Effectiveness of Alcoholics Anonymous


The effectiveness of Alcoholics Anonymous in treating alcoholism has been extensively studied. Many papers have been published studying the degree to which Alcoholics Anonymous helps alcoholics keep sober. The subject is controversial with some studies showing AA helping alcoholics, while other studies do not show AA efficacy. The U.S. Surgeon General states in a 2016 report on addiction that "Well-supported scientific evidence demonstrates the effectiveness of twelve-step mutual aid groups focused on alcohol and twelve-step facilitation interventions." The program appears to be helpful for a subset of alcoholics; Alcoholics Anonymous appears to be about as effective as other support groups recommending abstinence from alcohol and other drugs of abuse.

Overview

There are a number of ways one can determine whether AA works and numerous ways of measuring if AA is successful. The 2020 Cochrane review of Alcoholics Anonymous determines success as "abstinence, reduced drinking intensity, reduced alcohol-related consequences, alcohol addiction severity, and healthcare cost offsets."
Because of the anonymous and voluntary nature of Alcoholics Anonymous meetings, it is difficult to perform random trials with them; the research suggests that AA can help alcoholics make positive changes. The Surgeon General of the United States 2016 Report on Alcohol, Drugs, and Health states "Well-supported scientific evidence demonstrates the effectiveness of twelve-step mutual aid groups focused on alcohol and twelve-step facilitation interventions."
The research is quite complex and is still developing; some studies have suggested an association between AA and increased abstinence or other positive outcomes, but other studies have not. Likewise, some articles in the popular press state that Alcoholics Anonymous helps some alcoholics get sober, but others claim AA is not effective.
While older studies did not show a correlation between being assigned to AA and better treatment outcomes, newer studies show that Alcoholics Anonymous significantly increases abstinence after treatment. The 2020 Cochrane review saw, at the 12-month follow up, a 42% abstinent rate for AA and twelve-step facilitation treatments which encourage patients to regularly attend AA meetings, compared to 35% abstinent using non-AA interventions.
Longitudinal studies show a high success rate for the 25% to 30% who are heavily involved with AA. One study saw that AA adherents have a 67% success rate; another shows a 74.8% success rate among regular AA meeting attenders. Longitudinal studies suffer from self-selection bias, but one 2014 meta-study concludes that AA's effectiveness does not entirely come from self-selection.
Alcoholics Anonymous appears to be about as effective as other abstinence-based support groups.

Systematic reviews, meta-analyses and large clinical studies

Cochrane Reviews

The 2020 Cochrane review of Alcoholics Anonymous shows that AA results in more alcoholics being abstinent and for longer periods of time than some other treatments, but only as well in drinks-per-day. When comparing Alcoholics Anonymous and/or Twelve Step Facilitation to other alcohol use disorder interventions, at the 12-month follow up, studies show a 42% abstinent rate for AA/TSF treatments, compared to 35% abstinent using non-AA interventions. The study argues that Alcoholics Anonymous is a good treatment for a subset of alcoholics. It shows that AA is effective because it is available almost anywhere, but it does not work for all alcoholics.
The study concludes that "Manualized AA/TSF interventions usually produced higher rates of continuous abstinence than the other established treatments investigated. Non-manualized AA/TSF performed as well as other established treatments clinically-delivered TSF interventions designed to increase AA participation usually lead to better outcomes over the subsequent months to years in terms of producing higher rates of continuous abstinence." Here, a "manualized" treatment is one where a standard procedure was used. A TSF treatment is a "twelve-step facilitation" treatment: A treatment which encourages a patient to attend Alcoholics Anonymous.
Dr. Richard Saitz says the study looks at the effectiveness of psychotherapy along with AA, instead of the effectiveness of just going to AA meetings. Dr. Tim Brennan says that this Cochrane Review is a "compelling study", but says that this study does not necessarily conclude that AA is better than behavioral therapy; Brennan said people concerned about their drinking should get professional treatment. Dr. Antoine Douaihy says that AA is very helpful for people, especially those who can not get more formalized treatment.
An older 2006 Cochrane review stated that the "available experimental studies did not demonstrate the effectiveness of AA or other twelve-step approaches in reducing alcohol use and achieving abstinence compared with other treatments", but the newer study has more studies to work with and does not utilize all of the studies used by the older report.
Dr. Stanton Peele says "this announced positive result compared with the first review was due solely to switching measurements — from actual recovery rates to continuous abstinence", due to AA focussing on abstinence rather than harm reduction. He also claims that such benefits were not apparent across the board and that AA/TSF often performed worse on critical measures.

