04/14/20

Thoroughly Following the AA Path

© Vitali Krasouski

Chapter five of the AA Big Book, “How It Works,” begins with a bold statement: “Rarely have we seen a person fail who has thoroughly followed our path.” The following two and a half pages are typically read at the beginning of every AA meeting and contain the essence of the program of Alcoholics Anonymous. According to William Schaberg in Writing the Big Book, there is a persistent AA myth that Bill W. once said if he could change one word in the Big book, he would change “Rarely” to “Never.” But Bill categorically denied this, saying he never considered the change.

There are ongoing disputes over whether the claim made is true, namely that rarely does an individual fail who has thoroughly followed the AA path. There are many who agree with Lance Dodes, who said in his book, The Sober Truth, that the major studies of the effectiveness of 12-Step programs were “deeply scientifically flawed.” Dodes alleged the overall success rate for AA is between 5 and 10% and that his book was an expose on AA, Twelve Step programs and the rehab industry—how “a failed addiction treatment model” came to dominate America. But what does he mean by success rate? Dodes said he understood success rate to mean the number of people who enter these programs and are able to become and stay sober. We will look closer at this sense of “success rate” later.

Laurel Sindewald supposedly did a scientific, objective assessment of AA and found that “AA Is not Evidence-Based Treatment.” She referenced a 2006 Cochrane Review, whose authors concluded: “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF [Twelve Step Facilitation] approaches for reducing alcohol dependence or problems.” I don’t think Sindewald’s review was either scientific or objective and previously described my reasons in “More Equal Therapies Than Others,” Part 1 and Part 2. You will find a description of TSF, which was developed by Joseph Nowinski, in those articles. By the way, the National Institute on Drug Abuse lists TSF as an evidence- or research-based behavioral therapy approach in drug abuse treatment.

Dodes also cited the 2006 Cochrane Review, noting how it was one of the most prestigious scientific research organizations in the world. But he selectively quoted the Review as saying: “‘No experimental studies unequivocally demonstrated the effectiveness of AA” in treating alcoholism. This group reached the same conclusion about professional (12-step facilitation therapy, or TSF), which is the core of virtually every alcoholism-rehabilitation program in the country.”

I respectfully disagree that studies showing the effectiveness of 12-Step programs are “deeply flawed” and I am concerned with how Dodes conflated AA and the 12-Steps with the rehab industry/addiction treatment in his critique of the rehab industry, calling AA “a failed treatment model.” I do not think he had solid, scientific grounding in his critique of AA and the 12-Steps. In order to demonstrate this belief, let’s examine a recent Cochrane Review that did find evidence of AA’s effectiveness and then look at If You Work It, It Works! The Science Behind 12 Step Recovery, a 2015 book by Joseph Nowinski. Remember that research done by Cochrane “is internationally recognized as the benchmark for high-quality information about the effectiveness of health care.”

The 2020 Cochrane Review, “Alcoholics Anonymous and other 12-step programs for alcohol use disorder” found that manualized AA/TSF interventions usually produced higher rates of continuous abstinence than other established treatments. Non-manualized AA/TSF performed as well as other established treatments. “Clinically-delivered TSF interventions designed to increase AA participation usually lead to better outcomes over the subsequent months to years in terms of producing higher rates of continuous abstinence.” This effect was achieved largely by fostering engagement in AA beyond the end of the TSF clinical intervention.

Speaking to The New York Times, the lead author John Kelly said: “We now have good evidence that AA and 12-step-facilitation treatments produce high rates of remission and reduced healthcare costs.” He added that AA created a socially engaged fellowship. The social network attracted and engaged people longer term, which reduces the risk of relapse.

The analysis found that AA and AA-connected 12-step programs had 20% improved abstinence rates over a period of 12 months compared to other therapies. That effect remained constant at both 24 and 36 months. When the researchers looked at the data in terms of number of days of abstinence, they found AA and other 12-step programs worked as well as other interventions. The data also showed that AA and 12-step programs worked as well as others when it came to getting drinkers to cut back on the amount of alcohol they were consuming.

In an author interview with Cochrane, Kelly said the quality of evidence for the abstinence outcome was moderate to high, indicating a high degree of confidence can be placed in these new findings. He said the 2006 Cochrane Review was not strong, as it was only based on 8 studies and included just a few thousand participants. “The updated review is based on 27 rigorous comparative investigations and included around 11,000 participants.” The last 25 years has seen a rapid expansion in the growth of studies on AA and TSF clinical interventions designed to link patients with AA. Research can prove it is effective at helping people achieve sobriety and lasting remission.

