Here is an article, written by a medical student, which looks at Alcoholics Anonymous (AA) from the viewpoint of a doctor who needs to understand the program better. Not only does it have a favorable viewpoint about AA, it links to and summarizes scientific studies showing the AA works for most people who make a regular habit of going to meetings:
http://in-training.org/sitting-in-the-circle-what-a-third-year-medical-student-learned-from-alcoholics-anonymous-16951
Well worth a read.
Wednesday, February 13, 2019
Sunday, February 10, 2019
As one Reddit user put it
Here is a Reddit post which nicely summarizes the “AA does not work” nonsense out there:
Partial truth & twisting of facts is however representative of those with a bias and agenda against 12 Step recovery modalities. They expect the gullible to just accept their reporting as the entire truth and not take the time to check out the actual facts. Those with a predilection against 12 step or have a perceived resentment of course will jump on the partial truths and outright lies of those with a similar bias.How else can you describe a mindset where people believe AA has a 5% success rate even though no peer reviewed study has ever concluded this. Instead, the studies show a 67%-75% success rate among alcoholics who get serious about the program; people in denial, however, don’t let facts gets in the way of their flawed world view.
Friday, January 4, 2019
AA has a 67-75% success rate
Critics of the 12-step programs attempt to discredit the longitudinal studies, which show a 67-75% success rate for AA:
- They don’t like the fact that those high success rate numbers only come from people who actively go to AA meetings. However, this is consistent with AA’s own claim that “Rarely have we seen a person fail who has thoroughly followed our path” (emphasis mine)
- They claim the numbers are invalid because of “self selection bias”; in other words, they believe the people who are clean and sober because of AA would have gotten clean and sober anyway in an alternate universe where AA doesn’t exist. A 2014 paper demonstrates this actually isn’t the case.
- They complain that the studies do not include dropouts. However, the drop out rate is small enough to not significantly skew the numbers, especially since, most of the time, the dropouts undoubtedly 1) Didn’t work the AA program and 2) Didn’t get sober.
- They make other complaints about the methodology of the studies. However, this ignores the fact that these numbers have been pretty consistent across multiple longitudinal studies. Fiorentine 1999: 74.8% success rate. Moos and Moos 2006: 67% success rate 16 years later. The Natural History of Alcoholism Revisited by George E. Vaillant has a table on page 197 showing that 19 out of 100 alcoholics attended 300 or more meetings over a 10-year period, of those 19, 14 were sober: 74% success rate. Witbrodt 2012 saw similar numbers: “high 12-step attendance (abstinence rates averaging 75%)”. AA’s own Big Book has the same abstinence rate using 1955 numbers: “Of alcoholics who came to A.A. and really tried, 50% got sober at once and remained that way; 25% sobered up after some relapses”
Wednesday, January 2, 2019
Brandsma 1980: The AA treatment
The 1980 book Outpatient Treatment of Alcoholism (Brandsma 1980) has been quoted by anti-AA critics as showing AA as being ineffective. In this post, I will look at the “AA” treatment which the subjects of the book underwent. Here is how the book describes it (“SHARP” here is an office the
Brandsma research team set up for conducting their research; they tried
to get people in the community to attend, but it ended up that most people got treatment there
because the court mandated them to go):
The Brandsma 1980 “AA” treatment (and, yes, Kaskutas 2009 is slightly inaccurate in her description of the “AA” treatment offered in the Brandsma study; the meetings were open to the public, but it’s unknown whether the meetings were listed in a local AA directory) does not sound like a meeting where people were effectively working the AA program. Kaskutas’s concern that “a potentially important therapeutic ingredient of AA—the experience of longer-term members—would not have been present in the AA condition” is spot on: The leader of the meeting had barely a year sober and the other attendees were “court slip” members.
Based on the description of the “AA” treatment, any conclusions Brandsma 1980 makes about AA efficacy are suspect.
