The table in Handbook of Alcoholism Treatment Approaches

There is a table in the book Handbook of Alcoholism Treatment Approaches comparing various treatments of Alcoholism; it ranks AA as being one more the most ineffective treatments.

This table is, shall we say, weird. It rates acupuncture as one of the top 20 treatments of alcoholism, and gives motivational enhancement (#2 in the table), cognitive therapy (#13), and AA (#37) very different ratings, when the 2006 Cochrane study rate those as being about equal; other studies rate AA and/or TSF (Twelve Step Facilitation: teaching patients how to go to meetings and be a part of the AA culture) as being superior.

I also note that they only looked at seven different studies when rating AA, which leads me to believe they have only looked at old randomized controlled trials which do a terrible job of measuring AA's effectiveness.

I mean, if there was something besides this book out there arguing that acupuncture was a good deal more effective than AA, than maybe this table would convince me. But the results seem to be randomly placed on the table and I do not know of any other meta-study ranking AA as being inferior to other treatment methods. On the other hand, Cochrane 2006 said that AA is about as effective as other treatments, and Project MATCH shows that TSF is somewhat more effective than other therapies (See PMC2746426 for discussion). Fiorentine 1999, Vaillant 1995, and, yes AA's own big book give a success rate for AA around 75% for people who choose to attend one or more meeting a week; Moos & Moos 2006, which measures something slightly different, has similar figures.

Slate Star Codex discusses this table in depth in section VI (scroll down).

The most common anti-AA talking points

There are three key studies anti-steppers like to bring out when claiming the steps do not work:

• Ditman 1967. This is one of the earliest studies on AA, done before we knew how to properly study AA. It was a RCT -- a "randomized controlled trial." A RCT doesn't work with AA because 1) The people assigned to AA do not necessarily work the steps as suggested by oldtimers in AA meetings 2) The people not assigned to AA who are serious about getting sober end up going to the program anyway.
• Brandsma 1980. Like Ditman 1967, this was a RCT, with the same problems. In addition, there is an opt-repeated claim that this study shows AA results in increased binge drinking. However 1) The study looked at about three dozen different findings at multiple follow-up periods, but this result was only seen in this one finding at one follow-up period 2) This result has not been replicated in recent studies [1] even though 3) The study is 36 years old.
• The 1990 AA Triennial survey. This was not a scientific survey; this was an informal survey AA sent to members. Of the people in their first year of recovery, about 5% were in their 12th month of recovery, which is lower than the 8.3% rate we expect to see if AA had a 100% retention rate. Statistical extrapolations show that this survey shows a 29% retention rate; the question I ask is this: Is it AA's fault that 71% of newcomers decide to not come back to an AA meeting?

Note that the most recent information anti-steppers tend to bring out is over a quarter century old. What they don't like to talk about is the evidence that AA works: The more someone works AA, (That's from 2006 -- this century) the more likely they are to stay sober (That's from 2009). They dismiss this evidence with some hand-waving about "self selection", arguing that the people who stay sober by going to AA would have stayed sober anyway. While this is one possible explanation why people who go to AA stay sober, there is no evidence that this is the case. Indeed, there is a study from 2014 (under two years ago) showing that it's not just self-selection that keeps alcoholics in AA sober. 

Now, this study showing that it's not just self selection is just one study, and we need to have further studies to confirm that AA itself (and not just self-selection) helps keep alcoholics sober, but that's the direction the evidence points to right now. I would worry about these results being in just one study if the study was 36 years old, but this study is not even two years old.

Bottom line: If you have a drinking problem, and want to get and stay sober, AA is an effective way to do just that. 

[1] Edit: I need to point out Ogborne 1982, but this study is most likely just observing the fact that AA members are more likely to be honest about the negative consequences of their drinking.

A reasonable overview of the AA research out there

Here is a reasonable, if not great overview of the various studies about Alcoholics Anonymous' effectiveness:

http://slatestarcodex.com/2014/10/26/alcoholics-anonymous-much-more-than-you-wanted-to-know/

The biggest defect this essay has is that it too easily dismisses longitudinal studies, claiming they are completely ineffective because of selection bias. Unfortunately, because of the peculiar nature of AA, a proper randomized controlled trial is not feasible (the people who get sober in the control group and/or non-AA-treatment group will, as likely as not, end up going to AA meetings), so longitudinal studies are a reasonable research mechanism, albeit with the thorny self selection bias issue.

