The Addiction.com Debate: Do Treatment Centers Rely Too Much on the 12 Steps?

Do Treatment Centers

An estimated 90% of U.S. treatment centers use a 12-step approach. Addiction.com asked leading experts Dr. Lance Dodes, author of ‘The Sober Truth,’ and Dr. Joseph Nowinski, author of ‘If You Work It, It Works!’ to face off on whether addiction treatment is overly focused on AA programs and their spin-offs.

 

THE DEBATERS:

 

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Dr. Lance Dodes

Photo courtesy of Dr. Dodes

Lance Dodes, MD, is the co-author of The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry and author of Breaking Addiction: A 7-Step Handbook for Ending Any Addiction. Dr. Dodes is a Training and Supervising Analyst Emeritus with the Boston Psychoanalytic Society and Institute and a retired assistant clinical professor of psychiatry at Harvard Medical School.

Dr. Dodes: Yes, treatment facilities are too reliant on 12-step programs.

“I recently had the chance to review the past 40 years of studies examining the effectiveness of [Alcoholics Anonymous] for my book, The Sober Truth. The overall success rate for AA is between 5% and 8%.  Indeed, in 2006, one of the most prestigious scientific research organizations in the world, the Cochrane Collaboration, reviewed all of the studies conducted between 1966 and 2005 and reached an even more stunning conclusion: ‘No experimental studies unequivocally demonstrated the effectiveness of AA in treating alcoholism’ at all.

There are several reasons the public is not aware of this poor success rate. First, we hear mostly from the people who do well. They write books about how AA saved their lives and they speak glowingly about it. But the vast majority who don’t do well don’t write books about it and are too often ashamed that they haven’t benefited from what people believe is a wonderful program for everyone. And, not being scientists, those people who do well and praise AA have no sense of responsibility to tone down their enthusiasm to account for all the people who don’t benefit or are hurt by AA.

A second reason people don’t know the true success rate for AA is that we are all pummeled by efforts to tell us how effective AA is. Nearly all the rehabs in this country are 12-step programs, and they have a deep financial interest in saying that 12-step programs are effective. And as I’ll describe in the next answer, the scientific studies that do claim to show that AA is effective are riddled with major errors.”

Photo courtesy of Dr. Nowinski

Joseph Nowinski, PhD, is an internationally recognized clinical psychologist and author. He is the author of If You Work It, It Works! The Science Behind 12 Step Recovery, co-author of Almost Alcoholic: Is My (Or My Loved One’s) Drinking a Problem? and Saying Goodbye: A Guide to Coping with a Loved One’s Terminal Illness. He writes for the Huffington Post and Psychology Today.

Dr. Nowinski: No, treatment facilities are not overly reliant on 12-step programs.

The 12 steps work. In my recently published book, If You Work It, It Works!, I have gathered two-plus decades of rigorous clinical research on this subject. The bottom line — as attested to by many researchers whose work I include — is definitive: This approach is effective. Research has shown, for example, that consistent attendance at fellowships such as AA is associated with sobriety. This research has also looked into factors such as the significance of sponsorship in recovery, identifying oneself with a fellowship and becoming more deeply involved in a fellowship, and found that all of them contribute to long-term sobriety.

Some critics assert that fellowships such as AA help less than 5% of those who try them — but since AA conducts no such research it is impossible to evaluate such claims — as well as those who argue that AA is actually harmful to the other 95%. These claims have gone unchallenged partly because AA chooses by policy to refrain from getting involved in public controversy, and in part because the researchers whose work I discuss do not see their role as being advocates but rather report their findings and conclusions in academic journals.”

Q: Are 12-step programs grounded in science?

Dr. Dodes: “Definitely not. In fact, the research shows the opposite, as we described in The Sober Truth. Besides the Cochrane report’s conclusion that there is no scientific basis for 12-step programs, in our research we found numerous severe errors in studies claiming a positive result for AA. The worst of these errors was ignoring data that didn’t fit their preferred conclusion — a cardinal sin in science.

