Rethinking Twelve Step as Treatment
Alcoholics Anonymous (AA) is the largest self-help organization in the world, providing free support for individuals recovering from alcoholism. AA methodology is used in almost all drug and alcohol rehabilitation facilities. AA is routinely court mandated for drug and alcohol offenders, fueling its widespread acceptance as a viable treatment. Contrary to the popularly held belief that AA is an effective program, an abundance of research reveals AA is a complete failure but more than a rehabilitation failure it is a constitutional violation of religious freedom when court sentenced.
The Failure of Twelve Step Facilitation
The failure of AA has a long history that only recently has begun to unravel. In a study of twenty-one articles published between 1977 and 2014, researchers concluded that,
Research in this field has been characterized by a relatively uncritical discovery of AA narratives among AA members and by a lack of methodological rigor, which is likely to perpetuate its negative standing in the context of academia, and therefore in public and political discourse. Overall, findings demonstrated a pressing need for high quality qualitative research on AA (2020).
While the need for research continues to grow in urgency past research of AA or the twelve step methodology has shown that AA has a 95% failure rate and showed increased mortality rate of 3% (Vaillant, 1995). These findings are echoed by other researchers who studied eight trials involving 3417 people and determined that
Severity of addiction and drinking consequence did not seem to be differentially influenced by TSF [Twelve Step Facilitation] versus comparison treatment interventions, and no conclusive differences in treatment drop out rates were reported (Ferri, Amato, Davoli, 2006).
Perhaps one of the most compelling of these studies was undertaken by Professor George Vaillant. Professor Vaillant is the Director of Research for the Department of Psychiatry at Harvard Medical School. Professor Vaillant also sits on the board of AA World Services.
In an effort to prove that AA's effectiveness, Professor Vaillant proved AA a complete failure. After an eight year study of AA, Professor Vaillant candidly admits that AA is ineffective at treating alcoholism,
Not only had we failed to alter the natural history of alcoholism, but our death rate of three percent a year was appalling (Vaillant, 1995).
Worse than ineffective, AA may have raised the mortality rate amongst alcoholics by 3%. What Vaillant is stating in the preceding quote is important to understanding the rate of failure in AA. When he speaks of the natural history of alcoholism, he is referring to what would have happened had the alcoholics not been treated. The natural history of alcoholism is very significant because about 50% of alcoholics will recover on their own without any form of intervention at a rate of about 5% per year. This is 5% of the remaining sum after subtracting the prior year’s 5%.
Essentially, if AA treatment has a success rate of 5% per year then AA is doing nothing to curb the rate of alcoholism since alcoholics cure themselves at the same rate. But beyond just doing nothing, AA reflected a higher death rate amongst alcoholics by 3%. This means that not only did AA not work but was detrimental to alcoholics.
These numbers albeit startling, do not represent the true failure of AA. By AA’s own statistics most individuals leave AA very quickly and never return. According to AA’s own results from five surveys completed from 1977 to 1989, AA yielded a 5% rate of attendance (Hodgins, 2009). The following charts show the percentages of people who stay and leave AA over the course of a year in accordance with these surveys.
As one can see, just after one month, 81% of those attending AA leave. AA members will argue that those individuals who leave were not alcoholics to begin with. But out of thousands of people, many forced by courts to attend, it is difficult to believe 81% of these individuals attended AA by accident. The attendance by accident theory seems illogical when one considers the fact that many of the individuals who are forced to attend AA are guilty of some form of substance abuse violation. Their guilt provides evidence that these individuals may have a drinking or drug problem.
After three months there remain only 10% of the original attendees. These are not just court ordered individuals; these are also people who walked into AA unforced. These are persons who may have been seeking help on their own for their drinking problems.
At the end of one year there are only 5% of the original attendees remaining. According to AA’s own surveys, only 5% of all attendees remain for a year. But there is a far worse side to these numbers. This 5% only measures the number of attendees that stay in AA for one year. The percentage does not distinguish between individuals who are sober and those who are still drinking.
When one applies the natural history of alcoholism rate, one is left with 5% of 5%. This means that of all the people who attended AA, .25% benefitted from the program. If 1000 people go to AA for one year, only 2 to 3 persons will benefit from the program. But as stated previously AA may increase the death rate amongst alcoholics by 3%. These charts do not factor in that percentage; if one factors in the 3% death rate, the effectiveness rate of .25% will become zero or less than zero percent.
The ineffectiveness of AA is indisputable when one views these statistics. Many proponents of AA argue that since AA is not harmful to individuals then there is no reason not to send people to AA, but this reasoning is not true since AA may raise the death rate by three percent.
Besides the three percent increased mortality there are other factors that show that AA participation may be harmful. In a 20 year study of 4585 participants, researchers found that 80% of those who had received AA treatment were either sober or drinking normally. The clients who had never received any treatment, 90% were either abstinent, or drinking non-problematically. The treatment group showed that exposure to AA caused higher rates of alcoholism after 20 years (Dawson, 1996).
