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.
The Surgeon General of the United States 2016 Report on Alcohol, Drugs, and Health states "Well-supported scientific evidence demonstrates the effectiveness of twelve-step mutual aid groups focused on alcohol and twelve-step facilitation interventions."
There are two principal ways to measure the effectiveness of Alcoholics Anonymous (AA):
- A randomized controlled trial, or experimental study. Older trials (Brandsma 1980, etc.) tend to not show any difference in effectiveness between Alcoholics Anonymous, other treatments, and the control group. Some newer experimental trials such as Litt et al. 2009 and Walitzer 2009 suggest that some types of twelve-step facilitation (TSF, various ways where a professional consoler puts an addicted patient in to 12-step meetings) are more effective than a control condition.
- 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. 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.
While newer studies have suggested an association between AA attendance and increased abstinence or other positive outcomes, older studies and studies done outside of the United States have not.
Video Effectiveness of Alcoholics Anonymous
Clinical studies
Cochrane Review 2006
The 2006 Cochrane systematic review 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; 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.
The review only looked at "experimental studies"; in the case of this Cochrane Review that meant that the only studies they considered were randomized controlled trials. Observational studies, including longitudinal studies, were not utilized. Kaskutas, in a 2008 letter criticizing the Cochrane review, said, among other things, that non-experimental research should have been considered:
- I also urge providers to consider the mounting body of non-experimental research on AA's effectiveness, in judging what to tell patients. Experimental evidence is but one of the six criteria for establishing causation; for the other five criteria, the evidence for AA is compelling.
The authors of the Cochrane review responded to this statement:
- randomized controlled trials are only unnecessary when the strength of the association between two variables is sufficient to identify the treatment effect signal from the noise from bias and confounding. Nevertheless, [...] there are aspects of problematic alcohol use which can be difficult to study in experimental conditions.
The review used the following studies: Brown 2002, Cloud 2004, Davis 2002, Kahler 2004, MATCH 1998, McCrady 1996, Walsh 1991, and Zenmore 2004
There have been multiple experimental studies showing Alcoholics Anonymous and twelve step facilitation effectiveness which are more recent than this Cochrane review, such as Litt et al. 2009 and Walitzer 2009. 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."
Kelly 2017
In 2017, Kelly and others from the Massachusetts General Hospital released a randomized experimental study where they looked at how twelve step facilitation (TSF) affected recovery among teenagers. While the group who randomly underwent TSF had a higher percentage of days abstinent (58% vs. 49% at the nine-month follow-up, overall p=0.33) and a larger number of subjects either completely or "mostly" abstinent (33% vs. 21% at the nine-month followup, overall p=0.30), these numbers were not considered statistically significant. The study concluded there was no significant difference in percent days abstinent between the control group and the group undergoing TSF, and that the TSF group had better 12-step meeting attendance, as well as fewer negative addiction consequences: less guilt about their substance abuse, being more responsible, having more money, etc.
Galanter et al. 2016
A preliminary study with 20 subjects published in 2016 shows that prayer helps people who have achieved sobriety in Alcoholics Anonymous reduce cravings for alcohol. 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
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." 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.
Kaskutas 2009
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."
The study reported that while the evidence base for twelve step groups from experimental studies was weak, "other categories of evidence... are overwhelmingly convincing". Specifically, the correlation between exposure to AA and outcome, the dose-response relationship, and the consistency of the association were found to be very strong. In other words, the frequency by which individuals attend meetings appears to have a statistically significant correlation with maintaining abstinence. Kaskutas noted two studies which both found that 70% of those who attended twelve-step groups at least weekly were abstaining from alcohol consumption at follow ups two and sixteen years later. Those who attended less than once per week showed about the same success rate as those who didn't attend meetings. Kaskutas also found AA to function consistently with known behavioral change theories and substantial empirical support for specific mechanisms through which AA facilitates change.
Litt et al. 2009
Litt et al. 2009 randomly assigned to patients to one of three treatments: Network support, network support and contingency management, or a control condition (case management). The network support condition, which was "designed to use AA as an efficient means to engage patients in a supportive abstinence-oriented social network", had significantly better abstinence rates compared to the control and the combined treatments.
Walitzer 2009
Walitzer 2009 is an experimental study which randomly assigned patients to one of three treatments. Two of the treatments were Twelve Step Facilitation (TSF) treatments: Treatments which helped patients become involved with Alcoholics Anonymous and other twelve step programs.
One of the two TSF treatments, the 12-Step-based directive approach, resulted in increased number of days abstinent and other positive outcomes compared to the other two treatments.
Moos and Moos 2006
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."
Vaillant 2005
In 2005, Vaillant produced an extensive study of the efficacy and safety of AA in the treatment of alcoholism, reviewing the published works from 1940 until the present day. In this paper he acknowledges that, although AA is not a magic bullet for every alcoholic in that "there were a few men who attended AA for scores of meetings without improvement.", his overall observation is that "multiple studies that collectively involved a thousand or more individuals, suggest that good clinical outcomes are significantly correlated with frequency of AA attendance, with having a sponsor, with engaging in a Twelve-Step work and with chairing meetings." Vaillant's overall conclusion is that "Alcoholics Anonymous appears equal to or superior to conventional treatments for alcoholism, and the skepticism of some professionals regarding AA as a first rank treatment for alcoholism would appear to be unwarranted."
