This article was originally posted on the Fix.com.
Yes, there is science behind the 12-step model. Dr. Joe Nowinski, author of “If You Work It, It Works: The Science Behind 12 Step Recovery” lays it out.
Fervent and dogmatic opinions among addiction treatment professionals about 12-step programs are not difficult to find. It’s unfortunate that impartial, dispassionate and objective viewpoints about 12-step programs are less common; which is a disservice to our patients.
Obviously, many people have gone to a 12-step program, discovered that the whole program resonated for them and found recovery in the program. Many people benefit from certain 12-step elements, while ignoring others, but nevertheless continue to attend and benefit. Others are turned off right away and never return. And still others, unfortunately, have truly negative experiences and would have been better off not having attended at all.
All of these outcomes occur, and they are all part of the universe of research on the 12 steps. Should you recommend AA or NA involvement to your patients? Dr. Joseph Nowinsky spells out the case in favour. Stay tuned to Professional Voices for future articles on this issue; we owe it to the people that we work with to take a quiet and clearheaded approach to this polarizing topic.
Richard Juman, PsyD
My first exposure to the 12-step model took place in the mid-1980s, when I held the position of Director of Student Health Services at the University of Connecticut. At the time, the university was experiencing (as it unfortunately continues to) a virtual epidemic of heavy drinking among students. Along with the drinking came its usual consequences: accidents, fights, emergency room visits and rapes—not to mention a number of academic flameouts directly attributable to chronic drinking. In my prior graduate training in clinical psychology, I’d been steeped heavily in the cognitive-behavioral approach, which was then in its ascendance, along with some supervision in existential and psychoanalytic therapy during my internship. Needless to say, there was nothing particularly spiritual about any of these approaches. Having decided it would be good for me to learn more about addiction and its treatment, I asked the head of the university’s alcohol education program about possible training programs and was immediately referred to the Hazelden Foundation in Minnesota. At the time, Hazelden offered a unique training experience for professionals like me: we were embedded on an actual rehab unit for seven days. We participated in all of the activities that the patients did. The only differences were that the other men on my unit knew I was a psychologist in training, and our small group met twice a day for seminars to discuss various aspects of the Hazelden program.
The biggest shock for me, though, came on the day of my arrival when four fellow trainees and I were ushered into a small conference room. On the table in front of each of us was a small pile of books: Alcoholics Anonymous, Twelve Steps and Twelve Traditions, and Living Sober, all published by AA. I’d never seen, much less read any of them. Then I looked up at a large poster on the wall. It was the 12 steps. My eye was immediately caught by the word God that appeared there a number of times, and my gut reaction was something like, “Oh no! I’m a cognitive-behavioural therapist! I don’t believe in God!”
I began to see, more so than in the group therapy model I’d been taught, the healing power of honesty, acceptance, and group support.
The next week proved to be eye-opening, to say the least. I took my turn doing assigned chores on the unit, went to two AA meetings a day, shared meals with the other men, and sat in on self-led groups where they openly shared their experiences of loss, of harm done to others, of grief, abuse, and abandonment. And I began to see, more so than in the group therapy model I’d been taught, the healing power of honesty, acceptance, and group support.
A few years later, I left UConn to create and supervise adult and adolescent treatment programs in a psychiatric hospital. That experience led to my first book on the subject of addiction, entitled, Substance Abuse in Adolescents and Young Adults, published by W. W. Norton in 1990, and based on the 12-step model. Then, shortly afterward, I was invited to meet with a group of researchers at Yale, who told me that they were about to embark on a national clinical trial comparing different treatment approaches to alcoholism. They were frank in telling me that their own biases were with the cognitive-behavioural approach (CBT), as well as a new and emerging approach: motivational enhancement therapy or MET. They told me that they merely needed a 12-step based approach as a comparison to these treatment approaches and expected that it would pale in comparison. Having read my book, they asked me if I’d be willing to sign on to develop that treatment, and train and supervise the therapists who would be applying this 12-step based therapy to men and women who would be randomly assigned to it. This research, dubbed Project MATCH, proved to be the largest psychotherapy outcome study ever conducted. Since then, I have been more or less continuously involved in clinical research in the area of alcohol and drug abuse treatment and have remained aware of other research on the 12-step model. As it turns out, there has been a great deal of rigorous research done in the past two decades on this model, for two reasons. First, the Institute of Medicine issued a white paper in 1989 calling for such research. Second—and much to many people’s surprise—the 12-step treatment used in Project MATCH (Twelve Step Facilitation or TSF) worked! In fact, as William R. Miller, the principal creator of motivational enhancement therapy wrote: “On at least one time-honored outcome measure—the percentage of patients maintaining complete abstinence—those in the Twelve Step Facilitation treatment fared significantly better than did patients in the other two conditions—a substantial advantage of about 10 percentage points that endured across three years.”
Much to many people’s surprise—the 12-step treatment used in Project MATCH (Twelve Step Facilitation or TSF) worked!
Although a significant body of research on the 12-step model followed in the aftermath of MATCH, critics of the approach went into high gear. AA and its 12 steps are regularly accused of being either ineffectual or downright harmful. The MATCH results have been dismissed (despite effective rebuttals from the likes of Drs. Miller and John Kelly of Harvard), and AA itself has been dismissed as an international cult that brainwashes its members. And all the while individuals like myself, who had a different opinion, were left without much of a voice, first because AA itself follows a strict policy of staying out of public controversy, and second because the evidence in support of the 12-step model has remained essentially buried in professional, peer-reviewed journals.