In 1999 a study of Texas’ correctional substance abuse treatment programs discovered that participation in AA meetings had no more effect on substance abusers than no treatment. In follow-ups to this study the rate of relapse was larger in the treatment group than in the non-treatment group. Researchers claimed that there might be some individuals who have a negative reaction to AA and this reaction causes relapses (Peele, 2001).
Violation of Religious Freedom
When courts sentence individuals to AA, the mandate is intended to provide aid for a substance abuse problem. This practice is based on the common belief that AA is an effective means for helping people achieve abstinence from alcohol or drugs which is proven false. Along with harmful, court mandated therapy violates the first amendment by coercing participation in a religious activity.
There can be no doubt about the religious nature of AA. Bill Wilson, one of the founders of AA, at the Shrine Auditorium in Los Angeles announced,
Divine Aid was A.A.’s greatest asset. An alcoholic is a fellow who is ‘trying to get his religion out of a bottle,’ when what he really wants is unity within himself, unity with God. There is a definite religious element here (Hodgins, 2009).
AA continuously defines itself as a spiritual program not a religion, but in opposition to this claim, legal decisions have been upheld which define AA a religious organization. In Grandberg v. Ashland County, a 1984 Federal 7th Circuit Court ruling concerning judicially-mandated A.A. attendance, Judge Shabaz stated,
Alcoholics Anonymous materials and the testimony of the witness established beyond a doubt that religious activities, as defined in constitutional law, were a part of the treatment program. The distinction between religion and spirituality is meaningless, and serves merely to confuse the issue (Hodgins, 2009).
In the case of Inouye v. Kemna, a parolee violated for not wishing to attend AA meetings claimed the meetings were a violation of his freedom of religion. The court ruled that parolees could not be forced to attend AA meetings. Judge Marsha Berzon, writing for the court, stated,
While we in no way denigrate the fine work of AA/NA, attendance in their programs may not be coerced by the state (Mullins, 2007).
In Griffin v. Coughlin, a prisoner sued the state because his right to freedom of religion was violated when the prison tried to force him to attend AA meetings. Judge Levine ruled,
While it is of course true that the primary objective of A.A. is to enable its adherents to achieve sobriety, its doctrine unmistakably urges that the path to staying sober and to becoming happily and usefully whole is by wholeheartedly embracing traditional theistic beliefs (Conlon, 1997).
AA is a religious organization denoted clearly by the organizations or programs steps which request that the participant, “turn their will and life over to the care of God,” there is an implicit religious connotation in such as request. AA simply uses the word God and Higher Power interchangeably and redefines their religion as a spiritual program. Regardless the semantics, the law has judged AA to be a religious group and therefore unconstitutional to mandate attendance.
The Unfairness of Treatment
There exists unfairness in the quality of care given to substance abusers, considering the fact that the FDA would never approve a treatment method of such unscientific and low efficacy. Yet in the case of substance abuse, thousands of individuals are routinely sent to AA for help and for many this is a a death sentence.
Proponents of AA argue that continued use of AA may at least be helping some of the people who attend, which begs the question, at what cost?
The larger implication from continued AA use is that substance abusers are constantly lied to and placed in harm’s way whether intentionally or unintentionally. Doctors, clinicians, and judges routinely send substance abusers to AA completely unaware of the low effectiveness and violation of religious rights. A large part of the problem is the lack of ability to fight the issue as most people sentenced to AA are not in a position to refuse treatment and fight for their rights.
Substance abuse is a terrible problem. An estimated 20 million Americans are substance abusers and many of these individuals are chronic addicts and alcoholics. This number has steadily grown since the creation of AA, eighty years ago. There is very little hope of remedying this problem when the treatment being used is ineffective. Perhaps if a different mode of therapy was used the number of chronic substance abusers would begin to decrease.
Conlon, L,S (1997). Griffin v. Coughlin: mandated AA meetings and the establishment clause. Journal of Church & State, Vol. 39 , p427–428.
Dawson, D (1996).Correlates of past-year status among treated and untreated persons with former alcohol dependence: United States, 1992. Alcoholism: Clinical and Experimental Research. Vol. 20, 773–790.
Ferri M, Amato L, Davoli M. Alcoholics Anonymous and other 12-step programmes for alcohol dependence. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD005032. doi: 10.1002/14651858.CD005032.pub2. PMID: 16856072.
(2020) A Critical Review of Qualitative Interview Studies with Alcoholics Anonymous Members, Substance Use & Misuse, 55:3, 387-398, DOI: 10.1080/10826084.2019.1681450
Hodgins, T (2009). It’s spiritual not religious. Retrieved July 1, 2009, from Orange-Papers Web site: (Now Archived) http://www.orange-papers.org/orange-spirrel.html
Mullins, K,J (2007). AA cannot be forced onto parolees. Retrieved July 15, 2009, from Digital Journal Web site: http://www.digitaljournal.com/article/229810AA_Can_Not_Be_Forced_Onto_Parolees Peele, S (2001). Drunk with power. Reason. Vol. 33, 34.
Vaillant, G.E. (1995). The natural history of alcoholism revisited. Cambridge, MA: Harvard University Press.
Wilson, W (2001). Alcoholics anonymous. New York, NY: Alcoholics Anonymous World Services.
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Article Updated: 11/08/2021