More Revealed

AA: Cult or Cure?

How Effective Is AA?

"Of alcoholics who came to A.A. and really tried, 50 percent got sober at once and remained that way; 25 percent sobered up after some relapses . . ."

—Bill Wilson in Alcoholics Anonymous, p. xx

"Everything you know is wrong."

—Firesign Theater
 

The Problem of Definitions

Is AA an effective treatment for alcoholism? That seemingly simple question is far more difficult to answer than one would expect. A major problem is the difficulty of defining the terms "alcoholism" and "alcoholic." Since the terms were invented over 100 years ago, a great variety of defi­nitions have been offered, and there is still no uniformity of opinion among the "experts" about what constitutes alcoholism nor about what constitutes an alcoholic. The safest thing that can be said is that definitions are largely arbitrary and can (and do) change over time. For example, in the "Big Book," Bill Wilson mentions "a certain type of hard drinker. He may have the habit badly enough to gradually impair him physically and mentally. It may cause him to die a few years before his time." Wilson goes on to say that this person is not a real alcoholic because he can learn to "stop or moderate."i Needless to say, virtually all AA members, as well as a very large majority of alcoholism professionals, would now label such a person "alcoholic."

Another indication of the difficulties involved in defining the word "alcoholic" can be seen in the wildly varying estimates of the number of alcoholics in the United States. In the 1986 best seller, The Courage to Change, Dennis Wholely estimated that there were 20 million American alcoholics at that time (in other words, over 11% of the adult population). Wholely's figure is twice as high as the estimate of 10 million which is found in many professional journal articles and alcoholism reference texts published in the 1970s and early 1980s, and which is still occasionally cited. A facts sheet circulated by the NCADD, which I obtained in 1991, estimates that there are 12.1 million heavy drinkers exhibiting one or more of the signs of alcoholism; a 1997 NCADD facts sheet lists 13.9 million alcoholics. And if you accept the commonly cited figure that 10% of American adults are alcoholics, you arrive at a current figure of 19.7 million.

The primary reason why these estimates vary so greatly is that "alcoholism" is an elusive concept with several defining factors, the limits of which are seemingly arbitrary, with the exceptions of physical damage caused by alcohol consumption, physical dependence (habituation to the extent that physical withdrawal symptoms appear if alcohol consumption ceases), and tolerance (the need to drink a larger amount than the average social drinker in order to reach a similar state of intoxication). In addition to these physical symptoms, commonly cited defining factors include amount consumed per day, number of drinking days per month, number of days intoxicated (according to some number-of-drinks benchmark), legal problems (e.g., DUIs), employment problems, and family/relationship problems. Obviously, any definition based upon such factors must be imprecise and at least somewhat arbitrary. For example, what is the precise amount of alcohol consumption which separates the alcoholic from the social drinker? And what relation does alcohol consumption have to the other defining variables? Would someone who drank 7 ounces of alcohol per day but who had relatively minor problems in other areas be defined as an alcoholic? Would someone who drank only half that amount but had severe problems in other areas be defined as an alcoholic? It's difficult to view answers to such questions as anything other than arbitrary.

For this reason, researchers in recent years have begun to use the somewhat more precise terms "alcohol dependence" and "alcohol abuse" instead of "alcoholism." "Alcohol dependence" refers to the presence of physical dependence and/or tolerance (as well as, almost invariably, ad­ditional problems), while "alcohol abuse" refers to the presence (and magni­tude) of at least a certain number of the other defining factors. This distinc­tion represents a definite step forward, though definitions of "alcohol abuse" are still somewhat arbitrary, and almost certainly will remain so. But these more precise definitions do allow for more precise estimates.
 

How Many Alcohol Abusers?


The figures commonly cited for the number of alcohol-dependent persons in the U.S. and Canada are fairly uniform, with most estimates that I've seen being in the 5% range. A 1995 National Institute on Alcohol Abuse and Alcoholism (NIAAA) news release estimates the percentage of alcohol-dependent persons in the U.S. at 4.38%,ii while the Addiction Research Foundation (ARF), based in Toronto, estimated alcohol de­pendence among the local population at 5.3%.iii Estimates of the number of alcohol abusers vary more widely, with the NIAAA estimate being that only 3.03% of the population are alcohol abusers, while the ARF estimates the number of alcohol abusers at 5%.
 

Characteristics of AA Members


One thing that is certain is that the typical AA member today is different than the typical AA member in 1940. In the early days of AA, members were primarily "low-bottom" alcoholics who had been hospitalized for their drinking problems, and whose drinking had had devastating effects on their lives. At present, at least a large minority, perhaps a majority, of AA members are "high-bottom" problem drinkers who were never physically dependent upon nor tolerant of alcohol and who still functioned reasonably well socially and economically at the time they quit drinking. Thus, a well­designed study of the effectiveness of AA today would very probably yield a different result than a similar study conducted 50 years ago, simply because of the differences in the makeup of both AA's membership and the much-expanded pool of drinkers from which it now draws.

