Prologue

As little as two decades ago rigorous scientific research on the Alcoholics Anonymous 12 step program of recovery was all but non-existent. It was so lacking, in fact, that a panel of experts convened by the Unites States Academy of Science’s Institute of Medicine (IOM) published this conclusion in 1989:
Alcoholics Anonymous, one of the most widely used approaches to recovery in the United States, remains one of the least rigorously evaluated.

The IOM report went on to call for well-designed research studies aimed at evaluating the AA program. That is when fate crossed my path. Having gotten some training in the 12 step model of recovery, I had developed an adolescent treatment program rooted in that model of recovery, and subsequently had a book published based on that experience. I then had the good fortune to be invited to develop a parallel program for adults for use in a major national treatment outcome study. That study and its results will be included in the research to be looked at here.

Suffice it to say that since the IOM report and the first published results of that national study, research on the AA program has proliferated, to the point where it is no longer true that AA is the least rigorous studied (or objectively evaluated) approach to recovery in the U.S. However, to date much of the hard evidence regarding AA has of necessity been reported in academic journals, where it remains largely inaccessible to the general public. This book aims to remedy that situation, thereby shedding light for all to see about AA and how it works.


Introduction
Problem, or Solution?


It is hard to find someone who does not have an opinion about Alcoholics Anonymous -- from those who will say it has been their salvation to those who dismiss it as a harmful cult. Many people remain either skeptical or downright critical of AA. I know this from reading the critics, and also from the responses I sometimes get to the blogs I have posted on sites such as the Huffington Post and Psychology Today.

I’ve come to divide these critics into two broad categories: those who claim to criticize the 12 step model based on “scientific” evidence; and those whose criticism is merely their opinion—sometimes based in disappointing personal experiences. Here is an example:
Subject: Do you ever 'frontload'?
Then maybe you're an alcoholic. Another item to add to the alcoholism
self-assessment checklist. You might have a 'problem' so go to AA.

Well, seriously we don't need more reasons to send people to AA, which is an
unproven treatment and often just makes the problem worse (by requiring that
the attendee admit 'powerlessness' to their 'cravings' among other things).

Frontloading is often just a way to save money, like the above commenter
says, or to arrive at the party in a better mood, which is a perfectly good
reason to drink. The real problem is chronic excessive drinking (front, back,
or mid-loaded), which is normally a sign of an underlying psychological
issue. In most cases it's just a phase that young people go through and does
not lead to 'alcoholism'.

The above was written in response to a blog I wrote about how some college students drink heavily before going to a party (“frontloading”). In the blog I never mentioned AA; nor did I suggest that these students were destined to become alcoholics. Rather, I was writing about the increased risks associated with frontloading, such as fights, vandalism, and sexual assault. That did not deter this commenter, however, from gratuitously asserting that AA is an “unproven treatment that makes the problem worse.”

Here is another typical criticism:

I would like to start by saying that I have attended a lot of 12 step meetings; in fact, the more 12 step meetings that I attended the worse my drinking became. I finally realized that AA was doing me a lot of harm when I had to check into medical detox so as not to die of the DTs. It was at this point that I left AA and started getting better.

Again, the idea here is that AA and the 12 step program is actually harmful. Over the past several years I’ve read many such comments—some of them very biting, even bitter. I’ve sometimes wondered exactly what kind of meetings these people attended, what their expectations were, and how sincere they were about wanting to quit drinking in the first place.

Then there are those—some of them credentialed professionals—who claim that AA does not help based on “scientific” evidence. As an example, let me summarize a piece titled AA is Ruining the World:
Here are four reasons AA is harmful and will hurt societies:
AA denies reality
AA overemphasizes its own success
AA rules out other, often more effective, approaches.
AA’s underlying temperance message actually creates alcoholism and addiction.

By this last criticism the writer is arguing that advocating for abstinence actually promotes more drinking. Moreover, he asserts that he has evidence for this claim, though he does not cite that evidence.

Here is another criticism of the 12 step program, this also from a professional—no less than a psychiatrist who was in charge of a major substance abuse treatment program:
A.A. has the worst success rate in all of medicine

And here is one more typical critique of AA:
How much of the following do you recognize from AA?
Treachery
Disempowerment
Infantilization
Intimidation
Stigmitization


The official response of the Alcoholics Anonymous central office to a steady stream of criticism like the above about its 12 step program of recovery can be summarized in one word: silence. That is because AA by tradition identifies itself as a “program or attraction,” meaning, simply, that if you work its 12 step program sincerely, it will work; conversely, if don’t like it, then by all means don’t try it AA has never asserted that “it works for everyone”, only that “if you work it, it works.”