An AA treatment group was started at SHARP by contacting the local AA organization. They sent two volunteers, a man (with a B.S.) and a woman (with a high school education), to begin our new group. They had 14 and 10 years experience in AA, respectively. The AA group was open to all who would attend and was conducted by one or the other of these people for approximately 1 year until January, 1973. By that time (the beginning of the research in terms of assigning patients), a member of the group (not included in the research project) had become very adept at running meetings. This minority group member, who had a 9th grade education, had had no AA experience before modeling himself after the two initial leaders of this group. This person remained the leader for the rest of the time of the research project (with a 3-week hiatus when an experienced AA counselor filled in), and continues to be involved in AA today. He received no remuneration for this, but was very cooperative in providing attendance reports for the project.The “AA” treatment is described in more detail in another section of the book:
Our group met once per week and tended to focus on persons present for the first time, but not to the exclusion of other members. The 12 steps of AA were used as the content focus for discussions. The men were made aware of the availability of “sponsor-friends” and were encouraged to ally themselves with one or more of their own choosing. Generally our patients seems to neglect availing themselves of this opportunity, and the assignment of sponsors was not followed up on in this group. Beyond this description we are unable to be more specific. [...]So, as we can see, almost no one in the Brandsma treatment got a sponsor, everyone in the group was a “court card” attender, and, even worse, they would get a threatening phone call if they didn’t show up at the meeting.
The nature of scientific investigation did force some small changes in the usual AA norms. First, most of our clients came coerced from the court system and all were then randomly assigned to treatments. Thus they were not “free to choose” whether to have treatment or the type of treatment. However, a person’s first visit to AA usually results from some form of “coercion,” e.g. a wife or boss. Second, participation was not anonymous because we kept attendance records, although this was an unobtrusive procedure. If a man’s attendance was poor or nonexistent, he would be contacted at least once by a project social worker, reminded of the conditions of his parole, and encouraged to return. This type of “coercion” (in contrast to the “buddy system”) is different than usual AA procedures. Our group did not develop a high degree of cohesiveness or a formalized buddy system as some do, nor did we offer other “services,” as does Al-Anon. However, given our population, situation, and purposes, we believe this was a representative treatment effort within the AA framework.
The Brandsma 1980 “AA” treatment (and, yes, Kaskutas 2009 is slightly inaccurate in her description of the “AA” treatment offered in the Brandsma study; the meetings were open to the public, but it’s unknown whether the meetings were listed in a local AA directory) does not sound like a meeting where people were effectively working the AA program. Kaskutas’s concern that “a potentially important therapeutic ingredient of AA—the experience of longer-term members—would not have been present in the AA condition” is spot on: The leader of the meeting had barely a year sober and the other attendees were “court slip” members.
Based on the description of the “AA” treatment, any conclusions Brandsma 1980 makes about AA efficacy are suspect.
Monday, December 31, 2018
Some history behind Pendery 1982
Let me finish off 2018 by taking about how the seminal work refuting the notion that alcoholics can moderate their drinking again, Pendery 1982, came to be published.
Pendery 1982 (i.e. M.L. Pendery, I.M. Maltzman, and L.J. West. "Controlled Drinking by Alcoholics? New Findings and a Reevaluation of a Major Affirmative Study" Science 217) is a very key paper in the history of alcoholism studies; the release of the paper was the last nail in the coffin that alcoholics can engage in sustained controlled drinking again. It humiliated the controlled drinking for alcoholics proponents; the study undeniably shows that alcoholics who try moderate drinking end up either dead, drinking like an alcoholic, or abstaining from alcohol.
The paper has a very interesting history which can be seen in two articles from 1982, when this very important paper was published:
Ultimately, the addiction experts who supported Sobell’s point of view would appear to have never let go of Pendery 1982. As recently as 2015, in a poorly researched anti-AA polemic, Glaser inaccurately describes the Sobell study. The Sobell study was not accurate; while an initial 1982 panel felt the Sobells were reasonably accurate in their research, a later 1984 Federal investigation (you know, with subpoena powers) pointed out that the Sobells were “careless in preparing their manuscripts for publication”. Indeed, some of the “controlled drinking” subjects in the study sued the Sobells.
Since people who think alcoholics can drink moderately again bring this up: How the alcoholics given abstinence treatment fared is a red herring. The Sobell study was done in the early 70s, some four decades before we starting finding twelve step facilitation treatments which effectively got more people going to 12-step meetings and abstaining from alcohol.
The fact of the matter is this: With one exception, Pendery 1982 shows us that the supposedly moderately drinking alcoholics in the Sobell study were either dead, engaging in out of control drinking, or were abstaining from alcohol 10 years later.
Pendery 1982 (i.e. M.L. Pendery, I.M. Maltzman, and L.J. West. "Controlled Drinking by Alcoholics? New Findings and a Reevaluation of a Major Affirmative Study" Science 217) is a very key paper in the history of alcoholism studies; the release of the paper was the last nail in the coffin that alcoholics can engage in sustained controlled drinking again. It humiliated the controlled drinking for alcoholics proponents; the study undeniably shows that alcoholics who try moderate drinking end up either dead, drinking like an alcoholic, or abstaining from alcohol.