With the trend toward inclusion of those with shorter and shorter and ever-less-serious drinking problems in AA, the composition of AA's member­ship will very likely continue to change for some time to come. (According to AA's 1996 membership survey, there are now roughly 12,000 teenage AA members. In the 1930s, AA's early members would have considered the idea of teenage "alcoholics" ludicrou

s.) One question which arises from this is what percentage of AA's members are now "real alcoholics"? A compli­cating factor is that at least some disturbed persons whose primary problems are almost certainly not alcohol related attend AA because it's an easy way to meet their social needs. A further complicating factor is that a very high percentage of AA's current members, almost certainly at least a third, and probably more than 40%, are coerced into membership.iv
 

Biasing Factors


The changing makeup of AA's membership is, however, a minor problem compared with several others. The most important problem is that in attempting to gauge the effectiveness of AA it's very difficult to tell if you're gauging results due to the AA program or results due to the characteristics of AA's membership. There are several factors predictive of a positive outcome to alcoholism treatment—motivation, middle class status, marital stability, employment, relatively mild and short-term problems with alcohol, and absence of serious mental disturbance being probably the most important—with most being found in higher-than-average percentages (for problem drinkers) in AA's membership; and it should be noted that these factors are predetermining factors which were operative in a great many AA members before they joined AA. An indication of the importance of these predictive factors is found in Frederick Baekeland's evaluation of different varieties of alcoholism treatment. Baekeland compared studies of four group therapy programs serving high socioeconomic status (SES—an important prognosticator of treatment outcome) patients with studies of four group therapy programs serving skid row alcoholics and other low SES patients. The improvement rates of the programs serving skid row alcoholics were only 18%, 7.9%, 2% and 0%, while the improvement rates of the programs serving high SES patients were 32.4%, 46.4%, 55.8%, and 68%.v

As is almost universally recognized in treatment literature, the most important favorable prognosticator is "motivation." Like most cliches, the truism that "once you admit you have a problem, it's half-licked," seems to have a basis in fact. Simply showing up at an AA meeting implies that an individual recognizes that s/he has a problem, and in itself this self-selection seems predictive of a successful outcome. Further, certain aspects of AA are so unpleasant—especially the religiosity, anti-intellectuality, and the gas chamber-like, tobacco smoke-filled atmosphere at many meetings—that continued attendance in itself implies a high degree of motivation, at least for nonreligious and critically minded (not to mention nonsmoking) members.
 

Estimates of AA's Effectiveness


Biasing factors, such as "motivation," are a serious problem, but it does seem possible to draw at least tentative conclusions about the effectiveness of Alcoholics Anonymous. A good starting point is AA's most recently announced membership figures. As of January 1, 1996, AA claimed 1.251 million members in the U.S. and Canada,vi while there were approximately 218 million individuals 18 years of age and over in the two countries at that time. Taking the ARF estimates of the percentages of alcohol abusers and alcohol-dependent persons and multiplying them by total population figures yields a total of roughly 22 million individuals with alcohol problems in 1996; doing the same calculations using the NIAAA percentages yields a total of roughly 16.13 million persons. Taking these as high and low estimates of the number of alcohol abusers, as of the date of the last avail-able AA membership figures, somewhere between 5.7% and 7.7% of U.S. and Canadian "alcoholics" belonged to AA. And the percentage of those who will reach the AA goal of lifelong abstinence is much lower than that.

A noticeable feature of AA is that a large number of its members have been in the organization for a relatively short time. Based on my attendance at AA meetings in San Francisco in the late 1980s, I would estimate that over 50% of those attending meetings in that city at that time were members for less than one year and, in fact, that a majority were members for only a few months. The situation appears to have change little in recent years. (The discrepancy between my observations and AA's claim that only 27% of its members have less than one-year's abstinence is probably accounted for by AA's astoundingly high dropout rate; because of it, one constantly sees new faces showing up at AA meetings, with many of them sticking around for relatively few meetings.)

My estimate, however, isn't too far out of line with the figures given by Bill C. in a 1965 article in the Quarterly Journal of Studies on Alcohol.vii In it, he reports that of 393 AA members surveyed, 31% had been sober for more than one year; 12% had been sober for more than one year but had had at least one relapse after joining AA; 9% had achieved a year's sobriety; 6% had died; 3% had gone to prison; 1% had gone to mental institutions; and 38% had stopped attending AA. What makes these numbers even more dismal than they appear is the fact that Bill C. defined a member as someone who attended 10 or more AA meetings in a year's time. When you take into account the "revolving door effect," it becomes apparent that far more persons attended AA meetings than the 393 "members" Bill C. lists. It seems quite probable that he picked the figure of 10 meetings in a year as a membership criterion because AA's success rate would have been revealed as microscopic if he had used a smaller number of attendances as his membership-defining device. (It should also be mentioned that attendance at 10 meetings in itself seems to imply a fairly high degree of motivation.)

The success rate calculated through analysis of the 1996 AA membership survey is hardly more impressive. The survey brochure indicates that 45% of members have at least five years' sobriety. Using the figure of five years' sobriety as the criterion of success, one arrives at an AA success rate of approximately 2.6% to 3.5% (in comparison with the total number of "alcoholics" in the U.S. and Canada). And the success rate is lower than that if one defines "success" as AA does—as lifelong abstinence.

It could be argued that this is an unfair way of evaluating the effec­tiveness of AA, and that only "alcoholics" who have investigated AA should be considered. That's a reasonable argument, but there's evidence that a very high proportion of "alcoholics" have at one time or another checked into AA. Anyone who has attended many AA meetings can testify that droves of newcomers show up, attend one, or a few, meeting(s), and then are never seen again—the "revolving door effect." As well, roughly 270,000 individuals accused or convicted of drunk driving and other alcohol-related crimes are coerced into 12-step treatment every year in the United States.viii Based on the sheer numbers of such persons, it seems probable that well over 50%, perhaps as many as 90%, of American and Canadian problem drinkers investigate AA at some time during their drinking careers.

There's statistical evidence to indicate that this is so. Well known re­searcher Robin Room, of the Addiction Research Foundation, reports that a 1990 survey of 2058 Americans aged 18 and over revealed that 9% of American adults have attended an AA meeting at some time in their lives, and that an astounding 3.4% claimed to have done so in the previous year.ix (The latter percentage is almost certainly incorrect.x) If Room's 9% figure is even close to being correct, it's good evidence that a very high percentage of U.S. and Canadian alcohol abusers have attended AA at least once. In 1996, 9% of American and Canadian adults corresponded to roughly 19.6 million individuals. This figure, when compared with the previously men­tioned estimates of alcohol abusers and alcohol-dependent persons (16.13 to 22 million individuals), provides persuasive evidence that the percentage of "alcoholics" who have tried AA is high indeed—and that AA's success rate is very low.
 

