The irrationality of Alcoholics Anonymous
March 18, 2015 1:10 AM   Subscribe

Its faith-based 12-step program dominates treatment in the United States. But researchers have debunked central tenets of AA doctrine and found dozens of other treatments more effective.
Gabrielle Glaser explores alcohol-use disorder treatment of many types in a lengthy (quite lengthy) article for The Atlantic.
The Finns are famously private, so I had to go early in the morning, before any patients arrived, to meet Jukka Keski-Pukkila, the CEO. He poured coffee and showed me around the clinic, in downtown Helsinki. The most common course of treatment involves six months of cognitive behavioral therapy, a goal-oriented form of therapy, with a clinical psychologist. Treatment typically also includes a physical exam, blood work, and a prescription for naltrexone or nalmefene, a newer opioid antagonist approved in more than two dozen countries. When I asked how much all of this cost, Keski-Pukkila looked uneasy. “Well,” he told me, “it’s 2,000 euros.” That’s about $2,500—a fraction of the cost of inpatient rehab in the United States, which routinely runs in the tens of thousands of dollars for a 28-day stay.

When I told Keski-Pukkila this, his eyes grew wide. “What are they doing for that money?” he asked. I listed some of the treatments offered at top-of-the-line rehab centers: equine therapy, art therapy, mindfulness mazes in the desert. “That doesn’t sound scientific,” he said, perplexed. I didn’t mention that some bare-bones facilities charge as much as $40,000 a month and offer no treatment beyond AA sessions led by minimally qualified counselors.
posted by hippybear (140 comments total) 118 users marked this as a favorite
 
This article covers so much ground and is such an excellent thorough read on so much having to do with alcohol in our society, don't take that pull quote as being what the article is about. It's just one of the things it is about.
posted by hippybear at 1:11 AM on March 18, 2015 [7 favorites]


I was wondering if this would show up here. Didn't know how to frame it, otherwise would have done so myself. It was revelatory for me.
posted by bardophile at 1:39 AM on March 18, 2015 [3 favorites]


I didn't know about naltrexone for treatment of alcoholism. Good to know.
posted by persona au gratin at 1:50 AM on March 18, 2015


I think this article does a great job of addressing the downfalls of AA failing to adapt to modern medical science. That said, I'm concerned that an outsized focus on naltrexone places the treatment more squarely on brain chemistry grounds, downplaying the role of depression and other mental health issues on alcohol abuse (which, indeed, was one of the complaints about AA). J.G. still takes Valium from time to time to deal with anxiety, and my experience with Valium has been that it can really mess you up - which isn't to say I think he's taking it to get messed up, but I'm concerned about the approach that says he can only handle his anxiety with a very strong benzodiazepine.

I stopped drinking years ago - not through AA or anything else, but because it started making me feel horribly sick every time I drank. I know a lot of people in AA, though, and I think one thing this article overlooks is the social and cultural role that AA plays for a lot of people. Even if you're not participating in AA events, everyone I know has made friendships there that are, crucially, not founded on drinking. The article describes the social impact of abstinence from alcohol, and I've certainly experienced that myself. For the people who find it helpful, could it be that AA provides a social network that works for them?

All of this is very subjective, of course, and the article's biggest strength is in stressing the idea that there's no "one size fits all" solution. I'm just concerned about a preoccupation with brain chemistry over treating a larger issue of depression and anxiety by more stable means.
posted by teponaztli at 2:02 AM on March 18, 2015 [25 favorites]


At the Al-Anon newbie meeting I sometimes lead, I will say that AA is not an evidence-based treatment if it is the appropriate response to a question. Al-Anon has been tremendously helpful to me in coping with the problem drinking and addiction of various loved ones. But I nearly didn't make it to Al-Anon because the god talk and prayer stuff drives me crazy. I will never, ever turn my will and my life over to my supposed higher power (patriarchy, anyone?). Luckily, after 3+ years in the program I found a sponsor with a similar mindset who helps me interpret the steps in a helpful, practical, non-religious way. I have come to understand that "take what you like and leave the rest" is a bedrock principle of my 12-step program. I didn't believe initially that the fellowship was sincere. I expected to be judged and I haven't been. But how many addicts and alcoholics get lost because 12-step doesn't work for them? A friend of mine, in AA, killed himself in October 2013. He'd started drinking again and just couldn't see a way back to sobriety. What if he had seen something like this? I'm a Big Tent person; let 1000 evidence-based solutions blossom. And 12-step, too, because it is helping the people I know. But that's still a small fraction, I imagine, of the people who need help.
posted by Bella Donna at 2:32 AM on March 18, 2015 [41 favorites]


A success rate of 5-8% is remarkably low. We have to assume that there is some rate of recovery among people who have no treatment or therapy at all; I have no idea, but I'd have thought it could easily be higher than 10%. If those figures are somewhere near true (if) it seems possible that AA is not just ineffective but actually harmful, tending to worsen and extend the problem overall.

