Alcoholics Anonymous is the most widely used treatment for alcoholism. It is mandated by the courts, accepted by mainstream medicine, and required by insurance companies. AA is generally assumed to be the most effective treatment for alcoholism, or at least “an” effective treatment. That assumption is wrong.
We hear about a few success stories, but not about the many failures. AA’s own statistics show that after 6 months, 93% of new attendees have left the program. The research on AA is handily summarized in a Wikipedia article. A recent Cochrane systematic review found no evidence that AA or other 12 step programs are effective.
In The Skeptic’s Dictionary, Bob Carroll comments:
Neither A.A. nor many other SATs [Substance Abuse Treatments] are based on science, nor do they seem interested in doing any scientific studies which might test whether the treatment they give is effective.
In the current issue of Free Inquiry, Steven Mohr has written a thorough and incisive article “Exposing the Myth of Alcoholics Anonymous.”
Mohr characterizes AA as a religious cult. The founder, Bill Wilson, had a religious experience while under the influence of strong psychotropic drugs.
He had a vision of a bright light and the revelation that he could be saved only by giving his life completely and fully to God – and that an important part of his recovery would be to bring the news of his epiphany and recovery to other suffering alcoholics.
The 12 steps of AA refer repeatedly to God. They require admitting you are powerless, accepting that only a Higher Power can help you, turning your will and your life over to God, taking a moral inventory, admitting your wrongs, being ready to let God remove your shortcomings, making amends to those you have harmed, improving your conscious contact with God through prayer and meditation, and spreading the word (proselytizing).
Criticism of the religious orientation led AA to switch emphasis from “God” to any “higher power.” One member allegedly designated a doorknob as his higher power and believed that praying to the doorknob helped him maintain sobriety.
There are other options for treatment. Inpatient programs, various medications, Secular Organizations for Sobriety. Curiously, the best treatment may be no treatment at all.
The 1992, the National Institute on Alcohol Abuse and Alcoholism’s National Longitudinal Alcohol Epidemiologic Survey studied 42,000 Americans. 4500 had been dependent on alcohol at some time in their lives. Of these, only 27% had had treatment of any kind, and one-third of those who had been treated were still abusing alcohol. Of those who had never had any treatment, only one-quarter were still abusing alcohol. George Bush is a well-known example of someone who stopped drinking on his own without attending AA and without admitting that he was an alcoholic.
According to Stanton Peele in Psychology Today,
the most successful treatments are nonconfrontational approaches that allow self-propelled change. Psychologists at the University of New Mexico led by William Miller tabulated every controlled study of alcoholism treatment they could find. They concluded that the leading therapy was barely a therapy at all but a quick encounter between patient and health-care worker in an ordinary medical setting. The intervention is sometimes as brief as a doctor looking at the results of liver-function tests and telling a patient to cut down on his drinking. Many patients then decide to cut back—and do!
A Cochrane systematic review confirmed the effectiveness of brief interventions.
Instead of telling people they are powerless, wouldn’t it make more sense to empower them and build on their strengths? Why not tell them they are stronger than alcohol and they can choose not to let it control them? Even if you prefer a religious approach, you could pray for God to support your strength to change your own life, taking full personal responsibility rather than passively turning over the responsibility to a higher power. The old adage “God helps those who help themselves” applies.
Instead of the religious model of sin, confession and absolution, what if we avoided harping on the past and started fresh, concentrating on the patient’s behavior today and in the future? Sure, make amends to those you have harmed for the bad things you have done, but why not put the emphasis on doing good things for other people today and tomorrow? Instead of being “ready to let God remove your shortcomings,” how about taking active steps to improve your own behavior? Why not build self-esteem instead of re-visiting past experiences that damaged self-esteem?
There have as yet been no scientific studies of Secular Organizations for Sobriety, but their approach seems more promising than AA’s. More and more physicians are routinely screening all patients for alcohol abuse: every time I go to a doctor’s office I am asked “Do you drink” and “How much?” By asking everyone these questions we may help prevent some cases of full-blown alcoholism by catching problem drinking early. More and more doctors are offering the brief interventions that science has shown to be effective.
Surely we can do better than AA. If three-quarters of alcoholics can stop drinking on their own with no treatment, we should be looking for ways to help them succeed rather than imposing a treatment that has not been proven effective and that may actually make things worse.
This article was originally published in the Science-Based Medicine Blog.