Fiorentine 1999
Fiorentine 1999 was a 24-month longitudinal study measuring the effectiveness of AA and Narcotics Anonymous. Like other longitudinal studies, it shows a strong correlation between 12-step attendance and being both clean from drugs and sober from alcohol: People who went to 12-step meetings in the study had about a 75% success rate.
In more detail, at the 24 month follow up, 77.7% of people who went to one or more meetings a week self-reported being clean; urinalysis was very close to that figure, showing some 76.4% of the regular attenders begin clean. For participants who did not regularly go to meetings, the self reported figure for being clean was 56% and the drug test showed 57.9% being clean. The self-reported figures for alcohol abuse were similar: 74.8% of regular 12-step attenders self-reported being completely sober, but only 40% of people who did not go to 12-step meetings claimed to be sober. Urinalysis showed 96.6% of people regularly going to meetings as sober, in contrast to the 88.9% of people who didn't go to meetings once a week or more whose urine sample was alcohol-free.
The report then sees if 12-steps meetings have a specific effect (in other words, if there is causation or merely correlation) by using statistical analysis to compare participants self-reported level of motivation, 12-step attendance, and successfully getting clean and sober. The result of this observation was that "Weekly or more frequent 12-step participants are 1.59 times more likely than less-than-weekly participants to maintain abstinence after controlling for the differences in recovery motivation measured by the scale."
Kownacki and Shadish 1999
A review of older experimental trials on AA, carried out by Kownacki and Shadish in the late 1990s, showed that randomized controlled trials showed a negative effect for AA, suggesting that coercion to AA yields worse outcomes than the outcomes of people who received other types of addiction treatment and those who received no treatment. However, other trials showed that AA had a positive effect.
This paper used the following coerced experimental trials where the AA treatment was, according to Kownacki and Shadish 1999, a conventional AA meeting: Brandsma et al. (1980), Ditman et al. (1967), and Walsh et al. (1991) (the paper felt the residential treatment in Walsh 1991 was not AA); based on these three studies, the paper stated the following:
- conventional AA meetings yielded a nonsignificantly negative mean effect in the two randomized comparisons of such meetings to no treatment (Brandsma et al., 1980; Ditman et al., 1967), and yielded a nonsignificantly negative mean effect size in three randomized comparisons of such meetings to other treatments (Brandsma et al., 1980; Ditman et al., 1967; Walsh et al., 1991)
The only other coerced study in this meta-analysis was Argeriou and Manohar (1978). The most recent study used overall was Tucker and Gladsjo (1993).
Project MATCH (1998)
Project MATCH was an 8-year, multi site, $27-million investigation that studied which types of alcoholics respond best to which forms of treatment. MATCH studied whether treatment should be uniform or assigned to patients based on specific needs and characteristics. The study concluded that 12-step facilitation was as effective as the other psychotherapies studied.
The Natural History of Alcoholism Revisited
In the 1995 book The Natural History of Alcoholism Revisited Harvard professor of psychiatry George E. Vaillant, a member of the Board of Trustees of Alcoholics Anonymous World Services, described his investigations into the effectiveness of AA. In the sample of 100 severe alcoholics from his clinic, 48% of the 29 alcoholics who eventually achieved sobriety attended 300 or more AA meetings, and AA attendance was associated with good outcomes in patients who otherwise would have been predicted not to remit. In the sample of 465 men who grew up in Boston's inner city, the more-severe alcoholics attended AA, possibly because all other avenues had failed. Vaillant's research and literature surveys revealed growing indirect evidence that AA is an effective treatment for alcohol abuse, partly because it is a cheap, community-based fellowship with easy access.
Walsh 1991
In 1991, Walsh and a number of other researchers carried out a randomized controlled trial among 227 subjects. They were randomly assigned to mandated inpatient treatment, mandatory AA meetings, or allowing the subject a choice of options.
This study was one of the eight studies used to determine the conclusions for Cochrane 2006.
While the subjects assigned to inpatient treatment did better than the subjects only assigned to AA meetings, the inpatient treatment consisted of three AA meetings a week while in treatment, followed by a year of three AA meetings a week after the inpatient treatment ended; the study shows that inpatient treatment consisting of AA is more effective than just AA meetings.
Brandsma 1980
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 which received no treatment. While some people who went to the AA-like meetings indulged in 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. 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.
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)"
Ditman, et al. 1967
A 1967 study saw a judge randomly assign (ordered) offenders to either clinical treatment, AA treatment, or to a no-treatment (control) group (but not denied AA meetings). 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. 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.
Maps Effectiveness of Alcoholics Anonymous
Membership retention
Results from National Longitudinal Alcohol Epidemiological Survey (NLAES)
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.
Results from NIAAA's National Epidemiological Survey on Alcoholism and Related Conditions (NESARC)
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). 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).
