Don’t Force AA

[Alcoholic Anonymous] research tends to come to wildly divergent conclusions, often depending on an investigator’s biases. The group’s “cure rate” has been estimated at anywhere from 75 percent to 5 percent, extremes that seem far-fetched. Even the most widely cited (and carefully conducted) studies are often marred by obvious flaws. A 1999 meta-analysis of 21 existing studies, for example, concluded that AA members actually fared worse than drinkers who received no treatment at all. The authors acknowledged, however, that many of the subjects were coerced into attending AA by court order. Such forced attendees have little shot at benefiting from any sort of therapy—it’s widely agreed that a sincere desire to stop drinking is a mandatory prerequisite for getting sober.

Yet a growing body of evidence suggests that while AA is certainly no miracle cure, people who become deeply involved in the program usually do well over the long haul. In a 2006 study, for example, two Stanford psychiatrists chronicled the fates of 628 alcoholics they managed to track over a 16-year period. They concluded that subjects who attended AA meetings frequently were more likely to be sober than those who merely dabbled in the organization. … “I’ve been involved in a couple of meta-analyses of AA, which collapse the findings across many studies,” Tonigan says. “They generally all come to the same conclusion, which is that AA is beneficial for many but not all individuals, and that the benefit is modest but significant.” …

That statement is also supported by the results of a landmark study that examined how the steps perform when taught in clinical settings as opposed to church basements. Between 1989 and 1997, a multisite study called Project Match randomly assigned more than 1,700 alcoholics to one of three popular therapies used at professional treatment centers. The first was called 12-step facilitation, in which a licensed therapist guides patients through Bill Wilson’s method. The second was cognitive behavioral therapy, which trains alcoholics to identify the situations that spur them to drink, so they can avoid tempting circumstances. And the last was motivational enhancement therapy, a one-on-one interviewing process designed to sharpen a person’s reasons for getting sober. Project Match ultimately concluded that all three of these therapies were more or less equally effective at reducing alcohol intake among subjects. (more)

So apparently law makes alcoholics worse off by forcing them into AA.  And none of the above evidence shows AA is actually helpful to voluntary alcoholics.  More on Project Match.

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  • Matthew

    Following your recommendation to read the classics, everyone should read Infinite Jest for a great portrayal of (among other things) the AA program.

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  • http://blog.greenideas.com botogol

    I don’t understand how it is constitutional to force people into a religious organisation. Don’t you have an Amendment about that?

    here are the 12 steps in AA
    – We admitted we were powerless over alcohol – that our lives had become unmanageable.
    – Came to believe that a Power greater than ourselves could restore us to sanity.
    – Made a decision to turn our will and our lives over to the care of God as we understood Him.
    – Made a searching and fearless moral inventory of ourselves.
    – Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
    – Were entirely ready to have God remove all these defects of character.
    – Humbly asked Him to remove our shortcomings.
    – Made a list of all persons we had harmed, and became willing to make amends to them all.
    – Made direct amends to such people wherever possible, except when to do so would injure them or others.
    – Continued to take personal inventory and when we were wrong promptly admitted it.
    – Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
    – Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

  • http://www.phoenixism.net An Unmarried Man

    Court-ordered AA attendance is a farce. People attending meetings as part of a sentence are often viewed with thinly-veiled contemptuousness by attendees who choose to attend of their own free will. The anonymous nature of AA (its trademark) does not bode well for a symbiotic working relationship with State and DMV bureaucracies. The cards which the court gives you that must be (in theory) signed each time you attend a meeting as “proof” is a figment of the honor system. Countless court victims forge signatures without ever going to a single AA meeting. And there is absolutely no way for the court to disprove or dispute the signatures since there is no formally recorded roster of AA meeting participants.

    I found AA distasteful and unhelpful. Groupthink cultism where the KoolAid comes in styrofoam cups and cliques form as easily as any high school. Any data pointing to AA’s rate of “cure” is due to the ubiquitous organization’s presence as the “go-to center” for those drunks who are willingly seeking help. I have no doubt that court-ordered attendees (essentially captive members) fare less well.

  • http://kazart.blogspot.com Mike

    AA is what it is, it is certainly not AA’s fault or idea that courts order people to attend. People running AA meetings debate among themselves whether they should even sign-off on court-ordered attendees showing up. I expect most of them do and this makes sense to me, why punish those ordered by the court to show up who are unwilling to take the trivially easy step of just signing the sheet themselves?

    I am absolutely a fan of scientific study on whether and/or how AA may be effective and how effective, and for whom. At the same time, I know so many people who were addicted to meth, coke, and of course alcohol, who have been clean for years, more than a decade in most cases I know about, who go to AA regularly. I think it is important to keep the rationalist cart behind the rationalist horse: there is PLENTY of reason to believe unambiguously that AA has real value to people who succeed at being sober. The issue in testing is not primarily does it have any value, but rather can we discover in an unambiguous way the conditions under which it has value, and perhaps discover something about the nature of the value it has.

  • lemmy caution

    So apparently law makes alcoholics worse off by forcing them into AA.

    I don’t think that this is true. People court ordered to go to AA are going to be a much different population than the drinker controls who received no treatment at all.

  • http://www.nancybuttons.com Nancy Lebovitz

    Sober for Good is the result of interviews with people who’ve solved their drinking problems. AA works well for some, but so do a number of other approaches.