These superior benefits make sense when alcohol use disorder is viewed as a chronic illness, which for many is susceptible to relapse over months and years; one of the reasons why AA helps more people over the long-term is through its ability to keep people actively involved in its recovery-focused peer support social network over these long periods so that their brains and bodies can adjust to the absence of alcohol and the demands of recovery and help them adopt a new lifestyle that is more conducive and supportive to long-term stable remission and enhanced quality of life.

In the Prologue of If You Work It, It Works! The Science Behind 12 Step Recovery, Joseph Nowinski said that most of the evidence on AA was published in academic journals and as a result was largely inaccessible to the general public. His intent was to write about research done on AA in nontechnical, jargon-free language and make it available to the general public. “It is my hope that members of AA will find the evidence I present here relevant and insightful with respect to their own recovery.”

From the Alcoholics Anonymous 2011 Membership Survey, Nowinski reported that among individuals who were active in AA, 72% were sober more than a year, and a third (36%) more than ten years. The average number of meetings attended per week was 2.6; 81% have a sponsor and 86% have a home group. Nowinski said if you wanted to quit drinking, and stay quit, you should attend 2 or 3 meetings a week, get a sponsor and choose a home group. The 2014 Membership Survey is available online and reported similar figures. This consistency in membership surveys goes back to the first survey done by AA in 1977. But what about academic researchers who have studied AA and how involvement in AA relates to staying sober?

After examining studies that focused on the relationship between Twelve Step group affiliation and abstinence, Nowinski said there was a significant correlation between AA or NA meeting attendance and recovery. He added there was a noted distinction between attending self-help meetings and involvement. Individuals who merely attend meetings, but do not identify as program members were said to be on the outside, looking in; and their recovery may be less robust as a result. “Paths of entry into alcoholics anonymous” found that individuals who participated in both treatment and AA were more likely to achieve remission than individuals who only participated in professional treatment. “Alcoholics Anonymous Involvement and Positive Alcohol-Related Outcomes” said the study’s findings supported the hypothesis that AA involvement causes subsequent decreases in alcohol consumption and related problems. Analysis of longitudinal studies in “Alcohol and drug treatment involvement, 12-step attendance and abstinence” showed that greater 12-step attendance led to increases in 5-year abstinence and 7-year abstinence.

In the Epilogue of If You Work It, It Works! Nowinski said his book had looked at what objective science had to say about the effectiveness of the AA Twelve Step program, acknowledging that the bulk of research he reviewed was fairly new. He mentioned a group of “prominent researchers” who examined this emerging evidence on the effectiveness of AA and other abstinence-based mutual self-help fellowships. Their review, “Self-help organizations for alcohol and drug problems,” said: “Because longitudinal studies associate self-help group involvement with reduced substance use, improved psychosocial functioning, and lessened health care costs, there are humane and practical reasons to develop self-help group supportive policies.” In conclusion, Nowinski said: “So it would appear from research that the most appropriate answer to our initial question comes from the creators of the Twelve Step model: ‘Rarely have we seen a person fail who has thoroughly followed our path.’”

06/27/17

More Equal Therapies than Others, Part 1

© Allan Swart | 123rf.com

In the classic novella, Animal Farm, by George Orwell, the animals of Manor Farm revolted and drove the drunken and irresponsible farmer Mr. Jones from the farm. They renamed it “Animal Farm” and adopted the Seven Commandments of Animalism, the most important of which was the seventh: “All animals are equal.” Eventually the pigs cemented their role as the leaders of Animal Farm, and this commandment was modified to say: “All animals are equal, but some animals are more equal than others.”  Barry Duncan adroitly applied this example of double-speak in his discussion of those who apply the medical model of “diagnosis plus prescriptive treatment equals symptom amelioration” to declare that some psychotherapies were more equal than others.

Two other articles, “The Dodo Bird Effect” and “Another Brick in the Wall” explored Duncan’s argument for the power of common factors in psychotherapy and the dodo bird effect, an alternate way of understanding the process of therapeutic change from the dominant medical model of therapeutic change described above. He developed this position in: “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird” and a book he coauthored: The Heart & Soul of Change.” Here I want to explore how the Orwellian sense that some therapies are more or less equal than others runs wild in addiction treatment.

