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Alcoholics Anonymous can be effective for abstinence – Expert Reaction

More than two in five participants in Alcoholics Anonymous (AA) groups will still be sober a year on, according to a new Cochrane review.

The review encompasses 27 studies, with a total of more than 10,000 subjects, that compared AA and 12-step treatments to other treatments like cognitive behavioural therapy. The reviewers say this 42 per cent sobriety rate comes from people being encouraged to keep participating in AA after the end of the 12-step stage, whereas other programmes achieved a 35 per cent abstinence rate.

The reviewers say the AA programme is also cheaper for the healthcare system than other programmes.

The SMC asked experts to comment on the strategy.

Associate Professor Simon Adamson, University of Otago, Christchurch, Director – National Addiction Centre, comments:

“The Cochrane review highlights the value of 12 step participation for people wishing to achieve sobriety in response to an alcohol use disorder. Formal addiction treatment services can facilitate this by offering active encouragement to participate in 12 step meetings, and by discussing progress with 12 step engagement as part of normal clinical follow up. Alcoholics Anonymous are widely available throughout New Zealand and are free to attend.

“An abstinence-focused 12 step group is not the right match for all clients, but needs to be considered and promoted wherever it might reasonably aid a person’s recovery.”

Conflict of interest statement: Simon Adamson works at University of Otago, is a private practice clinical psychologist, and is on the clinical governance committee for the National Telehealth Service. 

Associate Professor Andy Towers, Mental Health & Addiction Programme, Massey University, comments:

“Alcoholic Anonymous and similar programmes around the world have a mixed history of success, and this review offers similar findings. This is a big review searching for studies that are as rigorous as possible. They’ve sorted through many studies, excluding those with issues or flaws and only retaining those they think meet a gold-standard. Overall, the review shows that 12-Step programmes can be effective for some people who wish to stop drinking and that such programmes are cheaper than many other treatment options. This supports the role that community-based support might play in helping those with drinking issues, especially low/no costs programmes that provide help seekers with a community of peers that can aid in their treatment. It also provides support for offering 12-Step programmes as one choice among a wider range of harm reduction treatment options. However, we need to be clear what this review was exploring and why they found this.

“First, the focus of this review was on abstinence as a key outcome. It showed that 12-Step programmes can help some people quit drinking, sometimes more effectively than other treatments. This is great to see but not surprising. Abstinence is the primary goal of 12-Step programmes. In contrast, abstinence may not be the goal of other treatment options (e.g., talk therapies). Drinking can often be a symptom of deeper issues that people are seeking help for (e.g., processing trauma, relationship issues or significant life events).

“Second, this review doesn’t suggest that AA is great for everyone. We know that people who are successful in 12-Step programmes tend to be those who are not dependent drinkers. Those with significant dependence issues often require medication and monitoring for withdrawal, which can be life threatening. In this case, going cold-turkey is not an option. Further, 12-Step programmes require people to submit control to god or a spiritual ‘higher power’ which suits some people. However, this excludes people who do not believe in religion or that relinquishing control is an option for them.

“Third, we know from other research that many people avoid 12-Step programmes specifically because abstinence is not an outcome that they want. Programmes like the AA are black and white; you are either on the wagon or off the wagon. However, many people want to do more than simply avoid alcohol for the rest of their lives. Instead, they want to be able to control their drinking behaviour.

“Fourth, 12-Step Programmes are cheap because they are not funded through the health system (generally). The AA is a fellowship which doesn’t cost anything to be a part of, other than some potential donations to cover meeting costs. This differs to many more comprehensive treatment options with counsellors or therapists which can be accessed either through the health system or by paying privately. In this respect many people attending AA might do so simply because it doesn’t cost (and they can’t afford more expensive options), while others might see a stigma in attending a low-cost programme and opt for other treatment (if they can pay).

“Overall, this is a solid review suggesting that 12-Step programmes can help some people stop drinking if that is their goal. The people most likely to benefit from AA are usually people with a sense of religion or spirituality, who are not currently alcohol dependent, and for whom avoiding alcohol is their desired goal. For those that don’t fall into this fairly narrow bracket we need a much wider set of treatment options.”

No conflict of interest.

Professor Doug Sellman, Professor of Psychiatry & Addiction Medicine, University of Otago, Christchurch, comments:

“Alcoholics Anonymous and related recovery networks are a hugely valuable community resource for assisting people with alcohol addiction and other substance and behavioural addictions in New Zealand. These groups promote a 12-Step programme which encourages complete abstinence from use of the particular addictive product as fundamental to recovery; and therefore bring about the key therapeutic manoeuvre required to overcome an engrained addiction – interruption of the brain circuits mediating the compulsive addictive behavior through behavioural cessation. They also provide the person with a supportive recovery community.

“It doesn’t surprise me that Alcoholics Anonymous has proved to be superior in this scientific review to cognitive behavioural therapy (CBT) and other psychological therapies in bringing about abstinence in alcohol addiction. Alcoholics Anonymous has always been abstinence focused whereas CBT focuses on people gaining control over their aberrant alcoholic behaviour through assisting the person to establish and practice new self-control thinking and is often aiming to help people moderate their drinking. Alcoholics Anonymous provides an ongoing supportive community whereas CBT is more individually based, even when delivered in a group setting.

“Alcoholism exists on a continuum from mild through to severe, and the evidence is clear: people with moderate-severe alcohol addiction almost always recover through abstinence from alcohol, whereas people with more mild alcohol problems are able to recover through moderating their drinking.

“A good rule of thumb is for people with established alcohol addiction to try out at least six Alcoholics Anonymous meetings as part of their quest for recovery before they give up on it.

“The overtly spiritual side of Alcoholics Anonymous can be a put-off to New Zealanders because of the secular nature of our society. However, the concept of Higher Power promoted in Alcoholics Anonymous is broadly conceived and can include anything greater than the person themselves including the group itself or broader concepts such as Nature, the Universe, or Love, while also including transcendental Gods of traditional religions.

“I know people who have recovered from alcohol addiction without going to Alcoholics Anonymous as well as many people with addiction who have benefited from CBT. However, over the past 35 years of working in the addiction treatment field, the most startling recoveries I’ve witnessed have involved 12-Step programmes of Alcoholics Anonymous and related 12-Step based recovery groups.”

Conflict of interest statement: I have no formal relationship with AA or associated recovery groups.