Humphreys, Blodgett, and Wagner 2014

A 2014 meta-analysis of the data from five studies by Keith Humphreys, Janet Blodgett and Todd Wagner concluded that "increasing AA attendance leads to short and long term decreases in alcohol consumption that cannot be attributed to self-selection." Austin Frakt, writing for The New York Times, discusses how the study's methodology minimizes outside factors, such as how motivated the people who succeed at becoming abstinent are. Frakt sums up the results of the research as follows: "Going to an additional two A.A. meetings per week produced at least three more days of alcohol abstinence per month". The article concludes that "A.A. helps alcoholics, apart from the fact that it may attract a more motivated group of individuals. With that established, the next step is to encourage even more to take advantage of its benefits."

Kaskutas 2009

In 2009, Lee Ann Kaskutas performed a meta-analysis of other studies looking at how effective Alcoholics Anonymous is. The article notes that "rates of abstinence are about twice as high among those who attend AA" but concluded that whether Alcoholics Anonymous has a specific effect is unclear, stating that there were "2 trials finding a positive effect for AA, 1 trial finding a negative effect for AA, and 1 trial finding a null effect."
The study reported that while the evidence base for twelve-step groups from experimental studies was weak, "other categories of evidence... are overwhelmingly convincing". Specifically, the correlation between exposure to AA and outcome, the dose-response relationship, and the consistency of the association were found to be very strong. In other words, the frequency with which individuals attend meetings appears to have a statistically significant correlation with maintaining abstinence. Kaskutas noted two studies which both found that 70% of those who attended twelve-step groups at least weekly were abstaining from alcohol consumption at follow ups two and sixteen years later. Those who attended less than once per week showed about the same success rate as those who didn't attend meetings. Kaskutas also found AA to function consistently with known behavioral change theories and substantial empirical support for specific mechanisms through which AA facilitates change.

Moos and Moos 2006

A 2006 study by Rudolf H. Moos and Bernice S. Moos saw a 67% success rate for the 24.9% of alcoholics who ended up, on their own, undergoing a lot of AA treatment: Of subjects highly involved with AA in their first year of alcohol treatment, 67% were sober 16 years later. The study looked at the outcome of a group of alcoholics seeking treatment over a 16-year period. The subjects decided on their own whether to use AA, and how much AA treatment they got. The study stated that "individuals who participated in AA for 27 weeks or more had better 16-year outcomes", showing that "only 34% of individuals who did not participate in AA in the first year were abstinent at 16 years, compared to 67% of individuals who participated in AA for 27 weeks or more."
The study's results may be skewed by self-selection bias.

Fiorentine 1999

Fiorentine 1999 was a 24-month longitudinal study measuring the effectiveness of AA and Narcotics Anonymous.
At the 24 month follow up, 74.8% of people who went to one or more meetings a week self-reported being completely sober, but under 40% of people who did not go to twelve-step meetings claimed to be sober. Urinalysis showed 96.6% of people regularly going to meetings as sober, in contrast to the 88.9% of people who didn't go to meetings once a week or more whose urine sample was alcohol-free.

Kownacki and Shadish 1999

A review of older experimental trials on AA, carried out by Kownacki and Shadish in the late 1990s, showed that randomized controlled trials showed a negative effect for AA, suggesting that coercion to AA yields worse outcomes than the outcomes of people who received other types of addiction treatment and those who received no treatment. However, other trials showed that AA had a positive effect.
This paper used the following coerced experimental trials where the AA treatment was, according to Kownacki and Shadish 1999, a conventional AA meeting: Brandsma et al., Ditman et al., and Walsh et al..

Project MATCH (1998)

Project MATCH was an 8-year, multi site, $27-million investigation that studied which types of alcoholics respond best to which forms of treatment. MATCH studied whether treatment should be uniform or assigned to patients based on specific needs and characteristics. The study concluded that twelve-step facilitation was as effective as the other psychotherapies studied.

Walsh 1991

In 1991, Walsh and other researchers carried out a randomized controlled trial among 227 subjects. They were randomly assigned to mandated inpatient treatment, mandatory AA meetings, or allowing the subject a choice of options.
This study was one of the eight studies used to determine the conclusions for Cochrane 2006.
While the subjects assigned to inpatient treatment did better than the subjects only assigned to AA meetings, the inpatient treatment consisted of three AA meetings a week while in treatment, followed by a year of three AA meetings a week after the inpatient treatment ended; the study shows that inpatient treatment consisting of AA is more effective than just AA meetings.

Brandsma 1980

The 1980 book Outpatient Treatment of Alcoholism describes a mid-1970s study of 260 individuals, 184 referred by the courts and 76 self-referred or referred by other agencies. Participants were assigned randomly within five treatments, including an Alcoholics Anonymous-like meeting. The study found that AA was more effective than no treatment, and about as effective as the other alcoholism treatments. Since the "Alcoholics Anonymous" treatment patients underwent in the Brandsma study did not use community Alcoholics Anonymous meetings, and since there was no effort to stop the people in the control group from attending real Alcoholics Anonymous meetings, later analysis says that there are "concerns with the Brandsma trial which call its experimental results into question".