AA's Triennial Surveys


AA's own statistics provide perhaps the most persuasive evidence that AA's success rate is minuscule. Since 1977, AA has conducted an extensive survey of its members every three years (though the survey scheduled for 1995 was conducted in 1996). These surveys measure such things as length of membership, age distribution, male-female ratio, employment categories, and length of sobriety. Following the 1989 survey, AA produced a large monograph, "Comments on A.A.'s Triennial Surveys,"xi that analyzed the results of all five surveys done to that point. In terms of new-member dropout rate, all five surveys were in close agreement. According to the "Comments" document, the "% of those coming to AA within the first year that have remained the indicated number of months" is 19% after one month; 10% after three months; and 5% after 12 months.xii In other words, AA has a 95% new-member dropout rate during the first year of attendance.

If success is defined as one-year's sobriety, on the face of it this 95% dropout rate gives AA a maximum success rate of only 5%; and a great many new members do not remain continuously sober during their first year in AA, which causes the apparent AA success rate to fall even lower. Of course, many of the 95% who drop out within the first year are probably "repeaters" who have previously investigated AA, and this would increase the apparent AA success rate; but at least for the present there is no way to know what percentage of the dropouts are repeaters. Additionally, at least some of the 95% who drop out of AA during their first year do manage to sober up; but to date there's no way to know what their numbers are. As well, it seems quite probable that most of those who drop out early in the program do so because they dislike and disagree with AA, so it could be argued that most of them who overcome their drinking problems do so in spite of, not because of, AA. Finally, at least some curiosity seekers and relatives of alcohol abusers show up at meetings, and this would further increase the apparent AA success rate. But to date, there are no reliable figures on what percentage of those who "walk through the door" fit those categories—though my personal estimate, and that of researcher/author Vince Fox, is that no more than 10% of new faces at AA meetings belong to relatives or curiosity seekers.xiii

One thing, however, is certain: An extremely high percentage of American drinkers who have been hospitalized for alcoholism or who have participated in other institutional alcoholism programs have participated in Alcoholics Anonymous. The number of patients treated for alcoholism is now approximately 950,000 annually,xiv which (because 12-step treatment is used in well over 90% of institutional programs) is a good indication that the proportion of alcohol abusers who have been exposed to AA is very high. It should also be kept in mind that in most parts of the country con­victed drunk drivers are still routinely forced to attend AA as a condition of probation, which pushes the percentage of alcohol abusers exposed to AA even higher. Further, in most areas AA is the only widely available—and widely media-promoted—alcoholism self-help group, so AA has a very high volume of "walk in" traffic.

But let's give AA the benefit of the doubt and estimate that only 50% of U.S. and Canadian alcohol abusers have tried AA. That would double the success rate calculated earlier (based on the total number of U.S. and Canadian alcohol abusers), and it would increase to 5.2% to 7.0% if the criterion of success is defined as five years' sobriety.

In a worst case scenario, where 90% of U.S. and Canadian alcohol abusers have tried AA, where success is defined as five or more years of sobriety, where 45% of AA members have been sober for five or more years (as AA indicates), and where there are 22 million alcohol abusers in the two countries, the AA success rate would be about 2.9% (and even lower than that if the criterion of success is lifelong sobriety rather than five years' sobriety).xv The true success rate of AA is very probably somewhere between these two extremes, depending, of course, on how one defines "success"; that is, AA's success rate is probably somewhere between 2.9% and 7% (of those who have attended AA).
 

Spontaneous Remission


This is far from impressive, especially when compared with the rate of "spontaneous remission." Contrary to popular belief, "alcoholism" is not a progressive and incurable "disease." Many studies have been conducted on so-called spontaneous recovery by "alcoholics" (that is, recovery without treatment, which can refer to achievement of either abstinence or controlled drinking), and the consensus of these studies is that "spontaneous" recovery occurs in a significant percentage of alcohol abusers, though the calculated rates of recovery vary considerably.xvi Other consistently supported con­clusions are that the rate of alcohol abuse and alcohol dependence (or, to use the older term, "alcoholism") declines far faster than can be explained by mortality among individuals past the age of 40,xvii and that "spontaneous" recovery normally occurs for identifiable reasons. In many cases, remission comes suddenly after a particularly dangerous or humiliating incident shocks the drinker into realization of the seriousness of his or her drinking problem. In other cases, recovery occurs as a result of religious conversion or as the result of an "existential" decision to quit based on a gradually increasing realization of the seriousness of the problem.xviii One review of available literature estimates the rate of spontaneous recovery at 3.7% to 7.4% per year.xix More recently, a large-scale longitudinal study of over 4,000 adults with prior, significant, diagnosable alcohol dependence (the National Longitudinal Alcoholism Epidemiological Survey, conducted by the Census Bureau) reported that 20 years after the onset of alcohol dependence, 90% of those who never received treatment were either abstinent or "drinking without abuse or dependence."xx Compared with these figures, the above­calculated rate of recovery via AA is not impressive. In fact, it appears to be no higher—and could actually be lower—than the rate of spontaneous re-mission.
 

