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.’”
