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5 Things Science Taught Us About AA and 12-Step
The topic of Alcoholics Anonymous (AA) often provokes passionate debate. Over the years, proponents and critics have argued about such things as whether AA should be considered a treatment, a cult, or religion, and whether it is really helpful or harmful.
While opinions and discourse have remained intense, a body of rigorous scientific research has been accumulating that can help us answer the question of AA’s effectiveness as well as the effectiveness of 12-step based professional treatments designed to engage people suffering from addiction with community-based mutual-help organizations (MHOs) like AA.
Here are five things that science has taught us about AA and professional 12-step interventions:
- AA and other MHOs can help reduce the public health burden associated with alcohol and other drugs and can be studied empirically
Studying a peer-led MHO, like AA, scientifically has not been without challenges, particularly in terms of the “gold standard” of treatment research: the randomized controlled trial (RCT). The highly insulated context of an RCT runs counter to the way real-world AA is run. AA is attended anonymously and (usually) voluntarily and groups vary widely in size and content. Because AA is freely accessible, it can be seen as unethical to randomly assign some RCT participants to attend and prohibit the attendance of others.
Whether effectiveness or efficacy studies, results find that engaging with AA either alone or during and following professional treatment, can enhance outcomes by 10-20%, and results in higher rates of continuous abstinence.John F. KellyThese issues have led researchers to examine AA through other methods, such as through longitudinal effectiveness studies. Researchers have also examined the efficacy of professionally-delivered twelve-step facilitation (TSF) treatments using RCTs, which systematically encourage and facilitate AA attendance, relative to other treatments that neither encourage nor forbid attendance. In combination, this research has provided insight into the benefits of AA attendance in a way that has both scientific integrity and real-world relevance. Whether effectiveness or efficacy studies, results find that engaging with AA either alone or during and following professional treatment, can enhance outcomes by 10-20%, and results in higher rates of continuous abstinence.
- AA works through mechanisms similar to those operating in formal treatment
Over 20 years ago, 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 similar to those activated by professional behavioral treatments. AA appears to work by helping people make changes in their social networks (e.g., by dropping heavy drinkers/drug users and increasing abstainers/low risk drinkers) and by enhancing motivation, coping skills, and self-efficacy for abstinence when encountering high-risk social situations. Among more severely addicted people, AA also appears to work by enhancing spiritual/religious practices, reducing depression, and increasing individuals’ confidence in their ability to cope with anxiety/depression. Thus, AA appears to work through diverse mechanisms and may work differently for different people. Stated another way, different people may utilize various aspects of AA, depending on their unique needs and challenges.
- AA participation can reduce healthcare costs by reducing patients’ reliance on professional services without any detriment to outcomes, and may enhance outcomes
Addiction is a chronic illness that often requires long-term monitoring and management. Unfortunately, individuals’ access to professional resources is often limited to short periods by insurance or insufficient personal funds. MHOs are a valuable adjunct to treatment, as they can be attended for as long as necessary for free. Research has shown that AA participation reduces the need for more costly professional treatment while simultaneously improving outcomes. One study found that individuals who attended only AA had treatment costs that were 45% lower than individuals who attended outpatient treatment, at no detriment to their outcomes, and despite experiencing more drinking-related consequences to begin with.
- Clinicians can use specific strategies to increase patients’ participation in AA and thereby enhance treatment outcomes
AA has proven to be an effective and cost-effective recovery resource, so studies shifted to testing new TSF interventions, to determine effective strategies that enhance AA participation. TSF has been found effective in several formats, including as a stand-alone treatment, as a brief intervention, or as part of, or following, other interventions (e.g., CBT). In RCTs, such as the NIH-funded “Project MATCH” which included 1,726 patients, TSF was as effective as CBT and motivational enhancement therapy (MET) at reducing alcohol use post-treatment, and at one- and three-year follow-ups, and TSF was superior to CBT and MET at increasing rates of continuous abstinence. Similar findings have been demonstrated in other RCTs using various forms of TSF. TSF is now recognized as a “well supported treatment” by the American Psychological Association and by SAMHSA’s National Registry of Evidence-Based Practices and Programs.
- AA and similar MHOs can provide recovery support over the long-term, but more research is needed on non-12-step MHOs
As national efforts focus on more cost-efficient health care, greater awareness of the important role MHOs and related professional interventions can play as part of our overall addiction response becomes increasingly vital.John F. KellyThe 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. As national efforts focus on more cost-efficient health care, greater awareness of the important role MHOs and related professional interventions can play as part of our overall addiction response becomes increasingly vital. Also, because of the diverse pathways and preferences of individuals seeking recovery, and the enormous public health burden associated with alcohol and other drug use, it is vital that we provide and support an array of MHOs and other options that support recovery. The majority of research has been conducted on AA. More research needs to focus on other MHOs such as, SMART Recovery, LifeRing, and others so that more objective evidence is gathered regarding these AA alternatives..