Controlled Studies of AA's Effectiveness


But haven't there been scientific investigations of the effectiveness of AA? There have been, but there haven't been many. One reason for this could well be that "A.A. does not like to have researchers around,"xxi that it is highly reluctant to "open its doors to researchers."xxii Whatever the truth of these charges, to date there have been only two well-designed studies of the effectiveness of AA—that is, studies which have included control groups and the random assignment of subjects. (Two recent, often-cited studies, Walsh, et al., 1991,xxiii and Project MATCH,xxiv did not have control groups, and Project MATCH was not even a direct study of AA.) Both controlled studies indicated that AA is not an effective across-the-board treatment for alcohol abuse or dependence ("alcoholism"). The subjects in both studies were, however, court-referred alcoholic offenders and hence different from the general alcoholic population in certain respects. Thus one distinguishing feature of the study populations is that they did not voluntarily seek treatment; they were forced to attend AA.

On the surface, these factors—the employment of coercion and the special-population status of alcoholic offenders—seem to lessen the credi­bility of the two controlled studies of AA's effectiveness. But it could be argued that one factor is irrelevant and the other actually enhances the studies' credibility. If, as is commonly asserted, AA is a universally ap­plicable treatment for all alcoholics, the makeup of the study populations shouldn't have mattered a whit as long as the assignment of subjects to AA and control groups was truly random. And the fact that the studies' subjects were coerced into participating could well increase the validity of the studies' findings, because a very important biasing factor, subject motivation, was eliminated, and the remaining biasing factors were spread out fairly evenly among the groups studied because of the random assignment procedure. Further, since at least a third of present-day AA participants are coerced into attendance either by alcoholism treatment programs or the courts, through programs for DUI and other alcohol-related offenders, the populations of these studies were perhaps not as different from the general AA population as one might suspect.

The first of these controlled studies of AA's effectiveness was conducted in San Diego in the mid-1960s.xxv In the study, 301 public drunkenness offenders were randomly divided into three groups. One group was assigned to attend AA, another to attend an alcoholism treatment clinic, and a third group, the control, was not assigned to any treatment program. All of the study's subjects were followed for at least one full year following conviction. Results were calculated by counting the number and frequency of rearrests for drunkenness. Surprisingly, the no-treatment control group was the most successful of the three, with 44% of its members having no rearrests; 32% of those assigned to the clinic group had no rearrests; and 31% of those assigned to AA had no rearrests. As well, 37% of the members of the control group had two or more rearrests, while 40% of the alcoholism clinic attendees were arrested at least two times, and 47% of the AA attendees were arrested at least twice. While far from a definitive debunking of AA's alleged effectiveness, these results are certainly suggestive.

The other controlled study of AA's effectiveness was very carefully designed and conducted, and was carried out in Kentucky in the mid-1970s.xxvi A large majority of its subjects were obtained via the court system, and seemed to be "representative of the 'revolving door' alcoholic court cases in our cities." The investigators divided 197 subjects into five randomly selected groups: a control group given no treatment; a group assigned to traditional insight therapy administered by professionals; a group assigned to nonprofessionally led Rational Behavior Therapy (lay RBT); a group assigned to professionally led Rational Behavior Therapy; and a group assigned to AA. Length of treatment varied from 202 to 246 days, and subjects were evaluated at the end of treatment and also at three months and 12 months following its termination.

In general, the groups given professional treatment did better than the nonprofessionally treated groups and the control group. A significant find-ing, however, was that treatment of any kind was preferable to no treatment.

Since a great many alcohol abusers never seek professional treatment, it's particularly important to compare the results of the AA, lay RBT, and control groups. Lay RBT was clearly superior to AA in terms of dropout rate. During the study, 68.4% of those assigned to AA stopped attending it, while only 40% of those attending lay RBT sessions stopped attending them. Further, at the termination of treatment, all of the lay RBT participants who had persisted in treatment reported that they were drinking less than they were before treatment, while only two-thirds of those who had continued to attend AA reported decreased drinking. As well, during the final three months of treatment, the mean number of arrests was 1.24 for the lay RBT group, 1.67 for the AA group, and 1.79 for the control group.

Perhaps most interestingly, the number of reported binges at three months after termination of treatment was far higher for the AA group than for the lay RBT or control groups. The mean number of reported binges by the AA attendees was 2.37 over the previous three months, while the mean number reported by the controls was 0.56, and the mean for the lay RBT group was only 0.26. This finding strongly suggests that the AA attendees had accepted AA's "one drink, one drunk" dogma, and had then proceeded to "prove" it. It's pertinent to note, however, that at 12 months following the termination of treatment there were no significant differences between the AA, lay RBT, and control groups. One possible interpretation of this finding is that the positive effects of Rational Behavior Therapy fade with time in the absence of continued practice, and that the harmful effects of exposure to AA (at least in regard to bingeing) also fade with time in the absence of further exposure to AA.

A particularly intriguing aspect of this study is that the relatively suc­cessful (compared with AA and the no-treatment controls) lay RBT group utilized a treatment based on Rational Emotive Behavior Therapy (REBT). The reason that this is interesting is that S.M.A.R.T. Recovery, the newest of the national secular alternatives to AA, is based on REBT. Thus, there's at least some slight reason to think that SMART might be more effective than AA. Unfortunately, no controlled studies of SMART's effectiveness have yet appeared, though one such study is now under way in Tucson, Arizona. But for now, speculation about SMART's effectiveness will remain just that—speculation.

Clearly, there's a crying need for additional controlled studies of AA's effectiveness, as well as for controlled studies of SMART's effectiveness and that of the other secular groups. In the absence of such studies (at least as regards the alternative groups) all that we're left with is educated guesswork.
 

What Works?