The National Institute on Drug Abuse (NIDA) defined addiction as “a chronic, relapsing brain disease” because drugs changed the brain—its structure and how it worked. Here is a short YouTube video of the Director of NIDA, Nora Volkow, discussing this view of addiction. This definition was purely a physiological, biomedical understanding of addiction. Philosophically, it also seems Volkow assumed there is no mind; that human traits like “free will” were products of the biology of the brain. Note where she said “free will” was a product of the biology of the brain.

As in medical practice, addiction treatments are quantified according to an evidence-base of effectiveness. Here, the buzzword is “evidence-based treatment.” NIDA has a listing of  “Evidence-Based Approaches to Drug Addiction Treatment,” which it categorized as “Pharmacotherapies” and “Behavioral Therapies.” The NIDA introduction said the section “presents examples of treatment approaches and components that have an evidence base supporting their use.” One of the behavioral therapies NIDA listed as “effective in addressing substance abuse,” was “12-Step Facilitation Therapy” (TSF).

This 12-Step-based treatment approach was developed by Joseph Nowinski, a clinical psychologist as part of the Project MATCH study into the effectiveness of three different perspectives on how to treat alcohol use disorders (then described as alcohol abuse and alcohol dependence in the DSM, the psychiatric Diagnostic and Statistical Manual). In his book, If You Work It, It Works!, Nowinski said many academic researchers were highly skeptical that TSF would work at all, as A.A. and the Twelve Step approach was poorly understood. “Many academic researchers inclined to think of it more as a cult or quasi-religion than a serious programmatic approach to recovery from addiction.”

The two other interventions, Cognitive Behavioral Therapy (CBT) and Motivational Enhancement Therapy (MET) had been extensively studied. But Twelve-Step interventions had not been the subject of significant, rigorous research. So Nowinski developed TSF, a psychosocial treatment manual based on engaging the individual in 12 Step support groups such as Alcoholics Anonymous (A.A.).

In 1997 published results from the MATCH Research Group showed that all three interventions (CBT, MET and TSF) were effective in reducing drinking and increasing abstinence after treatment. One year after completing treatment those who were in the outpatient section of MATCH were sober over 80% of the time. And TSF was found to be equally effective for individuals who had been diagnosed as an alcohol abuser rather than as alcohol dependent.

These findings were so unexpected that some long-standing critics of AA and its Twelve Step program went so far as to question whether the MATCH data were somehow falsified. Of course, nothing could be further from the truth. The reality, rather, was what some skeptics could not abide: the idea that the Twelve Step approach works.

Nowinski said his goal in writing If You Work It, It Works was to make information on the effectiveness of Twelve Step recovery, now documented in academic journals, available to the general public. His goal was “to stand for the Twelve Step model in the face of long-standing and unchallenged criticism and skepticism, much of which is not based in fact.” Equally important, he hoped that people on the fence about going to an A.A. meeting “will benefit from learning about the science (as opposed to the myths) of Twelve Step recovery.”

Nowinski referred to a long-standing bias against the Twelve Step approach to recovery. He said it was regularly portrayed as a quasi-religious approach, and then rejected because it is not a structured treatment approach. Therefore it lacked a clear demonstration of its scientific, evidence-based effectiveness. If an addiction treatment approach, like TSF, used the 12 Steps or actively encouraged clients to participate in 12 Step groups like Alcoholics Anonymous (A.A.) or Narcotics Anonymous (N.A.), it was often judged to be “a less equal treatment” than others. An article by Laurel Sindewald for The Fix, “AA Is not Evidence-Based Treatment,” illustrates this bias.

The author said she had previously done a literature review that found insufficient evidence to support the use of 12-step groups as treatment, so she was surprised the Surgeon General included TSF as an evidence-based behavioral treatment for addiction in Facing Addiction in America. She admitted to a personal bias, which apparently was against the spirituality of 12-step groups and what she referred to as “12-step philosophy.” It seems that since TSF encouraged participation in 12-Step self-help groups, it was suspect as a “less equal” treatment approach, because it retained “the spiritual emphasis of 12-step philosophy.” However, she would “set aside her bias” in her assessment of TSF, in order to give it a scientific, objective assessment. But that does not seem to have been the case.

