In this modern era of neuroscience, how can we take seriously the notion that an effective way to address the chronically relapsing brain disease of addiction is by recommending that those affected congregate frequently in rented church basements to discuss their addiction and recovery experiences?
And yet, over the past 75 years, Alcoholics Anonymous (AA) has grown from two founding members to over two million members. Meeting in rented rooms, school halls, hospitals, and the storied church basement, AA and similar
12-step organizations (eg, Narcotics Anonymous [NA]) remain the most commonly sought sources of help for substance-related problems in the United States (Substance Abuse and Mental Health Services Administration. Results from the 2007 National Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies; 2008; http://1.usa.gov/1qwnZ9d).
Not only that, many of the principles and practices of these 12-step community mutual-help organizations (MHOs) have made their way into professional interventions.
But is their place of prominence in our treatment culture and practice justified? Can MHOs like AA and NA—and 12-step based professional treatments designed to stimulate engagement with them—even be studied scientifically, let alone demonstrate effectiveness? Shouldn’t the only “steps” that these addicted individuals take be those that lead them up and out of those basements and into the sunlight of real, effective, clinical science?
Research Results and Challenges
Since the establishment of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse in the 1970s, many effective psychosocial and pharmacological treatments for addiction have been developed, tested, and approved. Despite growing influence over many decades, however, it is only during the past 25 years that the scientific community has conducted rigorous studies on the mechanisms, clinical use, and cost-effectiveness of MHOs like AA, and developed and tested professional interventions to facilitate their use.
Results from this body of rigorous research have surprised many. Here are five things that we’ve learned from the science on AA and professional 12-step interventions.
1. AA and Other MHOs Can Be Studied Empirically
Studying peer-led MHOs, such as AA, scientifically has not been without its challenges, particularly in terms of the gold standard of medical research: the randomized controlled trial (RCT). The tightly controlled and insulated context of an RCT runs counter to the way real-world AA groups are conducted.
AA is attended anonymously, usually voluntarily, no records are kept, and groups vary in size, content, and focus. Moreover, it might be seen as unethical to assign some RCT participants to attend AA and prohibit others.
These issues have led researchers to examine AA via other methods, such as through naturalistic, longitudinal effectiveness studies that use sophisticated analytic methods to control for confounding varibles (eg, propensity score matching) (Magura S et al, Drug Alcohol Depend 2013;129(1–2):54–59).
Researchers have also used RCTs to examine the efficacy of professionally-delivered 12-Step Facilitation (TSF) relative to other treatments that neither encourage nor forbid attendance. (For more on TSF see article “AA and TSF”)
In combination, these types of research have provided insight into the benefits of AA attendance in a way that has both scientific integrity and real-world relevance (Kelly J & Yeterian J, Mutual-Help Groups for Alcohol and Other Substance Use Disorders. In: McCrady B, Epstein E, eds. Addictions: A Comprehensive Guidebook, 2d ed. New York: Oxford University Press;2013:500–525).
Research has shown that attending AA, either alone or during and following professional treatment, enhances outcomes. One naturalistic study, for example, followed 466 previously untreated individuals with problem drinking for eight years. Participants self-selected into one of four groups: no treatment, AA alone, formal treatment alone, and formal treatment plus AA.
Those who received some sort of help—AA, formal treatment, or both—had higher rates of abstinence at all time points. At eight years, 26% of patients in the no treatment group were abstinent from alcohol compared to 49% who received AA alone, 46% who received formal treatment alone, and 58% who received the combination of treatment plus AA (Timko C et al, J Stud Alcohol 2000;61(4):529–540).
A systematic Cochrane review of the best scientific studies on AA and TSF found that they were as effective as any of the interventions to which they were compared for some factors, such as retention in treatment, but found that no studies unequivocally proved AA and TSF were superior to other treatments (Ferri M et al, Cochrane Database Syst Rev 2006;(3):CD005032).
Other studies have found a linear dose-response relationship between AA attendance and favorable drinking outcomes (Kaskutas LA, J Addict Dis 2009;28(2):145–157). Attending one meeting per week, on average, appears to be the minimum threshold to realize benefit and increasing meeting frequency is associated with progressively greater rates of abstinence.
In addition, research has shown that women engage with AA as much as men, become more involved with the 12-stepprogram, and derive similar benefit.
2. AA Works in a Way Similar to Formal Treatment
In 1990, the Institute of Medicine called for more research on how AA works. Since then, research has revealed that AA aids recovery through multiple mechanisms, many of which are also activated by professional behavioral treatments (Kelly J et al, Addict Res Theory 2009:17(3):236–259).