Here is just one example: One of the most famous studies (Moos & Moos, 2006) was conducted over 16 years and reached positive conclusions about AA’s effectiveness. But these conclusions ignored the fact that 83% of the people they were studying dropped out of their study. In fact, their favorable view at the end of the study was based only on the 17% who stayed. Even the authors acknowledged that the people who stayed were precisely the people who were doing well! By drawing their conclusions just from the small group that did well, their findings said nothing about the majority of people, who did not do well. Claiming good success for AA was an obvious example of circular reasoning.

But the worst part of studies like these — and there are many with exactly the same faulty logic — is that the authors ended up recommending that since the tiny group that stayed longest did well, everyone should attend AA and stay with it.  The correct conclusion from their own data should have been that only a small percentage are helped, and those are the people who should stay in AA. Just as important, knowing how small the group is that benefits, the 90% who will not be helped should leave. Too many people have lost years and even decades believing that they should ‘stick with the program,’ because that is what AA tells them to do. In fact, AA regularly tells people who are not doing well that they should ‘work the program harder’ and go to still more meetings. By telling people that the program ‘works if you work it’ (another AA slogan which is totally disproven), they are led to feel worse about themselves when they can’t benefit. In essence, AA tells anyone who finds the program useless that it’s their fault. Believing that AA works if you work it has produced one of the great tragedies of our society.

Debate: Do Treatment Centers Rely Too Much on the 12 Steps?Dr. Nowinski: “Prior to 1989, little to no rigorous research had been conducted on AA. But after the Institute of Medicine issued a white paper calling for such research, many carefully designed studies were conducted at the major research universities in the country. That led a prestigious group of researchers to eventually issue the following consensus statement after carefully reviewing that research:

‘Because longitudinal studies associate self-help group involvement with reduced substance abuse, improved psychosocial functioning, and lessened health care costs, there are humane and practical reasons to develop self-help group supportive policies.’

Citations for all of the studies I’ve reviewed, as well as the above statement, can be found in the appendix of my book, for those who wish to verify them.”

Q: Do 12-step programs have a place in addiction treatment? What should treatment look like?

Dr. Dodes: “Twelve-step programs have been wildly oversold, at a great cost to people suffering with addictions, but since they do have some success, they do have a place in addiction treatment. They may well be the best approach for the 5% to 8% who can buy into them. The public health issue is, how can we best determine who will benefit, and therefore whom we should send to AA?

There are basically three things we need to do: First, we need to educate the public about the fact that AA mostly does not work, so they do not try to force their loved ones or themselves to stay in the program when they are not doing well. Second, we need to educate people about the many alternatives to 12-step programs. These include harm-reduction approaches like the HAMS network and LifeRing, as well as the most modern advances in psychotherapy (I’ve described these in two books, The Heart of Addiction and Breaking Addiction). Finally, we need to get away from routinely sending people to 12-step programs by making it standard practice for them to have an individual evaluation by a neutral (non-12-step advocate) professional, to assess the best possibility approach for them.  Given the science, we know that we should never be sending more than 10% to 15% of people to 12-step programs and we should be closely monitoring the people who do attend 12-step programs in order to help them leave when they are not benefiting.”

Dr. Nowinski: “As Dr. John Kelly, associate professor of psychiatry in addiction medicine at Harvard Medical School has stated, ‘AA and Twelve Step treatments are among the most effective interventions currently available.’ Recovery from addiction is typically a long-term process. In one important study discussed in my book, men and women who stopped attending AA as long as 16 years after completing treatment were more likely to start drinking again.

So some ongoing involvement in a recovery fellowship such as AA (or Women for Sobriety) seems to be important. In my view, recovery can begin with rehab, and ongoing psychotherapy can also be helpful, but the research clearly indicates that active involvement in a recovery fellowship is an essential ingredient in long-term recovery.”

