Why Alcoholics Anonymous Works

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ca. 1950 --- Original caption: After three months without a drink, John finds himself an Alcoholics Anonymous crusader, helping the good work of saving others by telling of his successful fight. Photograph circa 1950. --- Image by ? Bettmann/CORBIS
Photo: Bettmann/Corbis

In a story in the April issue of The Atlantic that was posted online earlier today, journalist Gabrielle Glaser harshly criticizes Alcoholics Anonymous. AA and similar 12-step programs, she argues, simply don’t offer the benefits they claim to for those struggling with addiction, and they have become entrenched in both our culture and legal system — judges frequently refer defendants to 12-step programs as an alternative to jail time — as a result of faddishness and cultural appeal rather than sound science.

As with any story about a complicated social-science issue, there are aspects of Glaser’s argument with which one could easily quibble. For one thing, she repeatedly conflates and switches between discussing AA, a program that, whatever one thinks about it, is clearly defined and has been studied, in one form or another, for decades, and the broader world of for-profit addiction-recovery programs, which is indeed an underregulated Wild West of snake-oil salesman offering treatments that haven’t been sufficiently tested in clinical settings. Her argument also leans too heavily on the work of Lance Dodes, a former Harvard Medical School psychiatrist. He has estimated, as Glaser puts it, that “AA’s actual success rate [is] somewhere between 5 and 8 percent,” but this is a very controversial figure among addiction researchers. (I should admit here that I recently passed along this number much too credulously.)

But on Glaser’s central claim that there’s no rigorous scientific evidence that AA and other 12-step programs work, there’s no quibbling: It’s wrong.

She makes her strongest version of the argument in two places near the beginning of the piece. First, she writes that “Unlike Alcoholics Anonymous, [other methods for treating alcohol dependence] are based on modern science and have been proved, in randomized, controlled studies, to work.” In other words, “modern science” hasn’t shown AA to work. A little while later, she writes:

Alcoholics Anonymous is famously difficult to study. By necessity, it keeps no records of who attends meetings; members come and go and are, of course, anonymous. No conclusive data exist on how well it works. In 2006, the Cochrane Collaboration, a health-care research group, reviewed studies going back to the 1960s and found that “no experimental studies unequivocally demonstrated the effectiveness of AA or [12-step] approaches for reducing alcohol dependence or problems.”

Here and throughout the piece, Glaser is simply ignoring a decade’s worth of science.

No, that’s not true,” said Dr. John Kelly, a clinical psychologist and addiction specialist at Massachusetts General Hospital and Harvard Medical School, when I ran Glaser’s argument by him. “There’s quite a bit of evidence now, actually, that’s shown that AA works.” Kelly has a front-row view of the current generation of research: Alongside Dr. Marica Ferri, the original report’s lead author, and Dr. Keith Humphreys of Stanford, he’s currently at work updating the Cochrane Collaboration guidelines (he said they expect to publish their results in August).

Kelly said that in recent years, researchers have begun ramping up rigorous research on what are known as “12-step facilitation” (TSF) programs, which are “clinical interventions designed to link people with AA.” Dr. Lee Ann Kaskutas, a senior scientist at the Alcohol Research Group who has conducted TSF studies, explained that while these programs take on different forms, they’re generally oriented toward preparing participants for the (potentially weird-seeming, especially at first) culture and philosophy of 12-step programs like AA. By randomly assigning a group of study participants to either TSF programs or standard treatment, researchers can overcome some of the self-selection issues inherent to studying AA “in the wild” (that is, it could be that people who choose to go to AA are simply more motivated to kick their addiction).

The data from these sorts of studies, argued Kelly, Kaskutas, and other researchers with whom I spoke, suggest that it outperforms many alternatives. “They show about a 10 to 20 percent advantage over more standard treatment like cognitive behavioral therapy in terms of days abstinent, and typically also what we find is that when people are engaged in a 12-step-oriented treatment and go to AA, they have about 30 percent to 50 percent higher rates of continuous abstinence,” said Kelly.

The original Cochrane paper that Glaser cites came out before the latest round of studies did, so that research wasn’t factored into the conclusion that there’s a lack of evidence for AA’s efficacy. In a followup email, Kelly said he expects the next round of recommendations to be significantly different:

Although we cannot as yet say definitively what the final results will bring in the updated Cochrane Review, as it is still in progress, we are seeing 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. We can confirm that TSF is an empirically-supported treatment, showing clinical efficacy, and is likely to result also in lowered health care costs relative to alternative treatments that do not link patients with these freely available recovery peer support services. Another emerging finding is that a central reason why TSF shows benefit is because it helps patients become actively involved with groups like AA and NA, which in turn, have been shown to enhance addiction recovery coping skills, confidence, and motivation, similar to professional interventions, but AA and NA are able to do this in the communities in which people live for free, and over the long-term.

In other words, the most comprehensive piece of research Glaser is using to support her argument will, once it takes into account the latest findings, likely reverse itself.

In an email and phone call, Glaser said that TSF programs are not the same thing as AA and the two can’t be compared. But this argument doesn’t quite hold up: For one thing, the Cochrane report she herself cites in her piece relied in part on a review of TSF studies, so it doesn’t make sense for TSF studies to be acceptable to her when they support her argument and unacceptable when they don’t. For another, Kelly, Katsukas, and Humphreys, while acknowledging that TSF programs and AA are not exactly the same thing, all said that the available evidence suggests that it’s the 12-step programs themselves that are likely the primary cause of the effects being observed (the National Institutes of Health, given the many studies into TSF programs it has sponsored, would appear to agree).

Glaser said that her broader issue is with the culture of AA. “The therapeutic alliance is so hugely important when people are trying to get better from anything,” she said. “And understanding who’s going to thrive under different settings is really, in my opinion, the key to effective treatment.” She explained that she had encountered many people turned off by AA’s atmosphere, but she also acknowledged, as she does in her piece, that it works for others.

It’s worth pointing out that while critics of AA paint it as a bit cultlike and out-there, what with its reliance on “higher powers” and such, to the researchers who believe in its efficacy, there’s actually very little mystery to the process. “We have been able to determine WHY these 12-step facilitation interventions work,” said Kaskutas in an email. “And we have also been able to determine WHY AA works.”

Simply put, “People who self-select to attend AA, or people who are randomized to a 12-step facilitation intervention, end up having people in their social network who are supportive of their abstinence,” she said. Reams of research show that social networks, and the norms contained therein, are powerful drivers of behavior, so to Kaskutas — who noted that she is an atheist — the focus on AA’s quirks and spiritual undertones misses the point. “When you think about a mechanism like supportive social networks, or the psychological benefit of helping others, well, they have nothing to do with faith, or God — they have to do with the reality of what goes on in AA, with people meeting others in the same boat as they are in, and with helping other people (for but two examples of these mechanisms of action),” she said. So it can be the case both that AA rests on overly judgmental moral language, takes the unlikely view that God himself (or “a higher power”) is what cures people’s alcoholism, and has various other flaws — and that it still works for a lot of people, simply by connecting them to others going through the same struggles.

Glaser is right to point out that it is foolish, if not harmful, to treat AA and 12-step programs as one-size-fits-all panaceas. They’re not. She’s also right to point out that other treatments, including promising pharmaceutical options, may not always get the attention they deserve. But untangling a problem as complex as addiction requires taking into account all the best, most recent research. Glaser didn’t do that, and as a result she and The Atlantic simply aren’t giving readers an accurate view of the current addiction-research landscape.