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.
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.”
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.
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?