The paper has a very interesting history which can be seen in two articles from 1982, when this very important paper was published:
- Alcoholism study under new attack. This article shows how the 1970s Sobell studies resulted in alcoholism experts from that era believing that alcoholics could learn to drink in a responsible manner, and how Pendery 1982 refuted that notion.
- Showdown nears in feud over alcohol studies. This article shows how hard Pendery and Maltzman had to work to make their paper a reality: “At every step of the way the Sobells have tried to block the investigation by Dr. Pendery and Dr. Maltzman. [...] The Sobells refused to hand over their list of the participants [...] Undaunted by the Sobells' resistance, the Pendery group tracked down a list of the patients' names at a county alcoholism center [...] The Sobells retaliated with a suit to block the use of the names, but a Federal District court dismissed their action in April 1977 [...] It took Dr. Pendery, using thousands of dollars of her own money and whatever time she could squeeze in among her other obligations, several more years to track down patients”
Ultimately, the addiction experts who supported Sobell’s point of view would appear to have never let go of Pendery 1982. As recently as 2015, in a poorly researched anti-AA polemic, Glaser inaccurately describes the Sobell study. The Sobell study was not accurate; while an initial 1982 panel felt the Sobells were reasonably accurate in their research, a later 1984 Federal investigation (you know, with subpoena powers) pointed out that the Sobells were “careless in preparing their manuscripts for publication”. Indeed, some of the “controlled drinking” subjects in the study sued the Sobells.
Since people who think alcoholics can drink moderately again bring this up: How the alcoholics given abstinence treatment fared is a red herring. The Sobell study was done in the early 70s, some four decades before we starting finding twelve step facilitation treatments which effectively got more people going to 12-step meetings and abstaining from alcohol.
The fact of the matter is this: With one exception, Pendery 1982 shows us that the supposedly moderately drinking alcoholics in the Sobell study were either dead, engaging in out of control drinking, or were abstaining from alcohol 10 years later.
Thursday, December 20, 2018
More people are realizing that AA is effective
Just yesterday, someone wrote an article for a small regional magazine (which comes off as like those magazines which were free on every street corner back in the days before the Internet took over publishing) regurgitation the same old “AA only has a 5% success rate” nonsense which has long been refuted.
However, instead of the comments agreeing with the bogus 5% success figures, the comments pointed out how inaccurate those figures are. At the beginning of this year, with the exact same online magazine, I was the only commentator with accurate figures for AA’s success.
This indicates that the tide is really starting to turn; the days of being able to post an article claiming AA has only a 5% success rate without getting devoured in the comments section are behind us.
However, instead of the comments agreeing with the bogus 5% success figures, the comments pointed out how inaccurate those figures are. At the beginning of this year, with the exact same online magazine, I was the only commentator with accurate figures for AA’s success.
This indicates that the tide is really starting to turn; the days of being able to post an article claiming AA has only a 5% success rate without getting devoured in the comments section are behind us.
Monday, December 17, 2018
Charlie Sheen, clean and sober in AA
Charlie Sheen, back in 2011, claimed that Alcoholics Anonymous has only a 5% success rate. Thankfully, over the years, he realized that those numbers are questionable.
He now has one year clean and sober in Alcoholics Anonymous. I'm very happy that he was able to let go of outdated ideas like the idea that science shows AA is ineffective (it doesn't), and instead use the program to become clean and sober.
What is AA's real success rate?
The question is this: What is AA's real success rate? We can never know the true number for two key reasons:
While AA itself did not keep track of members, Moos and Moos 2006 did. It found the following: Of the people who were serious about AA, 67% of them were sober 16 years later.
But what about the dropouts? Not everyone who did the study did the 16-year followup, so we can't know the true success rate number, but looking at only the people who did follow up gives us a reasonable number (Dodes 2014 claims that Moos/Moos 2006 has completely invalid numbers because of these dropouts, but Dodes appears to have had no interest in an honest assessment of AA's success). Overall, 46% of the people in the Moos and Moos 2006 survey (again, only those who did the 16-year followup) were sober, regardless of their level of AA attendance.
Now we are getting in to the realm of philosophical questions: Do we count someone who was not serious about AA but still stayed sober as a success or failure for AA? Should we count people who weren't serious about meetings when calculating AA's success rate? Polemics like Dodes's The Sober Truth consider every single person who was not serious about AA a failure when making artificially low numbers for AA's success, even if the person got sober after all.