But is the situation hopeless? No. In fact, there's considerable data avail­able that indicates which approaches are effective and which ones aren't. William Miller and Reid Hester, editors of the most comprehensive and most methodologically sound evaluation of treatment methods ever published, state that, "We were pleased to see that a number of treatment methods were consistently supported by controlled scientific research."xxvii But they continue, "On the other hand, we were dismayed to realize that virtually none of these treatment methods was in common use within alcohol treatment programs in the United States."xxviii Worse, "A significant negative correlation (r=-.385) was found between the strength of efficacy evidence for modalities and their cost; that is, the more expensive the treatment method, the less the scientific evidence documenting its effi­cacy."xxix They list the treatment methods showing the most positive results, as shown by controlled studies, as brief intervention, social skills training, motivational enhancement, community reinforcement approach, and behavior contracting.xxx Importantly, 12-step treatment was nowhere in evidence in the list of effective treatments; but it was quite likely a com­ponent of four modalities for which a number of studies show significant negative results: unspecified "standard" treatment; confrontational coun­seling; milieu therapy; and general alcoholism counseling.xxxi As for AA, Miller and Hester list only the two controlled studies discussed above, both of which showed negative results.
 

What Doesn't—12-Step Treatment


There have been many studies of 12-step treatment, but the vast majority are of little use in determining treatment effectiveness for two reasons: 1) they lacked control groups; and 2) they were short- or medium-short-term studies. It's impossible to draw meaningful conclusions about treatment's effectiveness without control groups. And any apparent benefits from treat-ment tend to disappear with time. Thus, long-term studies utilizing control groups are necessary to determining the effectiveness of treatment. But there have been relatively few.

One important study was published in 1983. For eight years, its author, George Vaillant, followed 100 patients who had undergone 12-step treat­ment; he compared this sample to several hundred other untreated alcohol abusers. The treated patients fared no better than the untreated group. Fully 95% of the treated patients relapsed at some time during the eight years Vaillant followed them, and he concluded that "there is compelling evidence that the results of our treatment were no better than the natural history of the disease."xxxii He added, "Not only had we failed to alter the natural history of alcoholism, but our death rate of three percent a year was appalling."xxxiii

Another very important, very scientifically sound study appeared in 1996. The National Longitudinal Alcoholism Epidemiological Survey was de­signed and sponsored by the NIAAA and was conducted by the U.S. Bureau of the Census. It was notable both for its size (4,585 subjects) and its study period (20 years). Its subjects were divided into a treated group and an untreated group. All of the study's subjects "had to have satisfied the criteria for prior-to-past year DSM-IV alcohol dependence by meeting at least 3 of the 7 DSM-IV criteria for dependence: tolerance; withdrawal (including relief or avoidance of withdrawal); persistent desire or unsuccessful attempts to cut down on or stop drinking; much time spent drinking, obtaining alcohol or recovering from its effects; reduction or cessation of important activities in favor of drinking; impaired control over drinking; and continued use despite physical or psychological problems caused by drinking."xxxiv

The study's findings were surprising: At 20 years after onset of symptoms, 80% of those who had undergone treatment were either abstinent or "drink­ing without abuse or dependence." But those who had never undergone treatment were doing even better: 90% of them were either abstinent or drinking nonproblematically. That is, 10% of those who had never been treated were still drinking abusively 20 years after the onset of symptoms, as were 20% of those who had been treated. In other words, twice as many of those who had undergone treatment were drinking abusively as those who had never been treated.xxxv

Other important findings included the following: of those who had never been treated, fully 60% were drinking nonproblematically 20 years after the onset of symptoms; and even of those who had undergone treatment and had received dire warnings of loss of control, incurability, and progressivity, 28% were drinking nonproblematically 20 years after the onset of symp­toms.xxxvi As well, in both groups, the percentage of those recovered (abstinent or drinking nonproblematically) steadily increased with time.xxxvii

Those who had been treated reported more initial problems than the untreated group, but as anyone who has ever gone to a few AA meetings can attest, there's status in reporting horrendous drinking behavior: the worse the problems overcome, the more impressive the apparent recovery. And in treatment centers, patients are routinely encouraged to exaggerate their problems. Stanton Peele quotes major league pitcher Dwight Gooden on his experiences being browbeaten in 12-step rehab by fellow patients: "My stories weren't as good [as theirs] . . . They said, 'C'mon, man you're lying.' They didn't believe me . . ."xxxviii There are many similar anecdotal reports. Given such rewards and pressures, it would be surprising indeed if many persons who have undergone treatment didn't "come to believe" their own stories and would thus over-report previous symptoms. Indeed, there's evidence that only treated individuals display all of the classic symptoms of alcoholism.xxxix As Stanton Peele puts it, "Treatment here seems to be necessary for the development of the classical alcoholism syndrome."xl
 

Recidivism Rates


Another way of gauging treatment effectiveness is through recidivism rates. By all indications, they're sky high for 12-step treatment. The NCADD reports that in 1992, "nearly 13.8 million Americans had problems with drinking"; and it claims that in that same year 1.9 million Americans underwent treatment.xli These are astounding figures. If these figures are accurate and are typical of preceding and subsequent years, and assuming that "treatment works" and has a 0% recidivism rate, every single alcohol abuser in the United States should have been treated in an eight-year period (accounting for mortality, population increase, and the development of new problems), and well over 90% of the nation's alcoholism treatment centers should have shut down by now for lack of clients. Obviously, this hasn't happened. Even if treatment were only 50% effective and there were a 50% recidivism rate, the number of alcohol abusers in this country should have dropped by at least a third over the last decade. Again, obviously, this hasn't happened. Instead, the literally billions of dollars spent on treating the nearly two million people per year reported by the NCADD have had seemingly no effect whatsoever on the number of alcohol abusers in the United States. This is good evidence that the treatment industry's drumbeat chant, "Treatment Works!," is an outright lie, and it's also good evidence that the recidivism rate in 12-step treatment is astronomical. Reports from those who have undergone treatment indicate that this is so. One report from a pro-AA participant/observer in a 28-day program states that of the 42 patients who made it through treatment, "Twenty were in treatment for the first time, 15 were in treatment for the second time, and seven patients had had at least two previous admissions."xlii As well, the "National Treatment Center Study Summary Report" states that the recidivism rate at the overwhelmingly privately owned inpatient facilities it surveyed is fully 40%.xliii One suspects that the rate at publicly funded facilities is even higher. Anecdotal evidence indicates that this is so: a report written by a client who had undergone treatment in a VA hospital states that 11 of 12 patients in his 28-day program had previously undergone inpatient treatment, and that one of the recidivists had been in treatment 19 times.xliv
 