Most consistently and strongly, AA appears to work by helping people make positive changes in their social networks (eg, by dropping heavy drinkers/drug users and increasing abstainers/low risk drinkers), and by enhancing coping skills and self-efficacy for abstinence when encountering high-risk social situations (see for example, Kelly JF et al, Drug Alcohol Depend 2011;114(2–3):119–126).
Among more severely addicted people, AA also appears to work by enhancing spiritual practices, reducing depression, and increasing individuals’ confidence in their ability to cope with negative emotion (Kelly JF et al, Addiction 2012;107(2)289–299).
Thus, AA appears to work through diverse mechanisms and may work differently for different people. Stated another way: individuals may use AA differently, depending on their unique needs and challenges.
3. AA Participation Can Reduce Healthcare Costs
Addiction is a chronic condition requiring ongoing monitoring and clinical management (McLellan AT et al, JAMA 2000;284(13):1689–1695). Unfortunately, individuals’ access to professional resources is often limited by insurance or insufficient personal funds. In this context, MHOs are a valuable adjunct to professional treatment, as they can be attended for as long as necessary at no cost except for voluntary contributions.
Research has shown that involvement in 12-step MHOs can reduce the need for more costly treatments while simultaneously improving outcomes. A large multicenter study of over 1,700 patients found those treated in professional 12-step treatment went on to participate in community-based AA and NA meetings at a higher rate than those from professional cognitive behavioral therapy (CBT) programs, who relied more heavily on professional services.
This translated into a two-year savings of over $8,000 per patient among 12-step treated patients, without compromising outcomes. In fact, those treated in the 12-step treatment programs had one-third higher rates of abstinence across follow-up (Humphreys K & Moos R, Clin Exp Res 2001;25(5):711–716; Humphreys & Moos, Alcohol Clin Exp Res 2007;31(1):64–68).
4. Clinicians Can Facilitate Engagement With MHOs to Enhance Outcomes
Since AA and related organizations appear to be efficacious and cost-effective, the question arose as to how clinicians might best get patients involved in MHOs. The answer: TSF. A growing body of research on TSF has found it to be effective in several formats, including as a stand-alone treatment, as a brief intervention, or as part of, or following, another intervention (eg, CBT).
Project MATCH was a large randomized trial comparing three individually-delivered psychosocial treatments for alcohol use disorder—TSF, CBT, and Motivational Enhancement Therapy (MET)—that was funded by NIAAA. It included 1,726 patients from nine clinical sites across the US (Project Match Research Group, J Stud Alcohol 1997;58(1):7–29).
TSF was found to be as effective as the more empirically supported CBT and MET interventions at reducing the quantity and frequency of alcohol use post-treatment and at one- and three-year follow-ups. Moreover, TSF was superior to CBT and MET at increasing rates of continuous abstinence, such that 24 percent of the outpatients in the TSF condition were continuously abstinent at one year after treatment, compared with 15 percent and 14 percent in CBT and MET, respectively (Tonigan JS et al, Participation and involvement in Alcoholics Anonymous. In: Babor TF & Del Boca FK, eds. Treatment Matching in Alcoholism. New York: Cambridge University Press;2003:184–204).
Abstinence rates at three years continued to favor TSF, with 36 percet reporting complete abstinence, compared with 24 percent in CBT, and 27 percent in MET (Cooney N et al. Clinical and scientific implications of Project MATCH. In: Babor TF & Del Boca FK, eds. Treatment Matching in Alcoholism. New York: Cambridge University Press; 2003:222–237).
In light of findings from several such RCTs that demonstrated the efficacy of TSF, this therapy was added to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Practices and Programs (NREPP) in 2008.
5. AA and Similar MHOs Can Provide Recovery Support Over the Long Term
The chief strength of community MHOs, like AA, may lie in their ability to provide effective, easily accessible, free, and long-term recovery support that is responsive to undulating relapse risk (Kelly et al 2009, op.cit).
As national efforts progress toward improved efficiencies in healthcare, greater awareness of the important role MHOs and related professional interventionscan play as part of our overall response to addiction becomes increasingly important.
That said, AA and MHOs are only a part of the solution. AA is likely to resonate and benefit mostly those who have “moderate” to “severe” substance use disorder under DSM-5 (Kelly J & McCrady B, Recent Dev Alcohol 2008;18:321–346).
Because of the diverse recovery pathways and preferences of individuals seeking recovery from addiction, and the enormous public health burden associated with alcohol and drug problems, it is vital that we provide and support a broad array of MHO and other options that can support recovery.
The overwhelming majority of research has been conducted on AA. More research is needed on other MHOs, such as SMART Recovery, LifeRing, Celebrate Recovery, Women for Sobriety, Moderation Management, and others, so that more objective evidence is gathered on secular, religious, and non-abstinence-based AA alternatives (see the article "Alternatives to 12-Step Recovery" for more on these groups).