Does AA work? That’s (in part) up to you

Tonigan et al¹⁰ rated 74 studies of alcohol use disorders that measured patients’ affiliation with AA and drinking outcome and/or psychosocial adjustment. Most were cross-sectional inpatient studies; few used collateral interviews or biological measures to confirm self-report data. Most used poor methodology, and their assessments were not psychometrically validated.

Outpatient studies showed positive correlations between AA attendance/involvement and:

• reduced drinking
  
• improved psychological adjustment and improved family relationships.
  

Outcomes were much more heterogeneous in inpatient samples, and no predictive relationships were seen between AA use and drinking outcome or psychosocial adjustment.

All three meta-analyses excluded studies of alcohol-dependent individuals with co-occurring drug use disorders, leaving unaddressed the effect of adjunctive AA in that population.

Table 1

AA’s Twelve Steps of personal recovery

We admitted we were powerless over alcohol—that our lives had become unmanageable. Came to believe that a Power greater than ourselves could restore us to sanity. Made a decision to turn our will and our lives over to the care of God as we understood Him. Made a searching and fearless moral inventory of ourselves. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. Were entirely ready to have God remove all these defects of character. Humbly asked Him to remove our shortcomings. Made a list of all persons we had harmed and became willing to make amends to them all. Made direct amends to such people wherever possible, except when to do so would injure them or others. Continued to take personal inventory and when we were wrong promptly admitted it. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out. Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

Source: Reprinted with permission, Alcoholics Anonymous World Services (AAWS), Inc. 2005. Permission to reprint does not mean that AAWS has reviewed or approved the contents of this publication, or that AA necessarily agrees with the views expressed herein.

Project MATCH. Although not specifically an AA study, Project MATCH¹⁶ examined the efficacy of twelve-step, individual therapy in treating alcohol abuse or dependence. This multi-site RCT of 1,726 patients compared 12 sessions of a manual-driven, twelve-step facilitation (TSF) with two other empirically-supported, standardized, individual alcohol dependence treatments:

• 12 sessions of cognitive-behavioral coping skills (CBT)
  
• 4 sessions of motivational enhancement therapy (MET).
  

TSF encouraged and monitored AA attendance, whereas CBT and MET neither encouraged nor discouraged AA use. Although all three treatment groups were drinking less at 1-and 3-years follow-up, TSF was particularly effective for persons with severe alcohol dependence and low psychiatric severity.^4,5,17 After treatment, those in the TSF group participated in AA more than did individuals in the CBT and MET groups.

Project MATCH thus found that a twelve-step individual therapy was at least as effective as CBT and MET in reducing post-treatment drinking and maintaining abstinence.

Real-world efficacy. A naturalistic study that resembled Project MATCH enrolled 3,018 male military veterans with substance use disorders across 15 program sites.¹⁸ Drug dependence was not excluded, and 51% of the men had co-occurring alcohol and drug dependence.

Participants received inpatient detoxification, followed by 21 to 28 days of intensive twelve-step treatment, CBT, or both. Alcohol and drug abuse declined equally in all three groups, and subjects were referred for outpatient aftercare and self-help groups. After 1 year, involvement in a self-help group predicted better outcome, regardless of the initial treatment.¹⁹

Unlike earlier studies,^15,20,21 this trial found that individuals with co-occurring psychiatric disorders and those legally mandated to get treatment did as well at 1-year follow-up as those without these variables. It provides additional evidence that twelve-step treatments can reduce substance use across varied populations, including patients with co-occurring alcohol and drug dependence.

AA ATTENDANCE VS. PARTICIPATION

Twelve-step programs appear most effective for individuals who actively participate. This may seem obvious, but most studies of 12-step treatments have monitored meeting attendance rather than engagement. Most studies that separate these variables report that active participation—not passive attendance—correlates with reduced substance use.

Montgomery et al²² followed 66 alcohol-dependent individuals in a 12-step oriented, 28-day residential treatment program and investigated:

• relationships between AA attendance and participation
  
• drinking outcomes over 31 weeks after treatment.
  

Although AA attendance did not predict outcomes, active involvement in the 12 steps predicted reduced drinking and more-favorable perceptions about life having purpose or meaning (as opposed to despair that life has become meaningless as a consequence of alcohol dependence).