A Blog by Araminta Jonsson

"The greatest health risks […] by far are from alcohol or other drug use. Cognitive-behavioral and motivational programs are evidence-based, popular approaches for addressing […] substance-use disorder, and now data suggests that integrating these approaches with 12-step philosophy and practices can further help reduce the impact of substance use in their lives and potentially facilitate higher rates of abstinence. Given the prevalence of substance-use disorders […] having treatments that are both effective and cost-effective - linking patients to free and ubiquitous community resources - is needed and welcome.” - John F Kelly. Ph.D., ABPP, Elizabeth R. Spallin Professor of Psychiatry in Addiction Medicine at Harvard Medical School

Participation in 12-step programmes is now widely used both as an aftercare solution for people with substance abuse disorders and by treatment centres as the basis of their treatment model. This article attempts to analyse the criticisms and effectiveness of the 12 step recovery model as a means to maintaining abstinence.

The 12 steps, or the fellowship as it’s commonly known, was originally set up in 1935 by Bill Wilson and Dr. Bob Smith in Akron, Ohio. Today it is trusted by millions worldwide. In the beginning it was designed primarily to reach out to those affected by alcoholism. The concept of the group revolved around the fact that alcoholism is an illness that can’t be controlled but can be managed. Additionally, the group centred on spirituality and its impact on recovering from alcoholism. Each member must complete each step on their path to recovery through the guidance of a sponsor. Today the methods of the 12 steps have been adapted for a vast range of addictions and dependency problems, with over 200 different incarnations existing worldwide. As most of the research around the 12 step fellowship has been done looking at AA members, I will refer to the fellowship as a whole in this article either by using AA, the fellowship or the 12 steps.

Critics often cast scrutiny upon the “dominating” 12 step approach to recovery and question it’s poor statistical outcomes. One of the challenges for empirically examining the outcomes for people who attend 12 step programs is that they are designed to be spiritual programmes and people report transcendental experiences which are necessarily subjective. ‘For this reason, it is difficult to determine the validity of a definition of alcoholism that considers spiritual components to etiology or treatment (Chapman, 1997).[1]’ J.A. Neff also reports that despite the fact that there is more and more interest in spirituality and its benefit to health and wellbeing, there is still little research done on the efficacy of spiritual programmes for alcohol use disorder (Neff, 2005).

That said, The National Institute on Alcoholism conducted the largest ever alcohol treatment trial, Project MATCH, which started in 1989 and ran for 8 years. Project Match analysed whether certain treatment methods would work better with different individuals. Their results showed that treatment using the 12 step programme was equally as effective as Cognitive Behavioural Therapy (CBT) or Motivational Interviewing Techniques. (Werner, 2015)

However, a report published in 2000, by Alcoholism Treatment Quarterly, ‘analysed AA membership surveys taken from 1968 through 1996. On average, 81 percent of newcomers stopped attending meetings within the first month. After 90 days, only 10 percent remained. That figure was halved after a year[2]’ (Flanagin, 2014). Although this report doesn’t indicate whether those who dropped out of meetings remained abstinent or not, a more recent study by Lee Kaskutas in 2009 suggests that ‘abstinence from alcohol are twice as high among AA attendees [and that] more frequent attendance at AA meetings equates with high rates of abstinence[3]’. (Kaskutas 2009)

Returning to the spiritual aspect of the 12 step programmes, another of the biggest criticisms of the 12 steps are what people refer to as the programme’s religious affiliations. Despite 12 step programmes stating that they are a spiritual but not religious programme; AA was a self-identified Christian organisation and its founding literature clearly states “To some people we need not, and probably should not, emphasise the spiritual feature on our first approach. We might prejudice them. At the moment we are trying to put our lives in order. But this is not an end in itself. Our real purpose is to fit ourselves to be of maximum service to God.”

That being said, a significant percentage of the 12 step fellowship’s methodology is prayer based and prayer is a specific form of meditation, therefore it has the potential to convey all the health benefits that have been associated with meditation, such as the psychological and biological changes associated with improved health. Meditation has been found to alter levels of melatonin and serotonin, (Solberg et al 2004) boost the immune response (Davidson 2003) and reduces stress whilst promoting positive mood states. It is also known to reduce anxiety, pain and enhance self-esteem (Bonadonna 2003). Interestingly, spiritual meditation has been found to be superior to secular meditation and relaxation in terms of decrease in anxiety and improvement in positive mood, spiritual health, spiritual experiences and tolerance to pain (Wachholtz et al 2005).

Another extremely interesting finding relating to the power of prayer for members of the fellowship was discovered by Marc Galanter, MD, professor of psychiatry and director of the Division of Alcoholism and Drug Abuse at NYU Langone. In a study entitled, Spiritual Awakening in Alcoholics Anonymous: Empirical Findings, the authors applied a psychiatric survey instrument to 161 long-term AA members who reported having had such a spiritual awakening thanks to the fellowship. The conclusion of the study was that ‘sixty-seven percent of respondents reported no craving for alcohol or drugs at the time of this survey.[4]’ Galanter along with researchers from NYU Langone Medical Center, executed what is believed to be the first study that explores AA members brain physiology. According to the study AA members who prayed when looking at drinking related images, reported less cravings than those who simply read a newspaper. Those that prayed and experienced reduced cravings also demonstrated, via an MRI scan, more activity in the regions of the brain that are responsible for attention and emotion.

Of his study, Dr Galanter says “Our findings suggest that the experience of AA over the years had left these members with an innate ability to use the AA experience—prayer in this case―to minimize the effect of alcohol triggers in producing craving. Craving is diminished in long-term AA members compared to patients who have stopped drinking for some period of time but are more vulnerable to relapse.”

Another positive aspect of the 12-step experience which relates to spirituality is the sense of mutual support. The group has therapeutic value because participants identify with other people’s struggles and share both the positive aspects of recovery and the negative aspects of addiction. AA literature often refers to the “group” as the most important part of recovery, and the group’s solidarity is considered a critical component of the programme’s spiritual nature (Vaillant, 2005). An addict, like any human, craves a sense of belonging and community and 12 step meetings are able to offer that.

Lastly there has been research done by Rudolf H. Moos of the Department of Veterans Affairs and Stanford University, and colleagues looking at a 16 year study of alcoholics or problem drinkers who either tried to stop drinking alone, sought help from AA, sought help from a therapist and, in some cases, sought help from both. The results of this study were, when asked at the 16-year follow up, of those who went to at least 27 meetings in their first year, 67% were abstinent compared to only 34% of the individuals who hadn’t attended meetings. Those who saw a therapist in the first year reported that 56% of them were abstinent compared to 39 % who didn’t see a therapist. (Moos, 2006)

In conclusion I return to the statement by John F Kelly at the start of this article: a combination of both professional treatment and the 12 steps together seems like it is more likely to predict better outcomes than any approach alone, and the 12 step programmes are certainly better than no approach at all.