Anonymity lies at the core of AA, for two reasons. First, it serves to protect members who may be concerned that being publicly identified as an AA member could be detrimental to them in some way. Privately they may indeed think of themselves as an “AA member” yet they are loathe to be identified publicly that way.

The other reason why personal anonymity has remained so central to AA is that it stands as an impediment to personal ambition or a desire to stand out, or to accrue power, influence, or even financial gain through AA. The result is that AA has remained steadfastly decentralized--and consequently very adaptable, as it is a bottom-up as opposed to a top-down organization. At the same time those traditions mean that no one individual speaks for AA. Unlike a corporation, a government agency, a political party, or even an organized religion, AA has no spokesperson, no “press secretary.”

AA’s stance in this regard may not matter much to those whose personal experience of AA is that it has worked for them. They may simply regard these critics as ignorant. Yet AA’s policy of silence has given its critics license to freely criticize both what AA is and how effective it is. Say what you will about AA—and AA will not offer a rebuttal.
So what do we say to all those men and women who may be concerned right now about their drinking and are contemplating what to do about it? What would we say to those men and women who’ve been told that they must quit drinking or risk dire consequences in one form or another? What would these people be likely to conclude if they read only stinging criticisms like the above, while AA itself offers no retort? They may indeed conclude that AA either doesn’t work, that it lies about its effectiveness, or that it may even be some sort of cult.

This book aims to address critics and criticisms like the above. It directly addresses the underlying question: Is AA and its 12 step program a cult, or does it represent a solution for a very vexing problem that has plagued society for centuries? It will do so not through opinion, or even via testimonials, but rather through a wealth of real facts about AA that have been accumulated through actual research. It will describe that research and that data, so that you, the reader, can decide for yourself what the best course of action is if you or a loved one has a drinking problem. So before you draw any conclusions based on criticisms like the above, I invite you to turn the page…



Part 1
It Works


Chapter 1
Who Stands for 12 Step Recovery?

The purpose of this book, again, is straightforward: it aims to set the record straight, based on hard evidence and objective research conducted over the past twenty years or more, about the effectiveness of the 12 step model of recovery. No claims will be made here without reference—in a detailed Appendix--to the sources that support them. My goal is to stand for the 12 step model in the face of longstanding and unchallenged criticism and skepticism, much of which is not based in fact.

In 1990 I was asked by a research team at Yale University to design a treatment program for individuals with the diagnoses of alcohol abuse and alcohol dependence. This intervention was specifically to be based on the AA 12-step model of recovery. I was told that it was to be used in a clinical trial investigating the effectiveness of the 12 step model. I had no idea at the time, however, of the magnitude of the research venture I was stepping into.

This study--named Project MATCH—was to be the most ambitious psychotherapy study ever undertaken. It was to be national in scope, involving nine separate treatment locations, and nearly 2,000 patient/subjects. Half of the participants were to be men and women who were recruited directly from their communities (the “outpatient arm”); the other half were to be recruited as they completed treatment programs (the “aftercare arm”). A veritable Who’s Who of alcohol treatment researchers (I did not count myself among that group) were recruited to design and implement the project.

My 12 step-based intervention, which I called Twelve Step Facilitation, or TSF, was to be one of three interventions studied. The others were Cognitive-Behavior Therapy (CBT) and Motivational Enhancement Therapy (MET). The object of this study, which spanned seven years, was to determine not just if the three treatments were effective, but also what kind of treatment was most effective for what kind of patient (hence the inclusion of the word MATCH in the title).

The three treatments were chosen in part because represented three different perspectives on how to treat what are now called alcohol use disorders. CBT, for example is based on the idea that what would help such individuals the most was to teach them coping skills, because it was believed that men and women drank as means of coping, for example with stress. The MET perspective was different. It was based on the notion that men and women could and would find their own solutions for an alcohol use disorder, once they decided they had one. Accordingly, MET attempts to intervene in ways that leads these individuals to make that decision, for example by pointing out negative consequences that have been associated with their drinking.

Both CBT and MET already had been studied fairly extensively by the time MATCH went into development. In contrast, as pointed out earlier, the 12 step approach I was asked to create had not been the subject of much rigorous research. AA itself was ubiquitous, but a therapy based on the 12 step model was lacking. Moreover, in the academic community AA and the 12 step approach was poorly understood at best, with many academic researchers inclined to think of it more as a cult or quasi-religion than a cure. They were highly skeptical that TSF would work at all; or, if it did work, it would do so only for those with the most severe alcohol use disorders (those who had “bottomed out”). Nevertheless, TSF received the same resources for implementation