Misinterpretation of Data


One often hears claims that one or another new study has "proven" the efficacy of AA or of 12-step treatment. Invariably, these claims are made about studies that didn't include control groups and that often had other methodological problems as well. The most obvious recent example is Project MATCH.xlv Treatment industry spokesmen claimed variously that it demonstrated the validity of 12-step treatment; that it demonstrated that all of the tested forms of treatment work equally well; and some even claimed that it demonstrated that 12-step treatment was superior to other forms of treatment. In reality, it did none of these things.

Project MATCH was an incredibly expensive study ($27 million—some reports have placed the total at $35 million) funded by the NIAAA that compared three forms of outpatient and aftercare treatment: motivational enhancement; cognitive behavioral coping skills therapy; and 12-step facili­tation therapy. All three forms of treatment were delivered in one-on-one counseling sessions, though the number of scheduled sessions was only four for motivational enhancement, compared with 12 for the other two forms of treatment. The significant findings of Project MATCH were that patients in all three groups experienced very similar improvement, as measured by the number of drinking days per month and the incidence of bingeing, and that 12-step-treated clients with less severe psychological problems had more abstinent days than similar clients in the other two groups. The number of days that outpatient clients drank fell from 22 to 6, while the number of days aftercare clients drank fell from 25 to 4; and the number of drinks per drinking day fell from 12 to 3 among outpatient clients, and from 18 to 2 among aftercare clients.xlvi Clearly, these are dramatic results, but were they the result of treatment, or of other factors?

Project MATCH was so over-designed that it seems likely that any form of treatment used in it would have shown similar results. First, all clients in Project MATCH were volunteers, and their volunteer status in itself shows a fairly high degree of motivation, a very important biasing factor. This is in stark contrast to the coerced status and presumably low motivation of the average alcoholism treatment client. Second, during the screening process approximately 10% of potential clients opted out of the study for reasons such as "the inconvenient location of the study or transportation prob­lems."xlvii This helped to narrow the study to only the most motivated clients. Third, more than half of the remaining potential clients were eliminated from the study for reasons such as "failure to complete the assessment battery" and "residential instability."xlviii This not only helped to ensure that only the most motivated clients would participate in the study, but also that only the most well-adjusted clients would participate, thus introducing another positive biasing factor: social and emotional stability.

Client expectations were still another positive biasing factor. The clients knew that they were taking part in an expensive study, and the manner in which sessions were conducted undoubtedly led to high expectations: every session consisted of one-on-one therapy with a competent professional; and every session was videotaped. As well, the study's conductors engaged in "compliance enhancement procedures (i.e., calling clients between sessions, sending reminder notes and having collateral contacts),"xlix which certainly must have helped drive home the study's apparent importance, thus rein­forcing clients' positive expectations.

Yet another problem with Project MATCH is that the treatments em­ployed were of universally high quality—not only were all sessions video­taped, but supervisors monitored fully a quarter of them; they bore little resemblance to commonly employed treatments. The difference between Project MATCH and real-world treatments was probably most pronounced in the study's 12-step facilitation therapy. It seems highly unlikely that the therapists employing 12-step facilitation in Project MATCH would have engaged in the abusive behavior that is routine in 12-step treatment. It seems very unlikely that they would have bullied clients in order to coerce false confessions from them; it seems equally unlikely that they would have ridiculed clients who questioned the therapy or made comments critical of it or of AA; and one doubts that they would have lied to clients about "inevitable" loss of control after one drink, or about the "inevitable" pro­gressivity of their incurable "disease."

Given all of these biasing factors, it was hardly surprising that all forms of treatment showed remarkably similar positive outcomes; almost any form of treatment would probably have shown similar results. The study's con­ductors even recognized—at least after the fact—this possibility. They note: "Compliance enhancement procedures . . . and the greater attention of individual treatment may have produced a level of overall compliance that made it difficult for differences between treatments to emerge."l They continue, "The overall effect of being a part of Project MATCH, with its extensive assessment, attractive treatments and aggressive follow-up, may have minimized naturally occurring variability among treatment modalities and may, in part, account for the favorable treatment outcomes."li

We'll never know for sure, though, because, as the researchers put it, "the efficacy of the three treatments cannot be demonstrated directly since the trial did not include a no-treatment control group."lii But there does seem to be one clear lesson in Project MATCH: if you introduce enough positive biasing factors, almost any form of treatment will "produce" a positive outcome.
 

What We Know


For now, the best evidence available suggests that AA is ineffective as a means of overcoming alcohol problems, and there's some evidence that exposure to AA worsens at least one significant abusive behavior—binge drinking. But the evidence is not conclusive, and until additional controlled studies are conducted, it will remain impossible to draw firm conclusions about AA's (in)effectiveness. One thing, however, bears repeating: there's no good evidence to indicate that AA is any more effective than "spontaneous recovery." Assertions that AA is an effective means of overcoming alcohol problems, let alone assertions that AA is the most or the only effective means of doing so, are just that—assertions, and groundless ones at that.

