The Case for Alcoholics Anonymous: It Works Even if the Science Is Lacking
Susan Notes: A newly published review of addiction-treatment research delivers a verdict that is being interpreted as highly critical of the 12-step model of Alcoholics Anonymous, citing "lack of experimental studies."
The writer notes that What it actually means is that the pursuit of evidence-based medicine sometimes produces conclusions and headlines that are misleading. That untold multitudes of problem drinkers have become abstinent after attending A.A. meetings is undisputed. Also undisputed is that anyone who follows the A.A. recommendation of abstinence will never again experience drinking problems.
We can only hope that one day education writers will become enlightened enough to see the federal government's determination to allow only "evidence-based" materials in the classroom in a similar way.
By Kevin Helliker
A newly published review of addiction-treatment research delivers a verdict that is being interpreted as highly critical of the 12-step model of Alcoholics Anonymous.
"No experimental studies unequivocally demonstrated the effectiveness of A.A. or (professional 12-step therapy) for reducing alcohol dependence or problems," concluded a group of Italian researchers in a July review in the prestigious Cochrane Library. The purpose of the study was to compare the efficacy of A.A. and professional treatment based on A.A. with other types of alcohol therapies and interventions. The study concluded that A.A. and A.A.-based therapies were no more or less effective than the alternatives, and that more and better studies of A.A. and 12-step therapy are needed.
News coverage was immediate. "Review Sees No Advantage to 12-Step Programs," read the headline in a national newspaper.
Could this mean that A.A., the world-wide fellowship of recovering alcoholics, doesn't work?
What it actually means is that the pursuit of evidence-based medicine sometimes produces conclusions and headlines that are misleading. That untold multitudes of problem drinkers have become abstinent after attending A.A. meetings is undisputed. Also undisputed is that anyone who follows the A.A. recommendation of abstinence will never again experience drinking problems.
The Cochrane conclusion indicates that A.A. hasn't been subjected to the gold standard of medical experiments, the double-blind randomized clinical trial. As a result, no scientific proof exists that A.A. causes its members to quit drinking, that they wouldn't quit eventually on their own or that an alternative might not work just as well.
It is hardly scandalous that A.A. hasn't undergone the most rigorous of scientific testing. Evidence-based medicine is designed to root out false marketing claims and unnecessary costs. A.A. makes no marketing claims and charges no fees. Instead of being handed scientific literature, newcomers to A.A. hear existing members tell how they used the program to get sober. Evidence-based medicine is also designed to compare treatments. An A.A. spokesman in New York says, "We're not in competition with anybody. We're not saying we're better than anybody else. We don't recruit members, and there are no dues or fees for A.A. membership."
A.A. doesn't comment on published research or public criticism, including from addiction specialists or other treatment providers who might view A.A. as competition. This no-comment policy makes A.A. an easy target. A Penn & Teller documentary, televised in 2004 and viewable on the Web, characterizes A.A. as a marketing and financial fraud -- without mentioning that A.A. charges no fees. Subsisting on the sale of literature and donations, A.A. is a nonprofit that in 2005 reported total revenue of $13.2 million and total expenses of $12.9 million.
Many problem drinkers quit with no help. And for those who fail at that, differing addiction treatments tend to succeed at similar rates.
Founded in 1935, A.A. is a decentralized collection of nearly 53,000 groups in the U.S. alone, each autonomous and without any membership list, which would make difficult any effort to conduct a double-blind randomized clinical trial. Such a trial could raise ethical questions if, for instance, a newcomer were steered to an alternative treatment -- including possibly a control group receiving no treatment at all.
A multitude of studies show that A.A. attendance is associated with reduced drinking and higher social functioning. Addiction specialists say these benefits likely apply to newer self-help groups such as Smart Recovery, Secular Organizations for Sobriety and Women for Sobriety.
Unlike randomized clinical trials, associative studies don't prove cause, but are often treated as powerful evidence. For example, although no studies prove that moderate drinking enhances health, a wealth of highly publicized data show that a drink or two a day is associated with reduced rates of cardiovascular disease, among other benefits.
Questions about the efficacy of A.A. arise in part because the treatment industry often immerses its patients -- at a cost -- in the same 12 steps that A.A. introduces free. If professionals are charging for what amounts to an introduction to the A.A. model, experts say, there ought to be evidence of efficacy.
Some experts say the demand for efficacy data on A.A. reflects disbelief among professional therapists that their services are no more effective than a fellowship of recovering drunks. But Marica Ferri, lead author of the Cochrane study, says, "I do not distrust A.A."
Following professional therapy of any sort, A.A. attendance is associated with better outcomes, studies have shown. A year-2000 Journal of Studies on Alcohol study of 466 problem drinkers found that for those who attended A.A. following professional treatment, the three-year abstinence rate doubled, to more than 50%.
Professional therapy is often necessary because it gives the patient a chance to speak in private, and because it allows for the diagnosis of co-existing disorders such as depression and anxiety, which are common in alcoholics, particularly women.
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