Q: In closing, what would you like those who don’t agree with your views to know?

Dr. Dodes: “AA has become the de facto ‘correct’ or even only approach for addiction in this country, without scientific evidence to back it up. Twelve-step programs have caused enormous harm to the millions who have been sent to them and told to stick with them when they cannot possibly benefit. Claiming that AA ‘works if you work it’ is an insult to the many who do work hard at the program yet can never benefit from it. Instead of pushing this 75-year-old spiritual program with its very poor success rate, we should be guiding people to find other approaches based on a better, and more modern, understanding of addiction.”

Dr. Nowinski: “There is probably nothing I could say that would sway the hardcore critics of AA – those who confuse it with a religion (or worse, a cult) or who believe it is harmful. My message rather would be to those men and women who have become aware that their alcohol or drug use is causing harm in their lives and who are contemplating what to do about it. To those people, I would say be skeptical about the critics. Be thoughtful and questioning of those who may be simply marketing an alternative. Hard facts based on sound research are now available about the effectiveness of fellowships that support abstinence. I would suggest that those people avail themselves of those facts and then make a decision about what solutions to pursue.”

What do you think: Are treatment facilities too reliant on AA and other 12-step programs? Or are these approaches effective and useful for many?

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7 Responses to The Addiction.com Debate: Do Treatment Centers Rely Too Much on the 12 Steps?

  1. Avatar
    RichE April 29, 2015 at 1:19 pm #

    Thanks for this article. I don’t want to go to AA, frankly I don’t want to go to any program. But even more I don’t want my family and myself to deal
    with alcoholism either. So going into treatment and continuing to participate fully in AA, my quality of life has improved. My unscientific study over 13 years is when
    I participate and practice the 12 steps, I am sober and when I don’t I succumb to old habits. If AA didn’t work for me I would be trying something else and I suggest that to
    everyone.

    • Colleen Moriarty
      Colleen Moriarty April 29, 2015 at 1:56 pm #

      Hi, Rich. Thanks for your honest reply and for sharing what your experience has been like over the last 13 years with AA. And you make a good point that if AA didn’t work for you, you would try something else. I hope more people share their feelings on this topic.

  2. Avatar
    Joe Nowinski April 29, 2015 at 4:12 pm #

    That’s exactly the point; those who elect to get involved in a fellowship can expect positive results. There is no magic here; only a readiness to choose sobriety over using and a willingness to turn to others who are dealing with the same issue.

  3. Avatar
    PatrickH May 3, 2015 at 3:39 pm #

    Yes, “treatment centers” rely on the 12 step program way to much, in my opinion. Dr. Nowinski states in his response above “There is no magic here;” AA/12 step does offer miracles. In fact, one of the many AA slogans is “Wait for the Miracle”.

    I would like to point out that 12 Step programs are not considered treatment.

    Dr. Nowinski quoted a Dr. John Kelly, above, as stating that “AA and Twelve Step treatments are among the most effective interventions currently available”. In the interest of full disclosure, I would also like to point out that Dr. John Kelly is a member of the Like Minded Docs, a subgroup of members from the American Society of Addiction Medicine (ASAM) that feel that 12 step programs are not utilized enough and strongly push the AA/12 step program so it is no surprise to me that Dr. John Kelly made the above statement. No conflict of interest there, is there?

    These Like Minded Docs are insistent that a spiritual intervention is required in order for the alcohol abuser to get help. Really? A spiritual intervention? Why? Anybody that insists a spiritual intervention is needed ought to be suspect, don’t you think? Check out the Like Minded Docs website for more on them!!

    Keep in mind that in AA’s own literature, found in the Big Book Chapter “Into Action”, page 77, it clearly states that “Our real purpose is to fit ourselves to be of maximum service to God and the people about us”.

    Dr. Nowinski claims that AA/12 step is not religious, or a religion. I happen to think AA IS a religion, and in any event, it is now well settled law in the United States that AA/12 steps contain enough religious activities that coercing individuals to AA/12 Steps violates the 1st Amendment of the U.S. Constitution.