As for 12-step treatment programs, we'll deal with them further in the next chapter.
 
 
 

i1. Alcoholics Anonymous, by Bill Wilson. New York: Alcoholics Anonymous World Services, 1976, pp. 20-21.
ii2. "NIAAA Releases New Estimates of Alcohol Abuse and Dependence," March 17, 1995.
iii3. "How Many People Are Alcoholic?" page on the Addiction Research Foundation's web site: http://www.arf.org/isd/stats/alcohol.html
iv4. I base this estimate on AA's 1996 membership brochure. Because of the limitations of the data supplied by AA, my conclusions here must be somewhat tentative. I arrived at my figures as follows: 16% of those attending were openly coerced by the courts or penal system. I started with this as a baseline figure, because it involves undisguised coercion. Adding all of the percentages listed of other "important factors," one arrives at a total of 241%. To arrive at the coercive total percentage, I added the full 40% listed for treatment facilities (clients are almost invariably coerced into AA attendance by treatment facilities), three quarters of 16% listed for counseling agencies (counseling agencies often make counseling contingent on AA attendance), the full 9% listed for "employer or fellow worker" (undoubtedly, almost all of them were coerced into treatment by EAPs or professional diversion programs), 7% out of the 39% listed for family (the "National Treatment Center Study Summary Report" indicates that 17.5% of inpatient clients are adolescents, who would not enter treatment voluntarily), and half of the 8% listed for health care providers (who sometimes make treatment contingent on AA attendance). This yields a total of 65%, which I divided by 2.41, which yields a figure of roughly 27%. Adding that 27% to the 16% who were outright coerced by the legal and penal systems yields a total of 43% of current AA members who belong to the organization primarily as a result of some type of coercion. Of course, this method is inexact, but it does yield a reasonable ballpark figure.
v5. "Evaluation of Treatment Methods in Chronic Alcoholism," by Frederick Baekeland, in Treatment and Rehabilitation of the Chronic Alcoholic, Benjamin Kissin and Henri Begleiter, eds. New York: Plenum Press, 1977, p. 392.
vi6. "Membership" page on AA's web site:

http://www.alcoholics-anonymous.org/factfile/doc07.html

vii7. "The growth and effectiveness of Alcoholics Anonymous in a Southwestern City," by Bill. C. Quarterly Journal of Studies on Alcohol, 26:279-284, 1965.
viii8. National Admissions to Substance Abuse Treatment Services: The Treatment Episode Data Set (TEDS) 1992-1995. Rockville, Maryland: U.S. Department of Health and Human Services, 1997. Table 10, p. 46.
ix9. "Alcoholics Anonymous as a Social Movement," by Robin Room, in Research on Alcoholics Anonymous, Barbara McCrady and William Miller, eds. New Brunswick, New Jersey: Rutgers Center of Alcohol Studies, 1993, p. 169.
x10. If it were correct, and if it were even roughly comparable to rates for previous years, the full 9% of the population who claim to have attended at least one AA meeting would likely have done so during the previous three years, given minimal attendance overlap. And even if there were a 50% overlap, the full 9% figure would be reached in just over five years. These time periods are simply too short for both the 9% figure and the 3.4% figure to be correct. Further, given that AA grew in the U.S. and Canada by approximately 50,000 members in the year cited (1990), if 3.4% of the adult population had attended an AA meeting in that year, that would have come to 7,000,000 people, giving AA a new-member dropout rate well in excess of 99% for that year. AA has a very busy "revolving door," but it doesn't revolve quite that fast!

Room indicates that only 42% of the 3.4% who claim to have attended an AA meeting in 1990 admitted to doing so because of an alcohol problem. This simply doesn't wash with experience. From my own observations and those of other sharp-eyed former members (including Vince Fox and Ken Ragge), curiosity seekers are not terribly common at AA meetings, and neither are family members of alcohol abusers (though coerced persons, many of whom shouldn't be there, make up a significant percentage of attendees). My best estimate is that well over 90% of newcomers show up at AA either because of their own alcohol problems or because of coercion. It should also be remembered that even in anonymous surveys many individuals lie about things that they consider embarrassing, which would help to explain the low percentage admitting to attendance because of their own problems.

