Alcoholics Anonymous and the Challenge of Evidence-Based Medicine

I hope Gabrielle Glaser reads this.

After 22 years of trouble associated with alcohol I put my tail between my legs and went to an AA meeting. 13 years later I'm still sober. I don't care how or why it worked for me other than to say it worked when other options failed.

http://www.theatlantic.com/features/archive/2015/03/the-irrationality-of...

Just going to leave this hear and disagree with this article in general.

Instead of looking at A.A. vesrus non-A.A., I wish more research was dedicated to other treatment options. I was really swayed by this article in the Atlantic "The Irrationality of A.A," which talks about the many alternatives to A.A. that are scientifically supported and more effective, but do not receive same amount of attention. http://www.theatlantic.com/features/archive/2015/03/the-irrationality-of....

In extreme contrast to this article by Austin Frakt which, frankly, is stunningly in contrast to current medical and scientific work on alcohol use issues, I refer those who are in search of help which isn't based on anecdote or vague data to the following excerpt from a recently published article in The Atlantic:
"In his recent book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, Lance Dodes, a retired psychiatry professor from Harvard Medical School, looked at Alcoholics Anonymous’s retention rates along with studies on sobriety and rates of active involvement (attending meetings regularly and working the program) among AA members. Based on these data, he put AA’s actual success rate somewhere between 5 and 8 percent. That is just a rough estimate, but it’s the most precise one I’ve been able to find."
From The Atlantic: The Irrationality of Alcoholics Anonymous
Its faith-based 12-step program dominates treatment in the United States. But researchers have debunked central tenets of AA doctrine and found dozens of other treatments more effective.
Gabrielle Glaser
Art by Dan Saelinger
APRIL 2015
See: http://www.theatlantic.com/features/archive/2015/03/the-irrationality-of...

If people want to drink they're going to drink, no matter what. If people want to stop drinking they probably will, eventually. It may happen quickly, it may take a few years and some will die drunk never able to stop. Does this sound strange and very general? Well that's because the "alcoholic" is a very general category and their "recovery" if there ever is any, can take many permutations throughout one's life.

What is very commonly seen throughout the years of AA is a person who attends some meetings and because they aren't really done with their drinking yet leaves and then comes back some years later ready to stop for good and stays sober. That's hard to put into a statistic because you can say it was both ineffective yet effective. (cont)

Kudos to Flakt for his explanation of "selection bias." As an economist, however, he also needs to consider "opportunity costs."

The relevant issue is the relative size of the resulting effect uncovered. Attending 2 additional AA sessions per week--that is 9 extra sessions per month, plus all the travel time to and from--results in only 3 more abstinence days per month? You wouldn't have any time to drink! Nine extra sessions at the gym, instead of AA, should probably do better than that. Or nine classical music sessions. The proper comparator for AA effectiveness is not nothing, but nine sessions per month of something else taking up a similar amount of time.

The AA program effect itself looks pretty meager to me.

How long was the study period? How large were the treatment and control groups? Why, exactly, would this (or any) paper publish an article with this basic kind of data lacking?

The best study would have been to compare AA, another treatment method, and a control group. That way, we would have at our fingertips data on not only whether AA is effective, but how does it compare to the other methods out there.

I drank to the point that I knew I would die for over 10 years. I crawled into an AA meeting with one foot in a grave. I never took another drink…that was June 6, 1978. I will soon have 37 years because I never deviated from the knowledge I acquired in the "Big Book"…there is nothing unique in the Big Book….just basic spiritual truths that have been practiced by mankind throughout history.
There can never be an accurate study of "Alcoholics Anonymous".

Testing whether AA is effective is a valuable question, but only a limited slice of a much better-framed and larger question, one which was recently explored by the Atlantic. A much more productive question is how effective AA is in comparison to a range of other approaches, for a variety of different patients. AA may be better at promoting abstinence than no treatment at all, but 1) periodic abstinence may not lead to longer term control of drinking, 2) if abstinence is an appropriate goal, other approaches might better achieve it, 3) abstinence may not be the right approach for many people with alcohol-control issues.

