New Evidence That Alcoholics Anonymous Works

Free and open to all, AA may beat professional therapy.

Posted Jul 16, 2020

Nearly everyone has heard of Alcoholics Anonymous, the support groups available around the world, and the famous Twelve Steps. 

While Alcoholics Anonymous isn’t a sure bet, if you are aiming for abstinence, it’s currently the best therapy available, according to a new review for the prestigious Cochrane Library. The review concluded that 42 percent of AA participants are completely abstinent a year after they join, compared to 35 percent of people who receive a different kind of addiction therapy. AA had better results across groups—veterans, young and old, male or female.

“Twelve-step thinking has influenced most addiction treatment programs,” Keith Humphreys, a professor of psychiatry at Stanford who was part of the Cochrane team evaluating AA, told me in an email. Peer support is built into professional addiction treatment: About half of registered or licensed addiction counselors are people who are in recovery themselves. However, unlike AA members, they should have training in the standard therapies. Cognitive-behavioral therapy (CBT) focuses on identifying thought patterns that trigger the behavior you're trying to change. It is the most extensively studied kind of therapy and has scientific backing for many kinds of issues. Motivational enhancement therapy, as the name implies, focuses on getting you to take action—because you see how your life could be better. 

If those sound good to you and you want to participate in AA as well, go ahead. More than half of its members also seek other help, according to a 2014 AA survey. But Humphreys believes that AA alone may be fine.

Based on 27 rigorous randomized studies that compared the AA model to a different kind of therapy, covering more than 10,500 participants in all, he and two co-authors concluded that AA is your best bet for continuous abstinence over a year, two years and three. In one study, it was found to be 60 percent more effective than any other intervention or no intervention. None of the studies found AA to be less effective.

You’ll have plenty of company in AA. Open to all and free, AA now estimates that it has more than 2 million members.

AA has its roots in a religious experience, though you can interpret its "higher power" as you like. In 1934, Bill Wilson, a stockbroker known to drink two quarts a whiskey a day, checked into a hospital in New York City. He received a hallucinogen, belladonna, an experimental treatment, and the story goes, after calling out to God he saw a flash of light and felt an unfamiliar serenity. He was also in touch with a Christian organization called the Oxford Group. 

He had a crisis while on a trip to Akron, Ohio in 1935 for a shareholders' meeting and proxy fight. He lost. His first reaction was to seek out another drinker. He found Robert Smith, called "Dr. Bob" on the AA website, who had also been in contact with the Oxford Group. Together, they decided that their best chance lay in helping each other and other people with the same problem. They soon developed the famous 12 steps and their model spread around the globe.

Inspired by the Oxford Group, the founders included the term “God” or “higher power” in six of the 12 steps. In most meetings you’ll also hear the “Serenity Prayer,” which has been credited to the Protestant theologian Reinhold Niebuhr: “God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.” Spread by AA, this may be the only prayer ever to rival the Lord’s Prayer in popularity, notes the author of the Yale Book of Quotations.

One of the most famous early members was Charles Jackson, the writer-hero of Lost Weekend, the story of a four-day drinking bout that quickly inspired a Billy Wilder movie. In 1953, newly clean, he became a tireless speaker about alcoholism, crediting AA for saving him. In his most famous speech, in 1959, he scolds himself as “too self-absorbed, too self-infatuated,” blaming arrogance for his lapses and seeking humility and altruism as a cure. But Jackson is a sad example of losing the battle against addiction. He traded in alcohol for Seconal, and died from the drug while writing a sequel to Lost Weekend.

The American Medical Association named alcoholism a disease in 1956, but doctors could only offer detox. AA members—pledged to help others with their disease—began to visit hospital detox wards and invite patients to meetings.

So why don't more people go sober? The Cochrane study could be seen as a bad result for AA: the flip side of 42 percent being sober after a year is that most aren't. 

Some argue that AA only works for people who are highly motivated. The Cochrane study included solely randomized trials—the participants didn’t get to choose which treatment they received. In an AA group you join, more of the members will have chosen to be there, but not all: more than 10 percent of AA members have been ordered there by a judge. 

But the study also showed once again that fighting alcohol use disorder isn’t easy.

There are at least three obvious reasons for that.

Most of us can't steer completely away from triggers to drink. You see liquor advertising and waiters hand you a wine list. Your friends want to meet up at a bar. You may have to abandon your drinking friends if they won't join you elsewhere. Your spouse may still be boozing away. 

Your biology is probably working against you. Brain imaging studies suggest that people who develop addictions have fewer receptors for dopamine, a chemical that gives us pleasure. Children of people with alcohol use disorder are two to six times more likely than the general public to develop alcohol problems. Having a strong “head for liquor” is actually a bad sign: If you need more alcohol to feel the effects, you’re more likely to eventually develop problems.

Life changes and it gets rough. If you learned to drink to manage stress, at some point the stress will ramp up. You lose your job or your marriage crumbles and now it's much harder to stay away from the bar. If you used alcohol to manage depression, in the recovery period you'll have to deal directly with the depression and its consequences in your work and home life. Anti-depressants often don't work, or not quickly. 

AA isn't for everyone. You might need an anti-depressant or medication for cravings, and you can hit resistance in AA groups from people who think you need to be drug-free. AA also frowns on any attempt to drink moderately. Finally, some people overcome alcohol dependence on their own and if AA doesn't appeal to you, you shouldn't think you are doomed. But don’t kid yourself: if you’ve tried to quit and relapsed repeatedly you need help.

Who will you find in a meeting? If it’s typical of AA’s membership, according to its own 2014 survey, the participants will fall into four roughly equal groups: newbies sober a year or less, another group sober one to five years, another sober between five and 20 years, and 22 percent sober 20 years or more. If you’re new to AA, it might be inspiring to see so many who have made it work for decades. Remember that the drop-outs aren’t in the room. Over time, it’s important not to let that arrogance Jackson spoke of get the better of you. Be humble, rather than trying to lead the group or thinking you’re cured, one member explained. In short, trust the group and your higher power. “It’s a group conscience, bottom-up program,” he says.

A version of this post appears at Your Care Everywhere. 

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