Ditman, ''et al.'' 1967

A 1967 study saw a judge in San Diego randomly assign offenders to either clinical treatment, AA treatment, or to a no-treatment group. After one year, 68% in the clinic group were rearrested, 69% in the AA group were rearrested, and 56% were rearrested in the group receiving no treatment. No statistically significant differences between the three groups were discovered in recidivism rate, in the number of subsequent rearrests or in time elapsed prior to rearrest. Like the Brandsma study, the study did not stop people not assigned to AA treatment from going to AA meetings.

Membership retention

Results from National Longitudinal Alcohol Epidemiological Survey

In 1992, the United States Census Bureau and the National Institute on Alcohol Abuse and Alcoholism conducted the National Longitudinal Alcohol Epidemiologic Survey. Direct face-to-face interviews were conducted with one randomly selected respondent, 18 years of age or older, in each of 42,862 households within the contiguous United States and the District of Columbia. NLAES respondents were asked whether they ever attended an Alcoholics Anonymous meeting for any reason related to their drinking. 1106 respondents stated they had attended an Alcoholics Anonymous meeting for their drinking prior to the past year. 348 respondents stated they attended an Alcoholics Anonymous meeting prior to the past year and continued to attend Alcoholics Anonymous during the past year, a 31% continuance rate.

Results from NIAAA's National Epidemiological Survey on Alcoholism and Related Conditions

In 2001–2002, the National Institute on Alcohol Abuse and Alcoholism conducted the National Epidemiological Survey on Alcoholism and Related Conditions. Similarly structured to the NLAES, the survey conducted in-person interviews with 43,093 individuals. This time, respondents were asked if they had ever attended a twelve-step meeting for an alcohol problem in their lifetime. 1441 of respondents answered the question affirmatively. Answers were further broken down into three categories: disengaged, those who started attending at some point in the past but had ceased attending at some point in the past year ; continued engagement, those who started attending at some point in the past and continued to attend during the past year ; and newcomers, those who started attending during the past year. In their discussion of the findings, Kaskautas et al. state that to study disengagement, only the disengaged and continued engagement should be utilized.

Results from triennial surveys

To measure the retention of members, the 1968 AA General Service Conference voted to begin surveying those participating in AA. A survey was conducted beginning that year and subsequent surveys have been conducted about every three years, the latest of which was from 2014. The basic results of the surveys are made available in pamphlet form to AA members. Additional comments and analysis intended for academic and professional audiences were written to supplement the survey results from 1970 to 1990. Non-alcoholic board of trustees member Dr. John Norris wrote the second and third analyses. The second was presented at the North American Congress on Alcohol and Drug Problems, the third was presented at the International Congress on Alcoholism and Drug Dependence.
The 1990 commentary evaluated data of triennial surveys from 1977 through 1989 and found that after the first year, the rate of attrition slows. Only those in the first year were recorded by month. The survey states that the data "strongly suggests that about half those who come to A.A. are gone within three months." Comments published by AA about this survey claim that 26% of people who attend AA meetings continue attending for more than one year; this is very close to the results from several independent assessments. In the previous surveys, this group would be the only ones considered to have "tried AA". After the first year, the rate of attrition slows. The nature of the survey questions asked did not allow a direct comparison between the twelfth month of the first year and the first month of the second year. Only those in the first year were recorded by month. The necessity of an introductory period was not considered in the 1990 analysis, and the concept was not present in its analysis.

The popular press

''The Sober Truth''

, in The Sober Truth, says that most people who have experienced AA have not achieved long-term sobriety, stating that research indicates that only five to eight percent of the people who go to one or more AA meetings achieve sobriety for longer than one year. Gabrielle Glaser used Dodes' figures to state that AA has a low success rate in a 2015 article for The Atlantic, which says that better alternatives than Alcoholics Anonymous for alcohol treatment are available.
The 5–8% figure put forward by Dodes is controversial; Thomas Beresford, M.D., says that the book uses "three separate, questionable, calculations that arrive at the 5–8% figure." The New York Times calls The Sober Truth a "polemical and deeply flawed book". John Kelly and Gene Beresin state that the book's conclusion that " approaches are almost completely ineffective and even harmful in treating substance use disorders" is wrong, noting that "studies published in prestigious peer-reviewed scientific journals have found that 12-step treatments that facilitate engagement with AA post-discharge produce about one third higher continuous abstinence rates." Jeffrey D. Roth and Edward J. Khantzian, in their review of The Sober Truth, called Dodes' reasoning against AA success a "pseudostatistical polemic."
Lance Dodes has not, as of March 2020, read the 2020 Cochrane Review which shows AA efficacy, but in response to it says that he does not feel creating a social support network helps with addiction.