The focus on abstinence, which is inherent to the AA approach and is the only focus of the study in question, is based on no evidence; the efficacy of AA even at that very narrow goal is limited, and there is certainly no evidence that this approach to alcohol control is better than other approaches, which are backed by much more robust evidence. "Is AA better than nothing" is entirely the wrong question-- "nothing" is far from the only alternative.

Please be careful about "evidence-based" buzzword.

First, no evidence based care works for everyone! The evidence is that it works for a certain percentage (determined by research method) and even then, has some range of acceptable error.

Second, if something is "not evidence based"it doesn't mean that it doesn't work, it also means that, for what ever reason, no research was conducted.

BTW I am all for science, but if people want to use it, they should also understand what it means.

The only requirement for "membership" in AA is to have "a desire to stop drinking." This membership costs a member nothing, or maybe a buck in the basket. If the court system remands someone to AA meetings and the remandee is unsuccessful with his/her attempts at sobriety, don't blame AA. Ask the court why it ordered the person to AA. Could it be that because our jails, detention centers, and treatment facilities are so full with DWI and other substance abuse offenders that other ways of dealing with the problem are sought? Could it be due to the fact that in-patient treatment costs for a 28 day period may be in excess of $35,000? Could it be that alcohol abuse is but one of the psychosomatic problems many people have? AA isn't, hasn't, and won't be the only way people can live productive lives without alcohol or other addictive substances. But it has proven to be very effective for millions of people who have turned their lives around due to "this simple program."

Perhaps the greatest advantage of AA is one rountinely overlooked: It's cheap and easily accessible.

Think about it: what's the biggest obstacle today for many people with one form or another of mental illness? The cost of treatment - which can be prohibitive (with the resulting 'treatment' no guarantee of anything except the financial enrichment of the medical practitioner).

The AA model has it's issues (it's cult-like, in its way; it offers an incomplete healing plan for most alcoholics - which is likely why so few who make to the program ultimately stick it out) - but it's affordable, which is something we can't say about any conventional mental health approach.

Having unfortunately been around alcoholics and substance abusers all of my life, I've developed more than my share of theories about what does and doesn't work with regard to treatment modalities. But the insight that I remain most confident in is that healing requires a multimodal approach - of which the communal support meeting remains the most affordable and accessible.

So before we allow the usual skeptics to discredit a spiritually-oriented 12 step model for healing, we need to hear how they mean to replace it, and who pay for it.

Rob Berger's comment below, that "AA is not one intervention, it is many interventions," is the correct one. What, exactly, did the the AA participants in the Humpheys study experience when they were assigned to an AA group? Was it a Freethinkers group? a "Back to Basics" group? A group with many court-referred (or researcher-referred) participants? A neighborhood group or one that was housed in and elaborated on treatment center discourse? As a diffuse, unregulated, quasi-anarchistic organization, with all the up and downsides such a structure entails, "AA" is an imprecise entity. Until "evidence-based medicine" better understands AA history, structure, and ideas, and recognizes that the experiences people have in it cannot be standardized, clinicians and researchers will continue to flail in this area. http://preview.tinyurl.com/om4fczf

The AA program is for those who want in, not for those who need it. It works for those who will work it. It's not a business or even a health ideology. What I read in this article is that willingness can't be mandated successfully. The "type" of people who stay sober with the 12 Steps are those who admit that they're powerless to keep from drinking and that it has wrecked their lives and that the release from this insanity is a spiritual surrender that is not necessarily religious. Obviously, this doesn't succeed for many people. If you're facing a degrading death it's worth a try.

The question is not so much whether AA works, but what happens to those who work it. I've been a grateful sober member of AA for 14 1/2 years, but quit recently when I realised that although it's a great way to separate the alcoholic from what ails them, AA does not necessarily encourage long term well being.
This is 1930s mental health technology, after all, because our fellowship and it's steps are immutable to change. Today we know far more about our brains and thought processes than the pioneers of AA could ever have imagined.
Harmful elements of AA include its higher power thesis (sobriety on a "spiritual basis"), its black and white thinking ("we must or it kills us!"), and members' ignorance of more accessible up-to-date alternatives (seen as "outside issues").
Eventually I realised AA fosters a different mode of denial and dependency, so I quit going to meetings. I am still sober, and much happier as a result. AA should have the honesty and open-mindedness to accept change, inventorise itself, and offer more transparency about alternative options. Of course, we all know that'll never happen.
"Leaving AA, Staying Sober" at http://jonsleeper.wordpress.com

What many people have attributed to AA's success with certain people that have stayed sober through it's use is the fellowship and friendship they have found by going to meetings. It becomes part of a routine and that sense of belonging and camaraderie is something they had always found lacking in their lives. I believe that is was an unintended consequence of the AA "program" that it's founders were surprised at since they had been focusing on a "spiritual" solution to the problem.

