12-Step Skepticism and The Evidence

Recently, I have seen yet another wave of anti-12 step promotion via various digital formats and blogs. The various talking point involve, “AA is not evidence-based”,”AA has incredibly low success rates,” and a variety of cultural criticisms and safety warnings. Time and time again I run across people who quite suddenly demand that I offer evidence of AA, when I speak affirmatively about it. As such, I have decided to assemble, once again, a solid collection of openly accessible articles that I generally consider the evidence base for 12-Step efficacy.

I usually take the time to qualify the challenges of researching a self-selecting group, with anonymous members, and the ethics that prevent RCT study generally. I also try to outline some of the statistical maneuvering that is used to get around this. For the AA skeptic, the minute you begin to explain these things, there is a, “Tsk, tsk! Sounds like you are trying to make excuses!” So, for the purposes here, I will simply let the authors of the various articles speak for themselves. All of these article are openly accessible and do not exist behind paywalls.

I am also not going to break down these articles and explain them one by one. This is intentional and for a very simple reason- All too often, someone will demand evidence of AA efficacy, who then don’t bother to read the article offered in any serious way. Why? The answer is because they are not truly interested in the evidence for AA. They are interested in confirming their own biases to prove or disprove the 12-Steps. By not breaking down these articles, I am filtering out those types unwilling or uninterested in learning about 12-Step research. Additionally, we are all adults and we can all do our own homework.

Let’s Begin

Estimating the efficacy of Alcoholics Anonymous without self-selection bias: An instrumental variables re-analysis of randomized clinical trials https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4285560/

Keith Humphreys, Ph.D., Janet C. Blodgett, M.Sc., and Todd H. Wagner, Ph.D.

MECHANISMS OF BEHAVIOR CHANGE IN 12-STEP APPROACHES TO RECOVERY IN YOUNG ADULTS. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6224158/

Kelly JF1Bergman BG1Fallah-Sohy N1.

Do 12-step meeting attendance trajectories over 9 years predict abstinence? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3320672/

Jane Witbrodt, M.P.H,*,1,4Jennifer Mertens, Ph.D.,2Lee Ann Kaskutas, Dr.P.H.,1Jason Bond, Ph.D.,1Felicia Chi, M.P.H.,2 and Constance Weisner, Dr.P.H., M.S.W.2,3

Alcoholics Anonymous Effectiveness: Faith Meets Science https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2746426/?wvsessionid=wvf67cf635b6324d188696252499c8771f

Lee Ann Kaskutas, Dr.P.H.

Is Alcoholics Anonymous religious, spiritual, neither? Findings from 25 years of mechanisms of behavior change research https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5385165/

John F. Kelly, PhD

Mechanisms of Behavior Change in Alcoholics Anonymous: Does AA lead to better alcohol use outcomes by reducing depression symptoms? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3320672/

John F. KellyRobert L. StoutMolly MagillJ. Scott Tonigan, and Maria E. Pagano

Spirituality in Recovery: A Lagged Mediational Analysis of Alcoholics Anonymous’ Principal Theoretical Mechanism of Behavior Change https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3117904/

John F. Kelly, Ph.D., Robert L. Stout, Ph.D., Molly Magill, Ph.D., J. Scott Tonigan, Ph.D., and Maria E. Pagano, Ph.D.

Alcoholics Anonymous and other 12‐step programs for alcohol use disorder https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6486310/

John F Kelly,Keith Humphreys, and Marica Ferri

Recovery benefits of the “therapeutic alliance” among 12-step mutual-help organization attendees and their sponsors https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5331924/

John F. Kelly,*M. Claire Greene, and Brandon G. Bergman

USING PROPENSITY SCORES TO ADJUST FOR SELECTION BIAS WHEN ASSESSING THE EFFECTIVENESS OF ALCOHOLICS ANONYMOUS IN OBSERVATIONAL STUDIES https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2713354/

Yu Ye1 and Lee Ann Kaskutas1,2

A novel application of propensity score matching to estimate Alcoholics Anonymous’ effect on drinking outcomes https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3549307/

Stephen Magura,a,**Joseph McKean,bScott Kosten,b and J. Scott Toniganc

Lifetime Alcoholics Anonymous Attendance as a Predictor of Spiritual Gains in the Relapse Replication and Extension Project (RREP) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5293659/

J. Scott ToniganElizabeth A. McCallionTessa Frohe, and Matthew R. Pearson

My Thoughts

Undoubtedly someone, somewhere, will parade this post out and decry it’s contents. I just want to ensure that if this is the manner in which you came across this post, then do yourself a favor and read the above articles.

