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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Minding Your Mind Minding Your Mind

How Alcoholics Anonymous Works

October 17, 2012

By Michael Craig Miller M.D.

Harvard Medical School

Just about everyone knows what the initials "A.A." stand for. Alcoholics Anonymous was founded in 1935 and is the oldest, best known, most successful mutual help organization. With millions of members, it is the most widely used treatment for alcoholism, and has inspired many similar groups, including Narcotics Anonymous (NA). By some estimates, as many as 1 in 10 Americans, including two-thirds of those ever treated for alcoholism, have attended at least one A.A. meeting.

Many new treatments for alcoholism, including drugs and behavioral therapies, have been introduced since 1935. But Alcoholics Anonymous, which has meetings throughout the world and is nearly cost-free, still offers the best hope to many people. Researchers have been studying how and why the A.A. approach to addiction succeeds or fails. Their discoveries should improve the treatment of other people who are dependent on substances.

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AA and Mental Health Professionals

At one time the relationship between A.A. and mental health professionals was somewhat tense and distant. The two groups had different opinions about the best way to treat alcoholism and other addictions. But today cooperation is more common than conflict.

A.A. does not reject or compete with medicine or psychiatry. Many members seek psychotherapy or professional counseling, and some take psychiatric drugs. Most mental health professionals readily refer patients to A.A. Many draw on its 12-step principles or use 12-step counseling (often called 12-step facilitation) in their approach to therapy.

In treatment developed by researchers for the National Institute on Alcohol Abuse and Alcoholism (NIAAA), 12-step facilitation therapists provide patients with reading materials on A.A. and encourage attendance at meetings. They may also arrange contacts with volunteers from A.A. and other 12-step groups. The patient may be asked to keep a journal of experiences at A.A. meetings and discuss them with a counselor or therapist. In hospitals and clinics that treat chemical dependency, 12-step facilitation is part of detoxification (supervised withdrawal).

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Studying A.A.'s Effectiveness

A.A. is not easy to study because the organization doesn't keep records and follow-up is rare. Nevertheless, researchers have been trying to determine whether A.A. is more effective than other treatments for some or all alcoholics. They also have tried to identify which aspects of A.A. are the most important reasons for its effectiveness.

As a practical matter, most studies involve patients who join A.A. after receiving 12-step facilitation or other professional treatment. Research has repeatedly shown that alcoholics who participate in A.A. do better than those who do not. For example, in a study of patients with alcohol and drug dependence who moved from residential treatment to A.A. or N.A., 38% were still involved in the self-help groups two years later. Of the continuing participants, 81% had been drug or alchohol-free for the previous six months, compared with 26% of the nonparticipants.

Similar findings come from a study with an unusually long follow-up — 16 years. Two-thirds of patients who participated in A.A. for six months or more had few drinking problems after 16 years, compared with one-third of those who did not participate.

What research hasn't shown is whether A.A. or 12-step facilitation gives alcoholics some advantage that other treatments do not. Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) is a large and careful study of alcoholism treatment sponsored by the NIAAA. It compared 12-step facilitation with cognitive behavioral therapy and motivational enhancement therapy (an approach that helps motivate problem drinkers to change on their own). All three 90-day treatments were equally effective. Patients in all three groups had a higher rate of abstinence (not drinking) and a lower rate of binge drinking both immediately after treatment and a year later.

In 2006, The Cochrane Collaboration, an international organization that reviews and analyzes evidence from treatment studies, compared A.A. participation and 12-step facilitation with other psychosocial treatments for alcoholism. The eight clinical trials they looked at involved nearly 3,500 patients. All treatments had similar dropout rates and similar effects on the amount of drinking and its consequences.

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Getting the Most Out of Treatment

Here are some recommendations based on what research tells us:

  • Stick with it. The longer a person stays in A.A., generally, the better he or she does. A study with an eight-year follow-up found that patients who continue to participate for more than two years were drinking less with fewer adverse consequences and were more likely to be abstinent. Patients who stayed for only four months or less were doing no better than those who did not participate at all, and patients who dropped out between the first and second years actually had more drinking problems than nonparticipants.
  • Help others. In Project MATCH, patients who followed the 90-day treatment and participated in A.A. were asked a year later whether in the last three months they had been a "sponsor" (another sober alcoholic in the recovery program who acts as a mentor) or had completed the twelfth step: "...we tried to carry this message to alcoholics and to practice these principles in all our affairs." Patients must have interpreted this requirement strictly because only 8% thought they met it. But those who did had a much lower relapse rate even after correction for the number of A.A. meetings they attended. In a study of alcohol and drug dependent patients from the San Francisco area, the time they spent helping others during 12-step facilitation (providing moral support, sharing experiences, and giving advice about jobs, housing and staying sober), and their involvement in A.A. and N.A., were associated with a higher rate of abstinence and less binge drinking after six months.
  • Get treatment for any co-existing psychological problems. Long-term research suggests that people who have psychological problems besides alcoholism are less likely to recover through A. A. That makes getting treatment for these additional problems a priority. Other features of A.A. may be less important than they are thought to be. On the basis of the available evidence, success is not clearly related to the number of meetings attended (as opposed to the length of time participating) or to a special emphasis on spiritual awakening. It hasn't been found that members who continue to keep company with drinking friends are less likely to recover.

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Unanswered Questions

There's more to learn about which problem drinkers benefit the most from A.A., which ones are most likely to participate, and how long and intensely they need to be involved. But it may always be difficult to tell which features of A.A. account for its success because it means different things to different people. Today we know that alcoholism and other addictions are chronic illnesses, like diabetes or cardiovascular disease. They require long-term self-management — complete and consistent changes in the way a person lives. Many alcoholics find A.A. valuable because it offers fellowship and supports their new habits in a way no other treatment can.

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Michael Craig Miller, M.D. is Editor in Chief of the Harvard Mental Health Letter. He is also associate physician at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School. He has been practicing psychiatry for more than 25 years and teaches in the Harvard Longwood Psychiatry Residency Program.

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