In a compulsive alcoholic the booze seems to have a life of it's own and that's why it feels like a disease to the one's who are affected by it unlike many others who can take it or leave it alone. Even of the so called "first 100" in AA at least 70 of them died drunk.

"Selection bias" is indeed a very important concept for both laypersons and health reporters to understand and appreciate. It is why the common belief that exercise creates better health is totally wrongheaded--for two reasons.

First, because of unlucky genes or preexisting metabolisms or underlying health conditions, sedentary people have already self-selected to the sedentary cohort in observational studies on exercise. There starting point is why the sedentary group has worse morbidity and mortality outcomes, not because they don't exercise more.

And second, those who are motivated enough, health-conscious enough to exercise regularly are also, on average, more health-conscious in a hundred other ways (like better diet, more health screenings, better prescription adherence, etc.) that result in better net health outcome numbers. But all of these confounding, coincident healthy behaviors are not controlled for and so their effects erroneously get attributed to the exercise variable.

Sorry, but exercise won't cause better health outcomes, it is just selection bias in these studies.

One of my many problems with AA is the way they pressure the alcoholic to involve the whole family in all of the AA spin-offs, like Al-Anon and Al-Ateen. The alcoholic is already a vulnerable person, just trying to get some help, but once AA finds out a wife or kids are in the picture, the presence of the wife and kids at spin-off meetings becomes a big deal the alcoholic must answer for constantly.

Another one of my problems is that AA either encourages or allows blaming and excuse-making. Thanks to AA meetings, my alcoholic parent got the idea that alcoholism was a "family problem" so we were all "sick." Also, he believed that alcoholism was "a disease just like cancer," and he was no more responsible for being controlling his intake of alcohol or his behavior than a cancer patient was able to control cancer. Oddly, it did not occur to him that if alcoholism is like cancer, you need a medication to treat it and not a bunch of meetings (which are simply the closest thing to therapy most alcoholics will ever get--and intensive therapy and meds for their mental illnesses are what they really need).

The whole enterprise seemed very Scientology-ish to me. My parent stopped drinking soon after starting an anti-depressant, which didn't surprise me at all. I think alcoholism is a symptom of untreated mental illness (including depression). I'd bet cash anti-depressants "cure" far more alcoholics than AA.

I do not speak for AA, no one does; but, comments in this thread reveal such ignorance of the program. AA doesn't diagnose or track "members." That's against the spiritual foundation of anonymity. Any who have bothered to read the book, "Alcoholics Anonymous" would know it states this clearly. Get a book, make an effort to understand before discounting the concepts from an ignorant perspective.

For instance, the book describes several types of drinkers (not necessarily alcoholic) and then, after educating the reader on alcoholic behavior it even suggests that a candidate, after they have been armed with this "self-knowledge," go try some "controlled drinking."

Even after the candidate returns, the book still doesn't diagnose, it states that if they find that once they start they cannot control their behavior or stop drinking, it might indicate alcoholism. That's not an accusation. That's not a diagnosis, in fact it's more of a "welcome home" which is then followed by an invitation to a possible solution to this "problem" if they are willing to follow a few steps which have worked for others. It mentions a "spiritual solution" but does not specify what the spiritual solution for the reader must be.

When I'm having trouble figuring out how to do something, I go find someone who has done it and I ask them how. How can you discount that?