Additionally, others will say there are other or better articles out there: There are literally thousands of peer-reviewed research articles on AA. I chose these articles because I often refer back to them in my own work, and because they are accessible to the general public. I encourage folks to respond in the comment section and link additional articles they may feel warrant additional consideration. Please make these articles available to the public, if paywalled, by using a Google Docs Folder and providing a link to it.

You’ll notice many of these articles go back quite a few years. This is a source of frustration to me: open, publicly accessible research on AA has been available for over a decade now. Anyone can find research on AA, and yet, even among professionals, researchers, and clinicians, I still hear the blanket statement “AA is not evidence-based.” These statements are usually accompanied by the assertion that anyone who defends AA (even from a research perspective), is somehow supporting “folk wisdom,” and is merely being “reactionary” and “cult-like.” My personal recovery experience does involve AA, which worked well for me. But this isn’t why I defend AA. Scientifically, I defend AA because there is good evidence to do so. Period.

The Questions Everyone Wants to Know

1.
Q: Is AA for everyone?
A: Absolutely not. Everyone should explore if it is right for them. Fortunately there is an AA meeting going on nearby, right now. It is free, and requires no commitment to check it out. We should encourage everyone to find out if it is right for them.

2.
Q: Should treatment be more than AA.
A: Yes and No. 12-Step groups are the only guaranteed resource post treatment. Virtually every client will be able to access a 12-step group, no matter where they go. They should be oriented to the program during treatment. Additionally, TSF is, in fact, an evidence-based modality. And finally, ALL treatment of any positive repute should do MORE than simply teach the steps. If they don’t, then I would question their model (and the cost, since you can literally get the same thing for free.)

3.
Q: What about “the God thing.”
A: See number 1

4.
Q: What about NA and their beef with MAT?
A: If you are on medication, I would suggest you try out several other meetings, like CA, and OAA which has no such qualms. Also, there are *some* 12-Step meetings specifically catered to those on pharmacotherapy. Look around, offer these to your clients if you’re a clinician.

5.
Q: What about rape culture, patriarchy, and WASP criticisms?
A: Re: Rape Culture- There have been incidences. This does not mean that the rooms are any more dangerous than anywhere else. These incidences have also been greatly magnified by the internet, and by the anti-12 Step proponents. Though people in the rooms ALL have checkered pasts. Part of the value of the rooms is the fact they accept everyone as is and makes no judgement about an individual’s past. The more dangerous element is 13th stepping which happens to BOTH men and women. This is why it is suggested not to date for a while, and you should probably not date people from the rooms. Part of the problem here is that early relationships in recovery excite the brain along the same reward pathways as substances. Clients should be educated about this and sponsors should discourage dating, not because the literature says so, but because it is part of being responsible to the community. If one is still uncomfortable, take a friend to an open meeting to get the feel of the group.

Meetings vary greatly by regions, towns, even parts of the country and across the various groups (NA, AA, CA) etc. One will have to deliberately try out several meetings in order to make an informed decision about whether or not 12-step groups are for them.

Re: Patriarchy- 12-steps, particularly AA, use the Big Book. It is a historical document, the language and format are heavily gendered. You will have to decide for yourself if this is a barrier to attending. Other groups may use more modern literature.

Re: WASP- Some groups are heavily populated by white people. However, this varies a lot. There is no definitive way to determine whether one will feel comfortable until they try out a few different meeting places and groups. It is not so much an ethnocentric group, as it is a class-centric group generally geared toward working and middle-class people. The highly educated may struggle, those with cognitive challenges may struggle, and (surprisingly) those who are highly religious may struggle. Still, none of these are bars to engagement.

Changes I Would Personally Make to 12-Step Groups

Before someone says “Yeah, but, what about…” I will say this:

NO: People should not be mandated to 12-Step groups. It isn’t good for the dynamics of a self-selecting community to have people forced into these groups. I would change this. Asking for attendance cards to sign at the BEGINNING of the meeting, and letting the people who do not want to be there go on their way is probably the best way to handle this.