xi11. "Comments on A.A.'s Triennial Surveys," no author listed. New York: Alcoholics Anonymous World Services, n.d. (probably 1990).
xii12. Ibid., p. 12, Figure C-1.
xiii13. Telephone conversation with Fox in August 1997.
xiv14."National Drug and Alcoholism Treatment Unit Survey (NDATUS): Data for 1994 and 1980-1994." Rockville, Maryland: SAMHSA, 1996, Table 10.
xv15. The minimum success rate I calculated in the original edition of this book was 1.3%. Most of the difference between the two figures is due to AA's reported increase in five or more years' sobriety among its members from 29% in 1989 to 45% in 1996. Most of the rest is a result of AA's having grown faster than the rate of population growth.
xvi16. "Recovery Without Treatment," by Thomas Prugh. Alcohol Health and Research World, Fall 1986, pp. 24, 71 and 72.
xvii17. "Alcoholism as a Self-Limiting Disease," by Leslie R.H. Drew. Quarterly Journal of Studies on Alcohol, Vol. 29, 1968, pp. 956-967.
xviii18. "Spontaneous Remission in Alcoholics: Empirical Observations and Theoretical Implications," by Barry S. Tuchfeld. Journal of Studies on Alcohol, Vol. 42, No. 7, 1981, pp. 626-641.
xix19. "Spontaneous Recovery in Alcoholics: A Review and Analysis of the Available Research," by R.G. Smart. Drug and Alcohol Dependence, Vol. 1, 1975-1976, p. 284.
xx20. "Correlates of Past-Year Status Among Treated and Untreated Persons with Former Alcohol Dependence: United States, 1992," by Deborah A. Dawson. Alcoholism: Clinical and Experimental Research, Vol. 20, No. 4, June 1996, p. 773.
xxi21. "Is Alcoholism Treatment Effective?," by Helen Annis. Science, Vol. 236, April 3, 1987, p. 21.
xxii22. Baekeland, op. cit., p. 407.
xxiii23. "A Randomized Trial of Treatment Options for Alcohol-Abusing Workers," by Diana C. Walsh, et al. New England Journal of Medicine, Vol. 325, No. 11, Sept. 12, 1991, pp. 775-781. This study is sometimes cited as having a control group, when in fact it did not. A true control group would have received no treatment, whereas over 85% of the "choice" group in this study chose either hospitalization or AA attendance, thus rendering the results of the study ungeneralizable. Walsh et al. measured AA attendance only versus coerced hospitali­zation with AA attendance, and versus a mongrel "choice" group that voluntarily chose in large part either AA alone or hospitalization featuring AA. Thus the data in this study is of very limited use and cannot be cited (at least honestly cited) as evidence that AA or 12-step hospitalization "works" or doesn't "work," except in relation to each other. And even that comparison is of limited value given that this was a short-term study with a relatively small sample.
xxiv24. "Matching Alcoholism Treatments to Client Heterogeneity: Project MATCH Posttreatment Drinking Outcomes," by Project MATCH Research Group. Journal of Studies on Alcohol, January 1997, pp. 7-29. This amazingly expensive ($27 million) study not only did not have a control group, but did not directly measure AA's effectiveness vis a vis other treatments, and its methods of client selection and client handling probably served to distort the outcome. As the Project MATCH researchers themselves pointed out, "The overall effect of being a part of Project MATCH, with its extensive assessment, attractive treatments and aggressive follow-up [clients were paid, among other things] may have minimized naturally occurring variability among treatment modalities and may, in part, account for the favorable treatment outcomes." (p. 24)
xxv25. "A Controlled Experiment on the Use of Court Probation for Drunk Arrests," by Keith S. Ditman, George G. Crawford, Edward W. Forby, Herbert Moskowitz, and Craig MacAndrew. American Journal of Psychiatry, 124:2, August 1967, pp. 160-163.
xxvi26. Outpatient Treatment of Alcoholism, by Jeffrey Brandsma, Maxie Maultsby, and Richard J. Walsh. Baltimore: University Park Press, 1980.
xxvii27. Handbook of Alcoholism Treatment Approaches: Effective Alternatives, William Miller and Reid Hester, editors. Boston: Allyn and Bacon, 1995, p. xi.
xxviii28. Ibid.
xxix29. Ibid., Chapter 2, "What Works?," by Miller, Hester, et al., p. 13.
xxx30. Ibid., Table 2.4, p. 18.
xxxi31. Ibid.
xxxii32. The Natural History of Alcoholism: Causes, Patterns, and Paths to Recovery, by George Vaillant. Cambridge, MA: Harvard University Press, 1983, p. 284,
xxxiii33. Ibid., p. 285.
xxxiv34. "Correlates of Past-Year Status Among Treated and Untreated Persons with Former Alcohol Dependence: United States, 1992," by Deborah A. Dawson. Alcoholism: Clinical and Experimental Research, Vol. 20, No. 4, June 1996, p. 772.
xxxv35. Ibid., Table 1, p. 773.
xxxvi36. Ibid.
xxxvii37. Ibid.
xxxviii38. "AA Abuse," by Stanton Peele. Reason, November 1991, pp. 34-39. Reproduced at http://www.frw.uva.nl/cedro/peele/lib/aaabuse.html (p. 3 of html document).
xxxix39. See "Treatment Seeking Populations and Larger Realities," by Robin Room, in Alcoholism Treatment in Transition, G. Edwards and M. Grant, eds. London: Croom Helm, 1980, pp. 205-224.
xl40. "Denial—of Reality and of Freedom—in Addiction Research and Treatment," by Stanton Peele. Bulletin of the Society of Psychologists in Addictive Behaviors, Vol. 5 No. 4, 1986, pp. 149-166. The document is reproduced at http://www.frw.uva.nl/cedro/peele/library/denial.html

and the quoted text is taken from page 9 of the html document.

xli41. "Alcoholism and Alcohol-Related Problems: A Sobering Look."

Http://www.ncadd.org/problems.html (pp. 1 & 2).

xlii42. "Goal Setting and Recovery from Alcoholism," by Donna Marie Wing. Archives of Psychiatric Nursing, Vol. 4, No. 3, June 1991, p. 179.
xliii43. "National Treatment Center Study Summary Report," Paul Roman and Terry Blum, principal investigators. Athens, Georgia: Institute for Behavioral Research, 1997, p. 17.
xliv44. "Twenty-Eight Days in Wilson's Inferno," by Brian Barton. Journal of Rational Recovery, Vol. 9, No. 5, May-June 1997, p. 8.
xlv45. "Matching Alcoholism Treatments to Client Heterogeneity; Project MATCH Posttreatment Drinking Outcomes," by Project MATCH Research Group. Journal of Studies on Alcohol, January 1997, pp. 7-29.
xlvi46. Ibid., Figure 1, p. 15. These figures aren't exact, as there were minor variations in the outcomes for the three forms of treatment, and I derived these figures by interpreting graphs of results.
xlvii47. Ibid., p. 10.
xlviii48. Ibid.
xlix49. Ibid., p. 23.
l50. Ibid.
li51. Ibid., p. 24.
lii52. Ibid., p. 23.