One of my core issues with this kind of study is still that they are relying on what people say about themselves and their drinking. We know from the Tucson Garbage Project that people notoriously lie more about their consumption of alcohol than seemingly anything else. Thus, any study that just asks people about their drinking is going to be flawed as a starting place. Also any study that deals with AA needs to account for the fact that AA "influences," or as many would argue "brainwashes," members to both be more focused on total abstinence and also to credit this total abstinence to AA. However, while AA members are saying that they aren't drinking and it is thanks to AA, still only 5-8% of AA members stay sober and in AA for life. Some leave AA because of psychological abuse of other members (as I did as did many in the Anti-AA movement), some die because they believe that if they have one drink they will go on an uncontrollable binge that will kill them (brainwashing that comes directly from AA), and others just drift away and stay sober but tend not to think that much about AA. Thus, when the true numbers are counted, AA is far more of a failure than a success.

So sad. There is no mention of the member on member rapes, murders, molestation, financial abuses, etc..... then there is the member on CHILDREN-of-member who are raped, murdered, molested etc...

There are no safety provisions listed anywhere. It's AA's dirty little secret.

You wanted to write an article about what people experienced in AA? Why didn't you include any of this stuff? http://nadaytona.org

Go ahead, type any of those words into the search engine and see what happens. Then after you have done that - type in words like 'sponsor', 'teen', 'child'.

Children are being placed in the same rooms as people who have been sent there from the courts for violent offences. Not DUI's. Violent offences.

Unsuspecting men and women are being taken advantage of because there are no educated facilitators. There is no complaint process.

I personally consider your report to be incomplete. Will you be moderating my comment or is free speech allowed when it comes to AA?

As a psychologist who has participated in 12-step groups, I see great benefit in 12-step groups for many people, but not for everyone. For example, some people less likely to benefit from 12-step groups (or any group) are people with extreme social anxiety. It is very difficult to do clear cut research on the effects of AA because AA is not one intervention, it is a multitude of interventions. Some of the interventions may be much more beneficial for select individuals. Sponsorship is a powerful intervention which involves developing a mentor relationship with another more experienced member. Some members have strong sponsor/sponsee relationships, while others have none at all. How do you account for that in your research? Some work the 12-steps in writing, other by listening. I am not of the belief that AA or any other group is the end all and be all. Some will benefit by other methods or combinations. Even though I have participated in 12-step groups for 30 years, that is not all I've done. I've engaged in individual and group psychotherapy, exercise, dietary change, social groups, travel, workshops, bodywork, meditation and other activities. I've taken medication at times of depression. I certainly think that my life is better for my efforts, but no one activity or intervention deserves all credit.

The Atlantic is certainly a reputable magazine. The April 2015 issue has an interesting article for which the cover has this come-on: "The false gospel of Alcoholics Anonymous."

One might even wonder if this NYT article is written in response and defense of the usual AA pronouncements. As The Atlantic article says, there is quite a bit of scientific research that shows that Naltrexone and some other chemical alternatives work effectively for many of the problem drinkers who haven't found AA to be the answer for them.

The analysis of so-called "marginal patients" that the author claims will eliminate the effects of crossover is deeply flawed. If you randomly assign treatment and then eliminate those who leave treatment, you end up with those motivated to get treatment. If you randomly assign control (i.e. no treatment) and then eliminate those who seek treatment, you end up with those not motivated to seek treatment. Analysis of "marginal patients" is a complex, costly way to end up with the same two groups the author initially describes as flawed.

As a person who works in social services, I meet many people active in AA and NA who have benefited greatly from active participation in 12 step programs. However, I also see people who have been injured by such programs. The trouble is that meetings are totally autonomous, which means that there is no way to protect people from people who attend for their own purposes. I have talked to several women in early recovery who have been victims of the "13th step," the practice of some AA member men who seek out new women members for sexual exploitation. There are also some cult like meetings controlled by a leader who exerts total control over members' lives. This is a weakness that the AA movement needs to address.

It works. Period. If you would like to know for sure, Honestly and thoroughly work all 12 steps with someone who has also honestly and thoroughly worked all 12 steps and you will experience the transformation in yourself and see the transformation in countless others. It's free, it's everywhere, it's fun. You will also see why people fail to stay clean and sober and you will understand why articles like this are written. Contempt prior to investigation. I never met a scientist or an atheist or an agnostic who worked all 12 steps and then told me that 12-step programs down't work.