Results from triennial surveys
To measure the retention of members, the 1968 AA General Service Conference voted to begin surveying those participating in AA. 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. 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. Non-alcoholic board of trustees 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, the third was presented at the International Congress on Alcoholism and Drug Dependence.
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." Comments published by AA about this survey claim that 26% (not 5%) of people who attend AA meetings continue attending for more than one year; this is very close to the results from several independent assessments. In the previous surveys, this group (those remaining active for ninety days) would be the only ones considered to have "tried AA." 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. The necessity of an introductory period was not considered in the 1990 analysis, and the concept was not present in its analysis.
Anecdotal evidence
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. While AA World Services has continued to publish member surveys, they have not published any parallel commentary or analysis of the surveys since 1990. However, in 2015 AA Great Britain published a membership survey document commenting on nine surveys that they have done since 1972. These surveys found that 70% of members said they had over one year's sobriety, 64% said they had over two year's sobriety and 22% of members said they had been sober for less than 6 months.
In the forward to the second edition of Alcoholics Anonymous (1955) it says "Of Alcoholics who came to AA and really tried 50% got sober at once and remained that way; 25% sobered up after some relapses, and among the remainder, those who stayed on with AA showed improvement." These numbers are in line with observational studies: Fiorentine 1999 showed 74.8% of people who went to one or more 12-step meetings a week were sober two years after treatment, and Moos and Moos 2006 found that, 16 years later, 67% of the people who chose to regularly go to meetings were still sober.
In the main text it says "Rarely have we seen a person fail who has thoroughly followed our path", implying that the long-term sobriety rate among those who completed all twelve steps of the recovery program and continued daily work on their recovery, as specified in steps 10, 11 and 12, is very high. This claim has never been scientifically tested. However, Gabriel Segal reports that he has done extensive, though informal and unscientific, research into the question. He surveyed 15,000-20,000 subjects, mainly on the Internet, in Facebook and Google groups asking: "Have you done the Twelve Steps thoroughly and then relapsed while still doing them thoroughly? Or do you know of anyone meeting those conditions?" His sample included many who had been dissatisfied with twelve-step Fellowships and left them. If someone said that they had relapsed under the conditions, he discussed with them what they had been doing in relation to each step. He found only two subjects who, after discussion, continued to maintain that they had relapsed while thoroughly following the program. Segal concluded: "I believe that these informal studies provide good anecdotal evidence that 12-step programs are 99-100 percent effective, if followed thoroughly. This might seem incredible. But skepticism may be alleviated if one thinks of the program as analogous to diet and exercise: a strict regime of diet and exercise is more or less guaranteed to control weight. However, such regimes only work for people who follow them, and this is not easy to do. People who try to follow the regime and do not keep their weight down fail, not because the regime doesn't work but because they are not following it."
The Sober Truth
Dodes, in The Sober Truth, argues that most people who have experienced AA have not achieved long-term sobriety, making the controversial argument 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. Gabrielle Glaser used Dodes' figures to argue that AA has a low success rate in a 2015 article for The Atlantic.
The 5-8% figure put forward by Dodes is controversial; Thomas Beresford, MD. says that the book uses "three separate, questionable, calculations that arrive at the 5-8% figure." This is not the only criticism the book has received; The New York Times calls The Sober Truth a "polemical and deeply flawed book". John Kelly and Gene Beresin state 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." Jeffrey D. Roth and Edward J. Khantzian, in their review of The Sober Truth, called Dodes' reasoning against AA success a "pseudostatistical polemic."
See also
- Impact evaluation
- Program evaluation
- Project MATCH
References
Further reading
- German Lopez (2018-01-02). "Why some people swear by Alcoholics Anonymous -- and others despise it".
- Scott Alexander (2014-10-26). "Alcoholics Anonymous: Much More Than You Wanted To Know".
- G. Alan Marlatt; Mary E. Larimer; Katie Witkiewitz (1 December 2011). Harm Reduction, Second Edition: Pragmatic Strategies for Managing High-Risk Behaviors. Guilford Press. ISBN 978-1-4625-0256-1.
- Dennis C. Daley; G. Alan Marlatt (2006). Overcoming Your Alcohol Or Drug Problem: Effective Recovery Strategies Therapist Guide. Oxford University Press, USA. ISBN 978-0-19-530773-3.
- G. Alan Marlatt; Katie Witkiewitz (2009). Addictive Behaviors: New Readings on Etiology, Prevention, and Treatment. American Psychological Association. ISBN 978-1-4338-0402-1.
- Katie A. Witkiewitz; G. Alan Marlatt (28 April 2011). Therapist's Guide to Evidence-Based Relapse Prevention. Elsevier. ISBN 978-0-08-047104-4.
- Linda A. Dimeff (8 January 1999). Brief Alcohol Screening and Intervention for College Students (BASICS): A Harm Reduction Approach. Guilford Press. ISBN 978-1-57230-392-8.
- Dennis M. Donovan; G. Alan Marlatt (26 December 2007). Assessment of Addictive Behaviors. Guilford Press. ISBN 978-1-59385-640-3.
- G. Alan Marlatt; Dennis M. Donovan (26 December 2007). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. Guilford Press. ISBN 978-1-59385-641-0.
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