjp.128.6.572. PMID 1084198. 
  13. ^ a b Ferri, Marcia; Amato, Laura; Davoli, Marina (19 July 2006). "Alcoholics Anonymous and other 12-step programmes for alcohol dependence". Cochrane Database of Systematic Reviews (3): CD005032. doi:10.1002/14651858.CD005032.pub2. PMID 16856072. 
  14. ^ Singal, Jessee (2015-03-17). "Why Alcoholics Anonymous Works". New York Magazine. 
  15. ^ Marc Galanter, Zoran Josipovic, Helen Dermatis, Jochen Weber, and Mary Alice Millard (2016-03-25). "An initial fMRI study on neural correlates of prayer in members of Alcoholics Anonymous". The American Journal of Drug and Alcohol Abuse. doi:10.3109/00952990.2016.1141912. Lay summary. 
  16. ^ Frakt, Austin (2015-04-06). "Alcoholics Anonymous and the Challenge of Evidence-Based Medicine". The New York Times. Retrieved 2015-06-21. 
  17. ^ Brandsma, Jeffery M; Maultsby, Maxie C; Welsh, Richard J (1980). Outpatient treatment of alcoholism: a review and comparative study. Baltimore, MD: University Park Press. ISBN 0-8391-1393-5. OCLC 5219646. 
  18. ^ a b Magura, Stephen; Cleland, Charles M.; Tonigan, J. Scott (2013). "Evaluating Alcoholics Anonymous's Effect on Drinking in Project MATCH Using Cross-Lagged Regression Panel Analysis". Journal of Studies on Alcohol and Drugs 74 (3): 378–85. doi:10.15288/jsad.2013.74.378. PMC 3602358. PMID 23490566.  "The few randomized controlled trials of AA that have been conducted are significantly limited in their methods or interpretability [...] some alcoholism study subjects always go to AA on their own, even if not specifically assigned to go"
  19. ^ (August 1967). "A Controlled Experiment on the Use of Court Probation for Drunk Arrests". American Journal of Psychiatry 124 (2): Abstract.
  20. ^ SOURCE: National Longitudinal Alcohol Epidemiologic Survey Data, Manual 1 July 11, 1994, National Institute on Alcohol Abuse and Alcoholism.
  21. ^ a b Kaskutas, Lee Ann; Ye, Yu; Greenfield, Thomas K.; Witbrodt, Jane; Bond, Jason (30 June 2008). "Epidemiology or Alcoholics Anonymous Participation". Recent Developments in Alcoholism. Recent Developments in Alcoholism 18: 261–282. doi:10.1007/978-0-387-77725-2_15. ISBN 978-0-387-77724-5. PMID 19115774. 
  22. ^ a b c d e f McIntire, Don (December 2000). "How Well Does A.A. Work? An Analysis of Published A.A. Surveys (1968–1996) and Related Analyses/Comments". Alcoholism Treatment Quarterly 18 (4): 1–18. doi:10.1300/J020v18n04_01. 
  23. ^ "Alcoholics Anonymous 2004 Membership Survey". Alcoholics Anonymous World Services' General Service Office. 2005. Archived from the original (PDF) on 2009-12-12. Retrieved 2013-03-19. 
  24. ^ "Alcoholics Anonymous 1998 membership survey". New York: Alcoholics Anonymous World Services. 1999. 
  25. ^ "Alcoholics Anonymous 2001 membership survey". New York: Alcoholics Anonymous World Services. 2002. 
  26. ^ "Alcoholics Anonymous 2007 Membership Survey". Alcoholics Anonymous World Services. 2008. Archived from the original (PDF) on 2009-12-19. Retrieved 2009-12-19. 
  27. ^ Norris, John (18 December 1974). Analysis of the 1974 Survey of the Membership of A.A. North American Congress on Alcohol and Drug Problems. San Francisco, CA. 
  28. ^ Norris, John (3 September 1978). Analysis of the 1977 Survey of the Membership of A.A. 32nd International Congress on Alcoholism and Drug Dependence. Warsaw, Poland. 
  29. ^ a b c "Comments On A.A. Triennial Surveys". Alcoholics Anonymous World Services. December 1990. 
  30. ^ a b Lance Dodes, M.D.; Zachary Dodes (2014). The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. ISBN 978-0807033159. Even though AA does not conduct scientific studies on its success rates, a number of clinicians have tried to audit the figures. The National Longitudinal Alcohol Epidemiologic Survey, a 1992 review by the US Census Bureau and National Institute on Alcohol Abuse and Alcoholism (NIAAA), included a survey of AA members. It found that only 31 percent of them were still attending after one year. AA itself has published a comparable figure in a set of comments on its own thirteen-year internal survey, stating that only 26 percent of people who attend AA stay for longer than one year.33 A third study found that after eighteen months, between 14 and 18 percent of people still attended AA. So let us assume that between 14 percent and 31 percent of people stay with AA for more than one year. Now we must ask: out of this remaining population, how many stay sober? .... These totals all fall within a close range. Together, they support the fact that roughly 5 to 8 percent of the total population of people who enter AA are able to achieve and maintain sobriety for longer than one year. 
  31. ^ Glaser, Gabrielle. "The Irrationality of Alcoholics Anonymous". The Atlantic. Retrieved 2016-04-15. 
  32. ^ Beresford, Thomas (2016), Alcoholics Anonymous and The Atlantic: A Call For Better Science, National Council on Alcoholism and Drug Dependence, retrieved 2016-04-15 
  33. ^ http://www.nytimes.com/2014/05/06/health/the-sober-truth-seeing-bad-science-in-rehab.html?_r=3
  34. ^ In Defense Of 12 Steps: What Science Really Tells Us About Addiction | CommonHealth
  35. ^ Humphreys, Keith; Moos, Rudolf (May 2001). "Can encouraging substance abuse patients to participate in self-help groups reduce demand for health care? A quasi-experimental study". Alcoholism: Clinical and Experimental Research 1 (5): 711–716. doi:10.1111/j.1530-0277.2001.tb02271.x. PMID 11371720. 12-step patients had higher rates of abstinence at follow-up (45.7% versus 36.2% for patients from CB [cognitive-behavioral] programs, p < 0.001 

Further reading[edit]

Books[edit]

  • Marlatt, Alan., Harm Reduction Pragamatic Strategies for Managing High Risk Behavior, New York Guildford Press 1998, ISBN 1-57230-397-2
  • Daley Dennis C. and Marlatt, Alan, Overcoming Your Alcohol or Drug Problem: Effective Recovery Strategies Therapist Guide (Treatments the Work) Oxford ; New York : Oxford University Press, 2006,
  • Marlatt, Alan G. Vandenbos, Gary R., Addictive behaviors : readings on etiology, prevention, and treatment, Washington, DC : American Psychological Association, c1997. ISBN 1-55798-468-9
  • Witkiewitz, Katie A. and Marlatt, Alan G. Therapist's Guide to Evidence-Based Relapse Prevention (Practical Resources for the Mental Health Professional)
  • Dimeff, Linda A., Baer, John S. Kivahaln, Daniel R., Marlatt, Alan G., Brief Alcohol Screening and Intervention for College Students (BASICS): A Harm Reduction Approach, 2007,
  • Donovan Dennis M., Marlatt, Alan G. Assessment of Addictive Behaviors, 1988
  • Donovan, Dennis M, Marlatt, Alan G., Relapse prevention: maintenance strategies in the treatment of addictive behaviors, New York : Guilford Press, c2005. ISBN 978-1-59385-176-7
  • Lance Dodes, M.D.; Zachary Dodes (2014). The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. ISBN 978-0807033159.