Here's my take on this subject.
After 5 years of in and out of AA and 3 treatment centers, I finally had my last drink or drug. I have been clean and sober for 29 years now and consider myself recovered from my "seeming hopeless state of mind and body".
Think about this. Anybody who can come up with a cure for alcoholism, can become very rich.
Your friendly local out patient recovery center has a swinging door and has cashed in on alcoholics. In my opinion about all they can do is point their clients to AA. The courts do well when they sentence drunks to AA. Treatment centers that admit potential alcoholics as hospital patients may have better results than out patient facilities.
The book "Alcoholics Anonymous" has been in print for 76 years. Nothing of significance has been changed in the book. A lot of serious sceptics have wanted to change the book looking for an "easier, softer way". AA appears to be the real deal. It works if you work it.

Alcoholics confused science for a long time before AA, and now seem to still be confusing science. Some might say that we are looking at a spiritual solution with intellectual eyes, and that never seems to work out well. AA works for those that work the 12 steps and continue to do so. For those that stop working the 12 steps, or have tried I hope they find something that works for them. All that I know is that before I got sober through the 12 steps I had no idea how to be a son, brother, or a friend. Fast forward 7 years I have been the best man in several weddings, have a great relationship with my family, and best of all can fall asleep at night without having to worry. I need no more evidence that AA works I see it in my own life and that of my friends.

This article presumes that there is, in fact, some demonstrable improvement as a result of AA and its causes just need to be teased out. But there is no treatment effect of AA. Reviewing 60 years worth of studies, the Cochrane Collaboration found that “no experimental studies unequivocally demonstrated the effectiveness of AA or 12-step approaches for reducing alcohol dependence or problems.” A single study such as this cannot overthrow 60 years worth of research. It needs to be analyzed and replicated many times over to be considered sound enough to base large-scale policy on.

Well, people surely do get worked up about a voluntary program with no dues or fees, no paid administrators (at the most local level) and one that doesn't force its belief system on anyone, ever. "Attraction, not promotion" is the preferred modus operendi.

So, if it's not for you, don't go. If controlled drinking, eating, using works for you, feel free! AA isn't perfect, by the way. NOTHING IS. A lifetime of seeking 'total perfection and complete absence of pain' lies at the heart of my addictive personality. So, one day at a time, I can live with my own imperfections, and put off that 'one compulsive ______' until tomorrow.

Well a lot of scientific and statistical and confusing info here for me, a recovering alcoholic of 31 years.
AA works for reasons that may be hard to quantify. i am not a Christian nor were many of my AA friends. I realize much of the founding literature was written to reflect the times in which those books were written and many stories sound archaic in 2015.
But in AA you find a new set of friends who do not drink and the Womens Meetings I frequented also were cathartic much like group therapy. The 12 Steps give you a guideline for living. Who,can find fault with HALT - dot get too hungry, angry,lonely or tired. Or " feelings are not facts."I lost my desire to drink long ago but AA is a program for life that keeps on giving back.

I can't understand the "alternative method" model that advocates controlled drinking for an alcoholic. They seem to regard complete abstinence as a death sentence!

Compare input to output, when you measure any process. This is not how the studies Dr. Frakt looked at operated.

If a high school boasted that 70% of its students, who had a 90% attendance rate for four years, graduated, and that such a graduation rate proved that it had an outstanding program, we might ask them to compare the number of incoming freshmen to the number of graduates. They could have simply expelled failing students to generate a high graduation rate, or only counted seniors whom they measured from May to June of year four.

If we want to help people with alcohol abuse, we want to make a day 1 decision by looking at the outcomes of other day 1 decisions. There is little value in comparing year two to year five outcomes, when we need to know are day one to year five results.

Studies that have the integrity to measure input vs. output come up with figures between a 5% and 15% success rate for AA, when measured from day one. This is largely because AA refuses to provide the incoming data and only gives the data on their terms, because they want to protect privacy, they say, not because they cherry-pick data, of course.

The 12 step program, Narcotics Anonymous, is worse. Your kid is more likely to die of an overdose if your family is a victim of that method than if you just go it alone. Huffington Post told a horiffic tale of failure. It was titled,
" Dying-to-be-free-heroin-treatment ".