NO: I don’t agree with NA’s ban on the participation level of people on medication. I believe it violates the traditions. NA does NOT speak for the whole of 12-step members. Particularly other fellowships like AA and CA. The great thing about 12-Step groups is that you can find other groups if you do not like a particular one.

YES: The 12-Steps are hard, and they may look intimidating for a variety of reasons. However, each step builds on the last one. And you do not work them alone, or without support from the group. Trust this process.

YES: If you have significant trauma, co-occurrence, or a history of abuse, you should also be engaged in therapy. The steps are rigorous, and they stir up a lot of uncomfortability. You should know this ahead of time. The steps ARE NOT therapy. They are designed to help you overcome a SEVERE issue with substances.

In Closing
12-step communities offer tremendous benefit to individuals and to local communities. The benefits far outweigh any negatives. You will need an open mind, and multiple exposures to groups and such exposure should be encouraged by clinicians. Taking someone’s word for it, or not going because of something you read on the internet is probably not going to provide you with enough experience. You will have to see for yourself. But, the evidence that it will help, is quite good, and the likelihood you will make life-long friends is high. Do not let prejudice stand in the way of finding out for yourself what it is all about. Although, to some degree, 12-step groups are a reflection of their collective members, individual members are not always healthy people. It helps to keep this in mind. The person in the front row who says something offensive may be on day 1 of their journey. It may not reflect the group as a whole, and definitely not indicate the value of 12-Steps as a whole. “Principles before personalities” is the key. Tolerance is needed and should be cultivated by anyone who attends on a regular basis. It is one of the values of recovery.

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5 thoughts on “12-Step Skepticism and The Evidence

  1. Thanks for the post.

    This brings to mind a bunch of old posts. Here are a few:

    On the exaggeration of the hegemony of 12 step in treatment programs

    On the effectiveness of mutual aid, whatever the followship

    On the flawed and frequently misunderstood and misrepresented 2006 Cochrane Review

    DJ Mac on bias against 12 step groups

    Finally, I disagree with Austin’s response to question 4. I respect NA’s efforts to work its way through how to handle people who wish to be members and are on opioid agonist treatments. I think they are working through these questions, and without all the external pressure individual groups might actually be more likely to experiment with more inclusive approaches. I also question the standing of professionals to call-out a free self-organized fellowship and believe professionals should engage in the hard work of helping opioid agonist patients organize to develop similar social support. (This is actually a goal of mine for the coming year.)

  2. I find it quite interesting that you spoke such misguided information about NA and their “beef” with MAT, especially since you spent ample time speaking about research & adults doing their homework. NA has no opinion on MAT, let alone any “beef” with any way someone chooses to stop using drugs. I would recommend you visit http://www.na.org and read any of their literature regarding this topic before espousing an opinion as if it is evidence based. Other than this misrepresentation, the article & links were appreciated, including those from the additional post.

    1. Craig, I actually agree with you. The statements by NA make it clear that it is an “outside issue” and that NA has no opinion on the matter. Which is the official position of all groups and rightly so. These are medical issues. I think the general issue here is the limiting of people on medication in their role. This is based on the assumption that those on medication are not sober. We can debate that point back and forth. But that misses the greater point:

      This particular position by NA is being touted by the Anti-12-step proponents as a chief reason why the 12-steps should be dismantled. The validity of that point isn’t really what’s in question- the fact that it provides anti-12-step ammunition for propaganda is something I think warrants a review. The other issue is this: NA’s limited participation for people on medication is being extrapolated across all of 12-steps as evidence that the 12-Steps are anti-medication. So the actions of NA are affecting other anonymous groups. I think this qualifies as being drawn into a controversy, which 12-step groups particularly try to avoid.

      Whatever the rationale, 12-Step groups are built on their ability to accept anyone who walks in the door and to make those who walk in the door, regardless of condition, to feel welcome. I fully understand both sides of the argument. But, at least to me, it seems better to err on the side of acceptance of the medicated member. There were many parallels with the rise of SSRIs and anxiety medication. My hope is that for all 12-step communities, MAT becomes as much of a true “non-issue” as other medications. So much so that no stipulations are needed.

      At any rate, these are just my opinions.

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