12 Steps is not too many (Miller 2008)

Back in 2009, Time magazine published an article claiming 12 steps are too many. This article, in addition to having a section praising Naltrexone (a pill with limited value), uses a single study to conclude the 12 steps are not helpful.

The dubious study was led by pro-moderate-drinking-for-alcoholics advocate William Miller, and is entitled “Spiritual direction in addiction treatment: Two clinical trials.”

This paper is an outlier. A 2012 meta-study of hundreds of papers about religion, spirituality, and health (Religion, Spirituality, and Health: The Research and Clinical Implications by Harold G. Koenig) looks at hundreds of similar studies.  Of the 178 studies about depression and spirituality with the highest methodological rigor, the 2008 Miller paper is one of only 13 which showed spirituality resulting in more depression symptoms. In addition, this meta-study looked at whether spirituality helps people get clean and sober. Of the 145 studies with the best methodologies directly investigating the question of whether spirituality helps overcome substance abuse, 131 showed that it did, and only one could make the case that spirituality hurts someone’s chances of getting off of alcohol and/or drugs.

Koenig 2012 is not the only paper that contradicts Miller 2008. J. P. B. Goncalves et al. 2015 (Religious and spiritual interventions in mental health care: a systematic review and meta-analysis of randomized controlled clinical trials) looks at 23 studies; Miller 2008 is the only study they look at which concludes there is a negative correlation between spirituality and better results. 

Another paper may explain the issues with the methodology in Miller 2008. Greene 2012 (Gary Greene and Tuyen D. Nguyen The Role of Connectedness in Relation to Spirituality and Religion in a Twelve-Step Model) speculates that Miller 2008 “may point to the  immeasurable therapeutic value of the spiritual connectedness between members of  twelve-step and other groups and a measurable disconnect often present in research trial” (emphasis in original). In other words, Greene 2012 speculates that the subjects of Miller 2008 who got “spiritual” guidance did not get it in the form a newcomer gets it in the rooms of 12-step meetings, since the subjects did not experience the same connectedness.

Cherry picking a single study whose results are different than the results of the majority of similar papers does not make for a very compelling case against using the 12 steps to stay clean and sober.

The 12 steps work. A single study saying otherwise does not change this fact.

Surprise! An article in a stoner magazine doesn't like Alcoholics Anonymous

Surprise! An article in a stoner magazine doesn't like Alcoholics Anonymous.

This article uses the following two anti-AA tropes to claim that AA does not work:

• Lance Dodes' claim that AA has a 5-8% success rate, which I have have dealt with four years ago in this blog, and which has been fully refuted in the article "Alcoholics Anonymous and The Atlantic: A Call For Better Science"
• That table in Handbook of Alcoholism Treatment Approaches which anti-steppers (such as stoners lying to themselves) love to bring out, which is also quite inaccurate (yes, I have already blogged about this table). Did I mention that its author, William R. Miller, has recently written a book telling alcoholics how to moderate their drinking which is, quite bluntly, a fool's errand.

The article also claims the AA Big Book is inaccurate when it claims a 75% success rate. Actually, I have seen multiple studies with this figure or similar figures; e.g. Moos and Moos 2006 shows, among alcoholics who took AA seriously, 67% of them were still sober 16 years later.

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).