PMC4285560, which was published around the same time that blog entry was made, uses sophisticated statistical methods to minimize self selection bias; once that is done, we see that there is a specific effect from the AA program that keeps people sober.

This blog entry's strength is that it has good summaries of studies which are only available in books or behind paywalls. For example, reading its summary of Brandsma 1980, a long-time chestnut anti-steppers love to bring out, shows that the study does not actually reveal a pattern of increased binge drinking among AA members (a claim which is frequently parroted by anti-steppers, such as in the "Rational" wiki).

Salon's posts on AA

As I mentioned in my previous blog entry, with one exception, all of Salon's articles about AA have been negative. Let's look at Salon's list of AA articles:

• Pseudo-science and Bible-thumping, the worst of both worlds: The problem with rehab, AA and calling addiction a disease Negative, obviously
• Addiction is not a disease: How AA and 12-step programs erect barriers while attempting to relieve suffering Another negative one
• The drunkard’s loop: How one writer fought her way back from blackout alcoholism While this article mentions AA, it is not an article about AA
• AA is not a fraud: Why haters are afraid to listen Salon's one and only positive article about AA
• Debunking Alcoholics Anonymous: Behind the myths of recovery Here is one of the articles from Lance Dodes Salon published
• The pseudo-science of Alcoholics Anonymous: There’s a better way to treat addiction Salon likes Lance Dodes' bovine excrement about AA so much, they published two articles from him
• Is my friend suicidal? This article mentions AA but is not about AA
• My sober conversion to atheism While not as negative as, say, anything Lance Dodes ever wrote, this article is pretty negative about the AA program
• “Inside Rehab”: How it could work better, and why it doesn’t Surprisingly neutral when mentioning AA, but this is not an article about AA per se
• “Workaholism” is real This article only mentions AA in passing
• I was a sober college student Not directly about AA, but describes AA positively
• I didn’t even want these kids! Not directly about AA, but describes the 12-step program positively

In 2012 Salon was neutral, maybe even positive towards AA. By 2014, they took the Orange Papers kool-aid and were posting negative anti-AA polemics. If Salon is going to survive, they are going to have to be more positive about AA. They posted Lance Dodes' bovine excrement -- why don't they post Thomas Beresford's articles showing that Alcoholics Anonymous really works? 

Salon is cutting staff

With one exception, every single article that Salon has posted about Alcoholics Anonymous (mirror) has been negative. As it turns out, Salon is having financial difficulties and laid off a number of workers (mirror). 

I make this prediction: Salon will not be around too much longer. It will have the same fate as Substance, a magazine which was devoted to having an anti-12-step view of alcohol and drug abuse, closing its doors. On the day Substance magazine said good bye to the world, there were thousands of thousands of Alcoholics Anonymous meetings throughout the world, with countless oldtimers telling newcomers how they stayed sober by working the program using the first 164 pages of the Big Book. On the day when Salon closes their doors, there will be countless AA meetings all over the world and countless oldtimers telling newcomers how the 164 keeps them sober. The numerous anti-AA polemics that Salon has published will be relegated to the dustbin of history, and Alcoholics Anonymous will continue to thrive.

My prayers are with the people who have been laid off from Salon, that they find productive work again, perhaps for media outlets more receptive to AA's message, such as NY Mag (mirror).

"The Insane Idea"

Here is a very long -- probably too long -- article which goes in to, among other things, the fact that the science shows, as we say after the serenity prayer, "it works if you work it."

http://thepointmag.com/2016/examined-life/the-insane-idea Mirror: https://archive.is/u2ttt

One point this article makes is that it is an objective scientific fact that "the longer people attend twelve-step meetings, the more likely they are to achieve long-term sobriety."

The article, however, while acknowledging the countless studies showing a correlation between AA attendance and long-term sobriety, and correctly points out that "It is [a] gerrymandered set of data that leads Dodes to the conclusion that just “5 to 8 percent of the total population of people who enter AA are able to achieve and maintain sobriety for longer than a year”," simply quotes Dodes' assertion that AA's success rate may be because of self selection, without looking at PMC4285560 which indicates that it's not just self-selection which causes people who regularly go to meetings to stay sober.

