Alcoholics Anonymous is synonymous with getting help, the church-basement, default remedy for problem drinkers in real life and in the suds-soaked world of TV and movies.
But for years addiction experts have debated the role and scientific effectiveness of AA, a fellowship founded in 1935 that relies on 12-steps aimed at a spiritual awakening. Some viewed AA as old-school, even cultlike. Others hailed it as a bedrock of recovery. Numerous studies have tried to pin down how well AA and the many 12-step groups it spawned, actually work.
Dr. Lance Dodes is the most recent to wade into this debate in a new book, The Sober Truth: Debunking the Bad Science behind 12-Step Programs and the Rehab Industry. Dodes combed through more than 50 studies and found that the success rate for Alcoholics Anonymous is between 5 and 10 per cent, which he calls one of the worst in all of medicine.
“I’m not trying to eliminate AA,” says Dodes, the former director of substance abuse treatment at Harvard’s McLean Hospital. “I’m just saying it should be prescribed to that tiny group who can make use of it. It’s terribly harmful when you send 90 per cent of the people for the wrong treatment advice.”
AA doesn’t actually use the word treatment or therapy. Rather it’s about alcoholics helping one another beat booze by following the 12-step path that includes admitting powerlessness over alcohol, believing that a “Power greater than ourselves could restore us to sanity,” undertaking a “fearless moral inventory” and making amends. That can be hard to quantify, especially since members are anonymous.
“The model has been so popular, so widely disseminated, that people believe it should be something that works,” says Dr. Bernard LeFoll, head of Alcohol Research and Treatment Clinic at the Centre for Addiction and Mental Health. But at this point, he says, we have neither definitive data supporting that it works nor studies about whom it most benefits.
AA doesn’t have the answers either. “We are not a scientific or medical organization. We don’t do that kind of research,” says Jim, the public information co-ordinator at AA’s General Service Office in New York City, who maintains the anonymity tradition. AA’s sole data-gathering is a survey of 8,000 members in the U.S. and Canada every three years.
As part of its tradition, the organization, with more than two million members in 170 countries, does not express opinion or engage in debate, he explains.
But members will readily jump into the fray. “Yes AA works. I was in a very deep, dark, sad place. I walked into my first meeting, and people were so encouraging. It was a warm, friendly, safe place,” says John Fenn, now a recovery counsellor at Bellwood Health Services in Toronto. “I would never have been able to stay sober for 20 years without AA.”
In his analysis of the research, Dodes found many problems. For one, much of the data was based on individuals’ self-reports, which are often unreliable. Another sticking point is how to define success. Many of the studies done by outside researchers only followed people for a year or less, explains Dodes. “That’s insane. It’s a lifelong condition,” he says.
And, in what he calls a cardinal sin, some studies omitted the dropouts. The conclusions didn’t include the people for whom the program most likely didn’t work. While AA officially never comments, three AA members wrote a paper, “Alcoholics Anonymous Recovery Outcome Rates,” in 2008, refuting reports at the time of a very low success rate.
The authors reiterated numbers espoused since AA’s early years as still the “best estimate:” For those who seriously work the program, the success rate is 75 per cent (that’s 50 per cent achieving immediate reward and another 25 per cent who slip then recover). But here’s an important caveat: Of all AA prospects, they say, about 20 to 40 per cent fall into that category of seriously trying the program.
That leaves a lot of people not succeeding, likely dropping out. And they’re the ones who concern CAMH’s LeFoll. Since AA is so well known and easily accessible, it’s frequently the first place people try, he says. But if it doesn’t click for them, they may give up hope of recovery.
They need full information about other available treatment, such as in-patient or outpatient individual therapy as well as group support that offers behavioural strategies, insights into addiction and relapse prevention tools.Historically the addictions field has pushed abstinence, but some programs now aim for reduction, a level of consumption that doesn’t produce harm. “The difficulty,” says LeFoll, “is that we can’t predict who can sustain reduction.”
Advances in the neurobiology of addiction have led to more medications that deter the desire for a drink. Last year, CAMH opened the Alcohol Research and Treatment Clinic to improve access to these drugs, which have not been used by many physicians. One clinic patient, Terry, has started taking disulfiram, also known as Antabuse. It makes people extremely ill if they consume alcohol. “Now I don’t have to wrestle with wanting to drink. I know I can’t,” says Terry confidently.
He’s going to AA meetings for extra support, but AA hasn’t helped him in the past. Over 30 years, he’s started AA and dropped out about 10 times. “I’m not a people person, not a joiner,” he says. Researchers do know that some kind of ongoing help boosts chances for long-term recovery. “We don’t oppose anyone joining AA,” says LeFoll. “We encourage people to build as much support as they can. We just want to give a broader view of all options and they can pick.”
Most AA members don’t rely solely on fellowship. According to its 2011 member survey, the majority received additional treatment or counselling. Of the 62 per cent who got help after joining AA, 82 per cent said the added assistance played an important part in their recovery. “We’ve never claimed to be the only game on the block,” says the AA public information co-ordinator. “There isn’t a one-size-fits-all to that kind of personal struggle.”
At Bellwood Health Services, an addiction treatment centre, clients go through group and individual therapy during their stay and can sign up for the aftercare program, but they are also encouraged to join a 12-step group for long-term support.
Clients’ biggest objection is the religious aspect, says addiction counsellor David Paul. They don’t like the word “God” in the 12 steps or the idea of a Higher Power. The steps broadly define God “as we understood Him” and the Higher Power could be anything, he says, even the AA group itself. “I think at times people use God as an excuse,” says Paul.
In the Greater Toronto area, there are nearly 500 AA meetings a week, including five for agnostics, aatorontoagnostics.com.
While any 12-step program requires hard work, Dr. Peter Butt, an addiction specialist in Saskatoon, cautions against blaming the struggling addict for lack of effort. The focus should be: Why is this person struggling? Butt ticks through a list: Is there a concurrent mental health problem? Do they need medications for cravings? Do they first need help making their lives more stable?
Maybe the person needs a 12-step meeting that’s a better fit. “Some people I’ve met in the 12-step community are very rigid, while others are the most compassionate of people,” says Butt, a representative on the Canadian Centre of Substance Abuse’s national alcohol strategy. “People do best when they have access to a spectrum of options,” he adds. “A 12-step program is simply one tool in the tool box.” That’s Steve’s attitude. He’s been sober 120 days and proud of it.
To get there, he first tried AA but felt he needed a more intense intervention. After a stint of in-patient rehab, he now leans on a variety of supports: He’s back in AA, routinely sees a doctor specializing in addiction and also meets regularly with a group of non-AA recovering alcoholics who talk about their struggles. “I’m open to explore the best ways,” says Steve, as he eats lunch in a pub drinking a club soda. “Two months ago I could not have eaten here. I haven’t even looked over at the draft taps.”
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