Some Contentions/Misconceptions about AA and Mainstream Treatment

This is Part II of a look at some often-heard (or, at least, posted on the internet) statements that might elicit much doubt in people pursuing mainstream treatments for alcohol/drug problems -- with my attempt to provide balance. The last post focused on statements regarding the nature of alcoholism/addiction and recovery. The subject of the current post is statements about AA (and other self-help groups) and about treatment approaches.

AA loses many of its attendees shortly after their first exposure to the program, and 95% by the end of the first year.
It’s been my repeated experience that most people don’t like AA when they first attend, and not surprising that many drop away, especially if they are far from feeling ready to embrace a goal of abstinence. I wonder if the percentages often quoted are misleading, since my experience is that many of the same people return and connect to AA months or years later. Those who find another program for the same purpose, such as SMART, may find that their needs for recovery support are well met there. And while AA has been so successful that there are now over 115,000 groups meeting regularly around the world, more alternatives are clearly needed. (Here in Massachusetts, the only non-12 step peer program that has any kind of meaningful presence is SMART Recovery.) The early dropout rate (but not necessarily the outcome) is probably somewhat lower for professionally-run programs, where there would be a stronger sense of obligation (to a particular person) to continue to attend. But I don’t know of any professional program that offers groups available so conveniently and frequently over the long term (and if there is one, it would involve ever-escalating financial burden).

If a medication treatment was only successful on 5% of patients (the percentage of new AA attendees still regularly attending a year later), it would never be FDA approved.
I’m not so sure about that. If there were a medication that was highly effective for 5% of those with a given illness, and if no other treatment were more widely effective, I think it would be approved. The fact that people drift away from AA does not, by the way, prove that it is ineffective, only that people tend not to keep up the new behavior. You’d find a similar trend, for example, in how many heart patients who have never exercised are still going to the gym regularly a year after they begin – that doesn’t mean that exercise is ineffective, only that it’s difficult to get people to stick with it. Nevertheless, let’s keep looking for treatments that are more likely to keep alcoholics/addicts involved, and that have a salutary effect on their alcohol/drug use.

Twelve step programs teach people that they are powerless, which leads them to keep relapsing because they don’t think they have the power to stop drinking.
The AA notion is that the alcoholic is powerless over drinking – i.e., once s/he begins to drink, s/he loses the capacity to exert control. (For other 12-step programs, substitute the other addictive behavior for the object of powerlessness.) This does not mean that one is powerless of everything in one’s life. In fact, it clarifies the importance of one’s ability and personal responsibility to do what it takes to avoid taking the first drink. (But it takes a lot more than for a non-alcoholic to make that choice.)

AA should not claim to be the only way to recover. People should not be told that they are doomed to failure or death unless they keep coming. Most people drop out – they should know that AA is not their own option.
I don’t believe that the founders of AA ever took the position that they had found the only way for anyone to get sober – just that it was the only way that had worked for them. The 12 steps are phrased not as “You should” or “You must,” but as “We did” – in other words, here is our example, which you may or may not find applicable to yourself. Certainly, it is not uncommon to hear someone say that those to fail to make use of AA are destined for failure, but this is the opinion of individuals, not the program. It is likely based on having seen many alcoholics who did not stick, and whose lives continued to deteriorate. But AA itself, in its recurrent surveys, indicates that only a minority of new attendees form a lasting connection with the program. People getting ready to take a shot at sobriety who do not already have a positive connection with any particular approach should certainly be informed about the full range of options for treatment and support, none of which has consistently been proven superior to the others. [See below, discussion of Project MATCH.]

Treatment providers get attached to their own ideas about what should work, sometimes from their own personal experience, overriding their objectivity and thus shortchanging those who come to them for help.
Yes, this is in the realm of “cognitive dissonance.” We are all inclined to want to stick with beliefs into which we’ve already invested a lot of time, effort, etc., and to be motivated to dismiss or ignore contrary evidence. But it is equally true for those who firmly and vehemently embrace alternative perspectives and treatment approaches. My two cents: Whenever someone says, “I know the right way, the only way, the unimpeachable truth” – it’s a good time to politely excuse yourself and briskly walk away.

So-and-so’s exciting new form of treatment is the one that really works. OR: No treatment works for alcohol or drug dependence.
Project MATCH was a large, seminal multi-site study of over 1700 patients conducted under the aegis of the National Institute on Alcohol Abuse and Alcoholism for several years beginning 1989 (findings reported in 1996). Most people anticipated that certain treatment approaches would work better for certain patients considered well-matched (who would be considered well-matched based on characteristics such as severity of drinking, cognitive impairment, conceptual level, motivation for change, gender). As it turned out, all 3 treatment approaches (12-step oriented, cognitive behavioral, and motivational) were about equally effective, regardless of patient characteristics. The degree of improvement, regardless of type of treatment, was considered impressive because of dramatic and sustained reduction in drinkin (though unfortunately there was no control group of patients receiving no treatment). Many studies have found that more treatment is associated with better outcomes than less treatment, and in this respect AA has some advantages, since it is (a) free, thus cost is no obstacle and (b) more available than any other resource (with regard to numbers and frequency of accessible meetings).

The "Higher Power" Obstacle

When embarking on a goal of abstinence from alcohol/drugs, which for many is the only realistic goal, self-help groups are certainly a key resource, whether or not the individual is involved in professional treatment. Self-help groups (which would more accurately be called mutual-help groups) offer a number of advantages – some level of relatively constant availability, a sense of comradeship with others in the same position, a venue for support, acceptance, congratulation, empowerment, etc., a wealth of practical advice – as much as needed, and at no cost (and no need for managed care authorization).

By far, the majority of self-help groups follow the Twelve Step model (mainly AA and NA). SMART Recovery also has a meaningful presence, at least in Massachusetts, but the sheer number of available meetings pales by comparison. (Comparing these two programs can wait for a later column.) In some states, other programs such as Women for Sobriety are also prevalent. Given the prominence of AA/NA, not to mention the impressive history of 12-step programs since their inception in 1935, it makes sense for most people in what is often called “early recovery” to at least sample AA meetings.

My experience, however, is that the majority of people, early in their exposure to AA, don’t like it. There are a range of reasons given, including a perception that “their problems are worse than mine” (and of course, an underlying preference to avoid getting involved with an organization that symbolizes loss of the beloved substance), but the obstacle about which I hear most frequently is “the God stuff.” There is, of course, no denying that AA itself began as an offshoot of the Oxford Group, a non-hierarchical Christian movement of the 1920s and 1930s which emphasized many of the themes still echoed in AA (but in the context of seeking to place oneself, nation, and world under God’s control). On the other hand, AA is explicitly not a religion, and invites multiple and individualized interpretations of “higher power;” in reality, there are many atheists and agnostics who make use of the AA program. But the wording of the 12 Steps can be a problem. The term “God” is used repeatedly, followed twice by the phrase, “as we understood Him” – making it sound as if the adherent must surrender to a God of the sort that could have a gender, and that in fact the gender is male.

A person of more secular, 21st Century sensibilities may well conclude, “This is not where I belong,” and walk away from a program that could, in fact, have much to offer him or her. In order to continue making use of AA, s/he must view terms like "God" and "Him" as metaphors for some alternative concept of a higher power. Some ideas on how that might be done coming soon.
© 2010 Jeffrey Fortgang