As a physician, I find it funny that people demand scientific evidence that AA works when we have a ton of scientific evidence that few patients with back pain require MRIs much less surgery yet tens of thousands of patients undergo these each year. Also we have absolutely no evidence another than anecdotal that opioid analgesics work for chronic pain yet millions are prescribed these every year for this and, unlike AA, these drugs can have very real and very severe side-effects.

Wow. The factual notion that AA is not medically based, out of date, dogmatic, ineffective for the vast majority and eschews newer and better treatment alternatives is finally gaining traction in the media and medical establishment. While this article and the underlying research contain a kernel of truth, the article itself is a step backwards.

As a bedside nurse I can share that getting through the architecture of denial of alcoholism is dramatic and an art. Why is with this denial...really!

The body loves alcohol, wants it, and can rebel ferociously when consumption stops. The human body processes alcohol as glucose. The "perfect food" tricks us. The moral equivalent of this science is found in the 12 step program of AA. It works. Explaining why people drink to patients helps them gain a foothold over being overwhelmed at a loss to explain their behaviors.

There is no character flaw. There is no mystery. If you care, intervene, take AWAY the car keys, and locate your local AA Chapter.

A lucid explanation of many crucial points germane to teasing out Effect of Therapy in clinical trials. Lay folks should read this piece carefully, with a sharp number 2 pencil and pad handy for jotting notes here and there.

While there may be some marginal benefit, AA is so far from perfect that more research into the base cause must be done. To see a wide variety of personalities and history and genetics and to expect this one size (forcibly) fits all is, while helpful, a square peg in a round hole.

I am fortunate to not have any close friends or family members struggling with alcoholism, I do see the dramatic damage and what seems to be an almost certiain path to a less desirable quality of life (based on outside observation and my own definitions of quality of life experience).

Hurray for any who find help they need or choose to do, through AA, but so much of what it does is inherently objectionable to many, even those who are not alcoholic, that it seems close to forcing someone to genuflect to a religion they don't embrace.

One problem with AA is that it insists on binary thinking - either you are abstaining from alcohol or you are out-of-control binging. There is no scientific evidence that abstinence is the only successful approach to alcohol use for people who have problems with substance abuse. Many have in fact found that managed moderation works quite well for them. Cognitive behavioral therapy is very useful. The AA model works for some people, but certainly not all, and it's hardly the only viable method. It's unfortunate that it dominates the discourse on alcohol treatment. "Alcoholism" itself is not a diagnosis.

Also worth stressing that the population of marginal patients depends on the encouragement that you give. For example, if you offer a monetary reward for attending AA, you'll get the treatment effect of AA on people who would only attend if paid. If you give people pamphlets with information about the program, you get the treatment effect of AA on people who would only attend if given more information. These effects can be very different. The effect measured by an ideal randomized trial is the average effect of AA on the entire population of alcoholics if they were somehow forced to attend. (And it still may matter how they were hypothetically forced. Causal inference is hard...)

Alcoholism is a progressive disease, so there's no cure and treatment never ends. That's a daunting concept. It's often assumed that alcoholics are so focused on the here and now (a drink) that they forget about the future (the consequences of getting drunk). Yet, the key to sobriety is to think only of the here and now and not to project: I choose not to have a drink now - I'll worry about the next hour, or the next day, or the next month, when it arrives. I mention this because what works (in medicine, social science, etc.) is often counter-intuitive. One might have heard someone say at a family gathering yesterday that Uncle Fed can't have another drink, ever. No, Uncle Fed can't have a drink now.

The benefit of a daily meeting in A.A. is described in the "BIg Book" as: "a daily reprieve based on the maintenance of our spiritual condition." Alcoholism is seen almost as an entity that is "cunning, baffling, powerful". This is not an "Abstain for Success" program, where a year of meetings and working the steps will guarantee a lifetime of abstinence, but a fellowship of people who share the common problem of uncontrollable drinking, and which helps people to shift from a life of codependence to one of interdependence, living for the "we of me" [Carson McCullers] as opposed to "me, me, me."

The disease underlying the behavior is called "self-centered fear"; "I'm not much, but that's all I think about", reveals that problem drinking is but a symptom of a much, much deeper problem, that began long before we took our first drink.