    Yes, the 12 steps have no place in providing solutions for the alcohol or drug abuser. This ridiculous notion that a spiritual intervention is required needs to be discarded and real evidence-based scientific research should be funded for new tools. People with addictions deserve better than being told only God can help.

    Thanks for the article.

  4. Avatar
    Donnie K. June 1, 2015 at 3:01 pm #

    Dr. Dodes statement that between 5% and 8% succeeds in AA is probably correct, but any success is good. I have been working in the field of addiction for over 26 years and have been sober for over 28 years. I have an obituary wall in my office of people who have died sober and those who have died after going back to alcohol or drugs. We (Alcoholic Anonymous) will be celebrating 80 years in July 2015 with a convention in Atlanta, GA with over 50,000 attending. I wonder what the statistics of the other programs of success is. So, Dr. Nowinski I also suggest that those people avail themselves of those facts, and then make a decision about what solutions to pursue.

  5. Avatar
    michael D June 3, 2015 at 9:09 am #

    I thought this was an interesting piece. I used AA for a while for support but never viewed it as treatment. I did have some out patient treatment and this dealt with a lot of issues I had with my lifestyle and problems that had built up over the years, and been made bigger by my drinking. A lot of the treatment I received, helped deal with self esteem issues and I do not think I would have done as well if I had just stuck to the AA 12 step model. AA certainly has a huge infrastructure, and it was the fellowship and not the steps that were of use to me.

    I have read the books by Lance Dodes and have been impressed both by his description of how the 12 step treatment industry has grown and also on his books dealing with solutions, which used similar methods to those I was shown in the UK. Despite the fact I moved on from AA, I do realise that many people like it and enjoy being part of a sober 12 step fellowship.Many of the people I knew when I went, are still there and are happy. I guess this is in line with the idea that AA works through attraction, but that is why I am against it being used for everyone, because many are not attracted to it at all. I saw people in AA who should not have been there and who needed proper mental health treatment, yet were being told to work the steps. The results can be disasterous when gullible people are sent to AA as part of their treatment and they fall into the hands of a dominating sponsor who cannot see when somebody is suicidal or depressed, and who has no tools to help them.

    I think people need to be told about alternatives early on in recovery, and people matched to support groups that are in line with their own beliefs. There are are those who have a grudge against AA and are very loud about it – I even got attacked for my views on the subject on a piece I wrote for this site and I was saying I had left AA years ago in it. http://www.addiction.com/expert-blogs/why-i-dont-go-to-aa/ Emotions run high on this issue, and it does illustrate the need for non 12 step approaches to be made available for those who want them. I think AA itself needs to realise that things have changed in the last 80 years and it should reflect this in the guidence it gives to a newcomer. Some of those people who walk away from AA, walk away from recovery, but a leaflet talking about alternatives for those who are not attracted to AA for whatever reason could really help the still suffering alcoholic, and that is the whole point of AA.

    I have seen many people walk away from AA and do well if they have got some sober time and come to terms with their problems. They tend to be forgotten about by those in AA, who only see those who come back to the rooms after a relapse. I have little faith in the current statistics on the success and faliure of AA and think that much more extensive testing would need to be done to find any meaningful information. Perhaps this site could send out questions to people who comment here or who sign up for a survey as it hopefully attracts people from a wide range of recovery solutions.

  6. Avatar
    peter moinichen October 21, 2015 at 12:53 pm #

    if addiction is a disease how can spiritual intervention trump science when it comes to treatment? are atheists condemned to a chaotic life? and all that bias about “mood altering substances” seems to be provided with blinders on. to say that one’s mood is more genuine than another seems arrogant and dismissive. and this from an organization where the founder took LSD and said it helped in his recovery. Bill W. also met Dr. Dole and said that he wished there was a medication similar to methadone that was effective for alcohol misusers.

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