Sindewald noted where the Surgeon General’s Report classified TSF as a “professional behavioral treatment,” but then immediately asked: “How could a professional medical treatment be based on a definition of addiction as a spiritual disease?” She stated (without any supportive citation) that Twelve-Step philosophy stipulated that addiction was a spiritual disease born of defects of character; and that 12-step groups were the only cure. She later compared Twelve-Step literature to religious literature like the Bible and the Qur’an and contrasted Twelve-Step philosophy with medical science. She gave an extended quote from the A.A. “Big Book” of Alcoholics Anonymous, which she said represented Twelve-Step philosophy saying it can never be wrong. Her bias against spiritual/religious philosophy was all through her critique.

The A.A. pamphlet “How AA Members Cooperate with Professionals,” stated that A.A. is not in competition with anyone. “Our ability to help other alcoholics is not based on scientific or professional expertise.” Unpacking principles articulated in AA’s Twelve Traditions, the pamphlet also said: “A.A. is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy; neither endorses nor opposes any causes.” In his essay on Tradition Six in Twelve Steps and Twelve Traditions, Bill W. gave a brief history of early A.A. including attempts to institute A.A. hospitals and get involved in education. He noted where these activities raised confusion. “Did A.A. fix drunks or was it an educational project? Was A.A. spiritual or was it medical? Was it a reform movement?”

These adventures implanted a deep-rooted conviction that in no circumstances could we endorse any related enterprise, no matter how good. We of Alcoholics Anonymous could not be all things to all men, nor should we try.

In the same chapter of the A.A. Big Book, which Sindewald cited and linked, “How It Works,” there is a discussion of resentment being the “number one” offender, destroying more alcoholics than anything else. “From it stem all forms of spiritual disease, for we have been not only mentally and physically ill, we have been spiritually sick. When the spiritual malady is overcome, we straighten out mentally and physically.” So there is an understanding of alcoholism as a spiritual, mental and physical illness/disease.

Also in that chapter you will find the 12 Steps described as a suggested program of recovery. “The principles we have set down are guides to progress. We claim spiritual progress rather than spiritual progression.” So it seems that AA does not present itself as the only cure; nor does it describe alcoholism merely as “a spiritual disease born of defects of character.”

A clear distinction by the author between TSF, A.A., and rehab programs using the 12-Steps isn’t maintained in her critique. In her article for The Fix, she said she used “12-step approaches” to refer to all 12-step self help groups, all 12-step-based rehab programs and TSF. However, in another article she wrote previously for Handshake Media (linked as her literature review), she said: “TSF is distinct from AA and other 12-step support groups.” Yet in her conclusion for “AA Is not Evidence-Based Treatment” Sindewald said “after exhaustive research” she could assert with confidence that 12-step approaches—including TSF—were not evidence-based treatments. She called for the reallocation of funds away from these approaches to those “that can be studied rigorously and without such crippling methodological limitations.”

With regard to A.A .and other 12 Step groups, she was right when she said they were not treatment approaches to addiction recovery. A.A. is not developed as a treatment approach and doesn’t claim to be a treatment approach. The A.A. website said: “Alcoholics Anonymous is an international fellowship of men and women who have had a drinking problem.” It is also self consciously nonprofessional, stating in Tradition Eight, “Alcoholics Anonymous should remain nonprofessional.” As fellowship organizations, A.A. and other 12-Step self-help groups are not structured in ways that can be easily studied by researchers who want to assess their effectiveness within a structured medical model of therapeutic change.

But Twelve Step Facilitation is considered to be a treatment approach. According to the NIDA description of “12-Step Facilitation Therapy,” TSF is a manual-based, structured treatment approach. It is “designed to increase the likelihood of a substance abuser becoming affiliated with and actively involved in 12-step self-help groups, thereby promoting abstinence.” And TSF is listed by NIDA as an evidence-based treatment approach, the same organization, by the way, that Sindewald referenced as defining addiction as a brain disease. Apparently NIDA doesn’t agree with her that TSF is not an evidence-based treatment approach.

It seems Sindewald’s failure to acknowledge the difference of A.A. and other 12-Step groups from the various addiction treatment approaches that apply “Twelve-Step philosophy” was intentional. It sets up a straw man argument that illegitimately transfers a critique of the TSF treatment approach onto 12-Step groups. It also seems that Sindewald’s claim to have set aside her bias while she examined Twelve Step treatment philosophy and TSF was not true.