There are a lot of ways we can come up with a "success rate" number based on Moos and Moos 2006:
Alcoholics Anonymous's own success claims
Alcoholics Anonymous has, since 1939, made the following claim about AA's success "Rarely have we seen a person fail who has thoroughly followed our path." This claim was expanded in the mid-1950s: "Of alcoholics who came to A.A. and really tried, 50% got sober at once and remained that way; 25% sobered up after some relapses, and among the remainder, those who stayed on with A.A. showed improvement."
Alcoholics Anonymous has never claimed it would help people who did not take the program seriously. Any claim about AA's success should only look at the people who take AA seriously; once we discount the people who did not take AA seriously, the numbers we get are in line with the numbers AA gave us in the mid-1950s (75% success rate among those whose who "really tried" AA).
It is true that AA has a high drop out rate, so I contend this: Have we found a treatment which is effective for alcoholics who, for whatever reason, refuse to work the AA program? Zemore 2019 makes a strong case that people in other programs can also stay clean and sober, as long as the goal is abstinence from alcohol. So, yes, I think people who will not work the AA program can still be clean and sober, but I also think it's dishonest to label all such people "failures" when measuring AA success.
He now has one year clean and sober in Alcoholics Anonymous. I'm very happy that he was able to let go of outdated ideas like the idea that science shows AA is ineffective (it doesn't), and instead use the program to become clean and sober.
What is AA's real success rate?
The question is this: What is AA's real success rate? We can never know the true number for two key reasons:
- AA does not keep track of members.
- "AA success" is a poorly defined term, which can have several actual meanings
While AA itself did not keep track of members, Moos and Moos 2006 did. It found the following: Of the people who were serious about AA, 67% of them were sober 16 years later.
But what about the dropouts? Not everyone who did the study did the 16-year followup, so we can't know the true success rate number, but looking at only the people who did follow up gives us a reasonable number (Dodes 2014 claims that Moos/Moos 2006 has completely invalid numbers because of these dropouts, but Dodes appears to have had no interest in an honest assessment of AA's success). Overall, 46% of the people in the Moos and Moos 2006 survey (again, only those who did the 16-year followup) were sober, regardless of their level of AA attendance.
Now we are getting in to the realm of philosophical questions: Do we count someone who was not serious about AA but still stayed sober as a success or failure for AA? Should we count people who weren't serious about meetings when calculating AA's success rate? Polemics like Dodes's The Sober Truth consider every single person who was not serious about AA a failure when making artificially low numbers for AA's success, even if the person got sober after all.
There are a lot of ways we can come up with a "success rate" number based on Moos and Moos 2006:
- There were 461 people in the survey who did a 16-year followup
- Of those, 25% (115) took the AA program seriously. Of those 115, 77 (67% of serious AA members, 17% overall) were sober, and 38 (33% of serious AA members, 8.2% overall) were not sober. We could use these numbers to argue that AA has "only" a 17% success rate, but that argument is dishonest because it discounts the 16% of people (72) who had some level of exposure to AA and still stayed sober.
- Overall, 214 (46%) got sober. Since pretty much any alcoholic out there at least knows of AA's existence, we could make a case this is a 46% success rate.
- If we look at just people who had a least a little bit of AA treatment, this is 58% (269 of 461 total) of the people in the survey; of those 55% (149) were sober 16 years later. Contrast this with the 42% (192) who didn't try AA at all, 34% or 14% overall (65) were sober 16 years later.
Alcoholics Anonymous's own success claims
Alcoholics Anonymous has, since 1939, made the following claim about AA's success "Rarely have we seen a person fail who has thoroughly followed our path." This claim was expanded in the mid-1950s: "Of alcoholics who came to A.A. and really tried, 50% got sober at once and remained that way; 25% sobered up after some relapses, and among the remainder, those who stayed on with A.A. showed improvement."
Alcoholics Anonymous has never claimed it would help people who did not take the program seriously. Any claim about AA's success should only look at the people who take AA seriously; once we discount the people who did not take AA seriously, the numbers we get are in line with the numbers AA gave us in the mid-1950s (75% success rate among those whose who "really tried" AA).
It is true that AA has a high drop out rate, so I contend this: Have we found a treatment which is effective for alcoholics who, for whatever reason, refuse to work the AA program? Zemore 2019 makes a strong case that people in other programs can also stay clean and sober, as long as the goal is abstinence from alcohol. So, yes, I think people who will not work the AA program can still be clean and sober, but I also think it's dishonest to label all such people "failures" when measuring AA success.
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