Roughly two years ago, following a series of discussions with colleagues about this dilemma, I got a call from my editor at Hazelden. He asked me if I was up for a major project, which would be to “translate” much of the research on the 12-step model so as to make it accessible both to the general public and to clinicians who may not be steeped in research and its interpretation. It would be a vehicle that would enable clinicians, as well as those dealing with alcohol and drug problems, to make informed decisions as to what to do. It was an opportunity I could not pass by, and the result is If You Work It, It Works: The Science Behind 12 Step Recovery.
The evidence in support of 12-step recovery is substantial and growing. The effectiveness of Twelve Step Facilitation itself has been replicated in a randomized clinical trial conducted by Dr. Kimberly Walitzer, which compared TSF to MET and found that those assigned to TSF had more evidence of AA involvement and a higher percentage of days abstinent. Another intervention with the same goals as TSF is Making AA Easier (MAAEZ). Developed by Dr. Lee Ann Kaskutas of the Alcohol Research Group in Berkeley, MAAEZ has also been found to lead to higher abstinence rates than a comparison CBT treatment. After undergoing rigorous blind peer reviews, TSF was selected for inclusion in the National Registry of Evidence-based Programs and Practices (NREPP) as well as the American Psychological Association’s listing of Empirically Supported Treatments.
Other research has looked at what we might call the “dynamics” of 12-step recovery, or the role that different components might play. It’s been found, for example, that:
· Identifying oneself as a “member” of AA, as opposed to simply attending meetings, is associated with improved sobriety.
· Becoming involved in AA (getting a sponsor, reading AA materials, making AA friends) leads to improved sobriety.
Getting a sponsor early (within three months) is better than getting one later.
· Choosing to seek treatment of some form while simultaneously beginning AA involvement leads to better results – even 16 years later.
· Choosing to attend between 100 and 150 AA meetings a year is associated with better sobriety (up to 75%) even five years after making that decision.
· Attending AA meetings regularly is associated with becoming more spiritual (though not religious) over time (as opposed to spiritual people being drawn to AA from the outset).
· Adding one or two non-drinking friends to your social network can help support sobriety, but not nearly as much as attending AA meetings regularly.
All of the above findings and more have been documented through carefully conducted research. Moreover, this research has not been conducted by individuals who set out with an agenda of proving the efficacy of Alcoholics Anonymous; by and large these studies have been conducted at major research universities. They have gone through extensive peer review in order to be funded, and again in order to be published. For those who would like to verify that, they are all listed in the appendix of my book. I would encourage skeptics to check them out.
As the saying goes, some people refuse to let facts stand in the way of their opinions. Despite all of the evidence, there are those who continue to claim that AA is unproven and even causes harm (to the point of suicide). Then, there is the strange criticism that AA only works for those who “work it” and that this is a miniscule number of people. Miniscule? In comparison to what? The total population? All those who have alcohol or drug problems? As for AA working only for those who choose to work it, psychologist Thomas McClellan, in a personal communication, as well as others, has pointed out that roughly 40 to 50% of individuals with chronic medical conditions do not adhere well to recommended treatments. They take prescribed medications sporadically, or not at all. They do not lose weight, change their diet, or exercise as recommended. The result: their condition continues or worsens, and they have to go back for treatment two or three times. In that same vein, every therapist who treats substance abuse knows clients who have given AA a half-hearted try at best. Why do critics infer from this that medical treatments and AA are ineffective, as opposed to drawing the much more obvious conclusion that any treatment that is not adhered to will not succeed?
With respect to the criticisms that 12-step programs are not run by professionals, vary widely with respect to membership and format, and can potentially expose members to toxic, as well as healing, relationships with untrained sponsors, all of this is obviously true. But these are elements common to all self-help programs and are unavoidable. And yet, critics of 12-step programs conveniently ignore an essential fact, which is that all of these elements are obviously accounted for in the research data! When the dust settles on the entire universe of evidence, the research consistently demonstrates that participation in these programs is of significant benefit. A group of prominent researchers, after surveying the research, published the following joint statement in the Journal of Substance Abuse Treatment:
Because longitudinal studies associate self-help group involvement with reduced substance use, improved psychosocial functioning, and lessened healthcare costs, there are humane and practical reasons to develop self-help group supportive policies.
A Final Caveat
Alcoholics Anonymous is not the only fellowship that supports abstinence as a solution to a severe alcohol or drug abuse problem. Others include:
· Women for Sobriety
· Secular Organizations for Sobriety
· SMART Recovery
· Double Trouble in Recovery (for the dually-diagnosed)
AA has been selected as the supportive fellowship in research because it is ubiquitous. Given their shared goals and the commonalities between these approaches, I see no reason to doubt that the outcomes associated with AA would not apply equally to those who would choose these alternate fellowships. As a Clinical Psychologist, I am a firm believer in the efficacy of evidence-based treatments, including and especially psychotherapy, for substance use disorders; as a researcher and scientist, I am a firm believer in the literature that convincingly demonstrates that participation in 12-step programs is evidence-based as well, and a valuable part of any recovery plan.
[References and sources cited here.]
Joe Nowinski, Ph.D. has held positions as assistant professor of psychiatry at the University of California San Francisco and Associate Clinical Professor of Psychology at the University of Connecticut. He is now in independent practice in Tolland, Connecticut and is the author of If You Work It, It Works: The Science Behind 12 Step Recovery.