    IIRC, the only things all the people who succeeded had in common was at least a year without alcohol (a few were able to drink moderately after that) and attention to the ways that not drinking made their lives better.

  • noematic

    Court ordered mediation can suffer an analogous problem – the parties are so entrenched in their position that they cannot possible mediate in ‘good faith’ – the very premise of the mediation system. The court forcing them to do so often renders the process a costly exercise in frustration. Parties can come out of it angrier than previously and more determined to see their matter go ‘all the way,’ resulting in a huge burden on court resources.

  • Dave

    You left out the very interesting remarks immediately following that quote from the WIRED article:

    “Project Match ultimately concluded that all three of these therapies were more or less equally effective at reducing alcohol intake among subjects. But 12-step facilitation clearly beat the competition in two important respects: It was more effective for alcoholics without other psychiatric problems, and it did a better job of inspiring total abstinence as opposed to a mere reduction in drinking. The steps, in other words, actually worked slightly better than therapies of more recent vintage, which were devised by medical professionals rather than an alcoholic stockbroker.

    AA is still far from ideal. The sad fact remains that the program’s failures vastly outnumber its success stories. According to Tonigan, upwards of 70 percent of people who pass through AA will never make it to their one-year anniversary, and relapse is common even among regular attendees.”

    Link to the full article: http://www.wired.com/magazine/2010/06/ff_alcoholics_anonymous/all/1

  • y81

    There may be several different approaches that work, but note that AA is MUCH cheaper than the other approaches mentioned, being essentially free. Attendees are not charged, and even if the full cost were evaluated, the marginal cost of a church basement is almost zero, whereas the marginal cost of a trained therapist is something like $100 per hour.

  • NA Survivor

    It may be cheaper, but that still doesn’t improve its effectiveness for everyone. For many it is actually a net negative. I speak from experience.

    The ultimate factor comes down to the individual and their history and mindset. “You gotta believe!” is a wonderful thing, but it can’t be forced. Treatment needs to be geared toward the individual and unfortunately this is imprecise and prone to error.

    It doesn’t mean AA shouldn’t be heavily accounted for in education for recovering people, but it shouldn’t be looked at as a “if it doesn’t work for you, it’s because the program is fine and you are broken” thing.

  • AA-reject

    As an alcoholic (or maybe a former one, or recovering, I don’t know) and a biomedical scientist, I’ve researched the issue exhaustively – both on practical and theoretical levels. And the deal is, no “conventional” alcoholism treatment truly works (that’s what Project MATCH actually shows). What we have are several approaches that are somewhat helpful to a small subset of patients – but we can neither predict that subset nor predict the degree of treatment effectiveness among that subset. In that regard, it’s a lot like many of the cancers today. Unlike cancer, the issue is heavily contaminated with a lot of lies, moral judgments and special financial interests. It’s all a tangled mess. Coercion into AA is one of the ugly signs of it. The flourishing rehab business is another (excellent profits there!)

    For those unfortunate ones who ended up being truly and badly dependent (that is a minority of heavy abusers), the hope appears to lie with pharmaceuticals targeted on the basis of genotype. For now, we have a bunch of drugs that barely do anything and one drug that maybe does a lot but breaks the existing paradigm and as such is a heresy to the most medical professionals. I am a user of one and I’d like to plug it here for any alcoholics around here. It’s called “The Sinclair Method”. Look it up on Wikipedia and on the user forum:
    http://www.thesinclairmethod.net/community/
    (Warning: to the most scientifically/rationally inclined folks, the user forum gives first an impression of yet another quackery that lots of desperate people want to believe in. That is not exactly correct. There is some solid but very, very limited science behind it and once one reads on TSM and its users’ experiences enough, it is more or less clear that there is probably a lot more to it than a mere placebo.)

    The biggest trouble with TSM is that, even when it works, it requires a lifetime commitment to taking pill (unless one commits to 100% sobreity). Addiction can physically remodel brain. Reversing such a thing is difficult or impossible. The alternative is to compensate for these changes in brain function with drugs. In my case, I went from 1.5 liters of gin/vodka/brandy every night for almost ten years to an average of two bottles of beer or a glass of wine per day. And it’s 100% effortless by now. Took 8 months of self-medication with TSM to get where I am now from where just about everything else under the sun totally failed. A rehab followed by AA was particularly dreadful experience.

  • AA-reject

    “1.5 liters of gin/vodka/brandy every night”

    That’s wrong. Poor editing. 1.5L of red wine or 0.75L of hard liquor.

  • Baskerville Boozehound

    A series of American appellate court decisions have ruled that it’s not constitutional if they are able to raise a religious objection to the 12 step program, but there are several problems with this. AA’s religion is so vague that it might be difficult to raise an objection unless one claims to be an atheist. In order to do this, it might be necessary to show a pattern of consistent unbelief. “I became an atheist after I got arrested” might not work. Defendants who raise such a claim might have to appeal to prevail, even though the law is relatively clear. In addition, they risk causing friction with judges and probation officers, who are generally anti-atheist and pro-AA, and who are also in a position to require, as an alternative, a secular treatment program which might be much more expensive than AA. In other words, beating AA probably won’t get you out of some sort of court-ordered treatment.

  • http://duischooltruth.wordpress.com JR Harris

    I have started a blog which explains why some people are sent to AA meetings because a DUI. It may be of use to understand why they are sent to AA in many cases.

    duischooltruth.wordpress.com