A somewhat disappointing article; while it engages Glaser and Dodes for their inaccurate polemics, the author did not look at the recent research showing that AA is effective before writing this extended rambling piece.

the longer people attend twelve-step meetings, the more likely they are to achieve long-term sobriety - See more at: http://thepointmag.com/2016/examined-life/the-insane-idea#sthash.v6jBN2HS.dpuf

the longer people attend twelve-step meetings, the more likely they are to achieve long-term sobriety - See more at: http://thepointmag.com/2016/examined-life/the-insane-idea#sthash.v6jBN2HS.dpuf

the longer people attend twelve-step meetings, the more likely they are to achieve long-term sobriety - See more at: http://thepointmag.com/2016/examined-life/the-insane-idea#sthash.v6jBN2HS.dpuf

the longer people attend twelve-step meetings, the more likely they are to achieve long-term sobriety - See more at: http://thepointmag.com/2016/examined-life/the-insane-idea#sthash.v6jBN2HS.dpuf

the longer people attend twelve-step meetings, the more likely they are to achieve long-term sobriety - See more at: http://thepointmag.com/2016/examined-life/the-insane-idea#sthash.v6jBN2HS.dpuf

More Revealed by Ken Ragge

Before I begin, let me make something crystal clear: While I have strong disagreements with Mr. Ken Ragge about how effective Alcoholics Anonymous is, I keep him in my prayers and give him the utmost dignity, because all human beings deserve to be treated with dignity. This entry is in no way a criticism of Mr. Ken Ragge as a person; it is a criticism of his book More Revealed.

There have been multiple attempts to add More Revealed to the Alcoholics Anonymous Wikipedia page. Each attempt has failed. The reason is because the book is not notable enough to be added to a prominent Wikipedia article. To quote one Wikipedia editor:

• It has no new research; it merely regurgitates other research.
• It is not a research book; it is a polemic. It was written with a conclusion in mind; any evidence that contradicts that conclusion is ignored.
• The book claims that "There apparently have been no controlled studies done of AA against other treatment in a non-coercive environment." (p 30) This is completely wrong.
• "There are also many exclusive meetings in private homes where an invitation is necessary and “undesirables” ... are not invited." (p 98) This is a very extraordinary claim (since any such meeting can not be an Alcoholics Anonymous meeting because it violates the third tradition), and Ragge presents no evidence to back this claim up.
• Alan Ogborne in a 1993 review of More Revealed said that "This reviewer found nothing particularly new in the book but was concerned that the author found nothing positive to say about AA. This is difficult to reconcile with the obvious fact that very large numbers of people have found AA helpful and live productive and fulfilling lives within the movement. Certainly some AA groups become cultist and some members are convinced that AA is the only way to recover from alcoholism. However, this is clearly not universal."
• See Sharp Press, who published this book, has only published a few books in small numbers, and tends to only publish fringe content.

AA has a higher success rate than 5%

There is a frequently quoted 5% success rate figure for AA's success. This is a popular figure which anti-steppers love to bring up in the comments sections of articles about AA, almost always without citation. This number comes from no less than three different sources, all of which use incorrect methods to derive the 5% number:

• The 1990 Triennial Survey which the anti-steppers love to bring out had, of the population of people in their first year, 5% in their 12th month. To say this shows a 5% success rate shows a profound ignorance of statistics, as a HindsFoot article clearly shows.
• Agent Orange started a rumor that Vallant in The Natural History of Alcoholism Revisited showed a 5% success rate. The old green-papers site refuted it quite nicely; I summarize those findings in the Wikipedia talk page for Valliant's book. The actual AA success figures in that book, for people who attended 300 or more meetings over a ten-year period, is on page 197. The "this many people who attended 300 or more meetings" numbers are not in that table, but easily enough determined with some simple math: 74% of the people who went to 300+ meetings had stable remission, 21% of the 300+ meetings attenders had intermittent alcoholism, and only 5% of people who went to 300 or more meetings were still chronic alcoholics -- numbers, that, interestingly enough, agree with the figures in the preface to the second edition of AA's own Big Book (50% got sober right away, 25% got sober after relapsing, and the rest showed improvement).
• Lance Dodes used some questionable math in The Sober Truth to come up with this same figure; Gabrielle Glaser, in her 2015 hit piece, parroted Dodes' figures. Thomas Beresford, writing for the National Council on Alcoholism and Drug Dependence, directly refutes Dodes' bogus 5% figure in one article and shows some actual success figures for AA in another article.