That is astonishingly at odds with the usual consensus.
posted by Segundus at 2:44 AM on March 18, 2015 [9 favorites]


I remember well when Jack and Lois Trimpey came out with Rational Recovery. And things went pretty well until they went head to head with the incumbents in the recovery industry. They were squashed like bugs. AA itself is many peoples' "comfort zones", and when you mess with peoples' comfort zones, they can *start* at irrational and escalating to violence is a real concern.
posted by mikelieman at 3:17 AM on March 18, 2015 [5 favorites]


I wrestle with this every time a twelve-step related article comes along. I know it's unclear whether it's better than no treatment at all, epidemiologically. I know it can be read as blaming the victim and making a set of medical/psychological maladies into a moral one. I know it's God-y.

I also know that NA was part of my three-legged stool (Therapy and zen are the other two legs) that have helped me turn my life around over the past 5 clean years. Few things in my life have had more impact than really working through the steps and sucking the meaning out of them, Talmud-style.

I really worked through what exactly would constitute a higher power that would work for me, a hard atheist. One way I looked at that specific issue is by analogy with what I think I understand about Aristotle's 'Metaphysics', as a book, not a set of ideas. At some point his works were collected. One of them was 'Ta Physica' (Physics). The next piece physically in the collection was called 'Ta Meta Physica', literally 'After/Past Physics'. It works both ways: it's literally after the book Physics' in the collection, but it has also become comfortable in it's more typical sense of 'Beyond'. As in past physics, more fundamental than physics, etc.

So I see an analogy with my higher power in this way, as opposed to my, I guess, regular power: my power, say, is my ego. My sense of deciding for myself what I will do. It is in that sense that can say with full conviction as an atheistic addict "I am powerless over my addiction'. My regular power is powerless. My ego is not up to the task of regulating my addictive behavior. My ego will manufacture reasons why I should wait until tomorrow, why heroin doesn't count if you snort it, whatever. The conscious process of deciding to get/stay clean routinely fails me. I am powerless.

My higher power, otoh, is not. My higher power is fully me, no leprechauns here, but it is a power I have that is beyond my ego-power. It is the part of my self that lies under and beyond my ego. My higher power is this present moment within my consciousness. It needs nothing, it has all that I ever have or will ever need or had: this present moment of existence.

My higher power allows me to see clearly that I need no drugs, I need nothing. I am an experience of consciousness, full stop. How could I need anything beyond the present moment? My feelings aren't necessarily pointers to something real. To paraphrase someone, feelings don't mean things, feelings are things. That's it.

I have power within me that, if I can tap into it, can allow me to let go my desire to use.

Anyway, the point is that I have come to this place by asking myself what the concept of 'higher power' would have to mean in order for me to honestly use the concept. I got there by taking the steps seriously because I did not want to die. I got there because someone cared about me and pointed me to a meeting. That chain of events is what I would call Grace if I were an evangelical.

So all that goes rough my head when I hear a (fellow) skeptic mock 12 step. The criticisms are all valid, I'm sure. But there are those of us for whom they work, and for us the criticisms sound supremely irrelevant and small-souled themselves.

Like we say, take what you need and leave the rest.

I'll pass.
posted by hoanthropos at 3:46 AM on March 18, 2015 [98 favorites]


A success rate of 5-8% is remarkably low. We have to assume that there is some rate of recovery among people who have no treatment or therapy at all; I have no idea, but I'd have thought it could easily be higher than 10%. If those figures are somewhere near true (if) it seems possible that AA is not just ineffective but actually harmful, tending to worsen and extend the problem overall.

That is astonishingly at odds with the usual consensus.


The figures I've heard repeatedly over the years are +/-5% manage to get sober with AA/NA/whateverA and +/-5% get sober using nothing other than willpower. I've seen reasonably reliable sources that back these numbers but I'm much too sleepy to try to dig them up right now.
posted by item at 3:48 AM on March 18, 2015 [2 favorites]


I read the Dodes book. It seemed a little half-baked. I wish he had worked on it for another 6 months. His brother co-wrote it; he did the chapter that analyzes studies and meta-studies of treatment effectiveness. I don't have any training in statistics or research methods, but my main takeaway was that the studies on the effectiveness of alcohol treatment are really not very good. But this criticism was, I thought, vitiated by the unscientific nature of Dodes' own work in the book. That's fine, writing a non-scientific argument (he put up a post asking for people who had poor experiences in AA to write up their stories, which is important in that the treatment regime as well as AA's literature excludes these voices ("these unfortunates" in the Big Book), but it's surely not a scientific survey). Dodes' own view is that addiction is a kind of compulsive disorder that typically comes from people's attempts to escape emotionally intolerable situations that they do not know how to ameliorate otherwise. That's pretty plausible sounding, but is it actually any more scientific than the views he's rejecting? After reading the book, I do not know.

I thought his critique of the rehab industry was apt. It's a mess and a profit-driven one, and it often provides, at enormous expense, no more actual treatment than clients could get for free by showing up for AA meetings and taking them really seriously (90 in 90, getting a sponsor, etc).

Full disclosure. When I quit drinking, I did so outside of rehab or 12-step programs. I wanted nothing to do with either. I was terrified that I couldn't do it and would have to go into a program. Based on my experiences with AA folks.....I didn't "want what they had". But I was determined to find out if I could or not. What would happened if I really tried, and refused to accept the bullshit that I had generated the other times I had "quit", only to decide after a week or so that I could really do so later? This is later, I said, this is it, there is no more second chance. If I couldn't do it then I would accept that I was powerless over alcohol and try it their way. I was right up to the edge of full-blown, late stage alcoholism. Drinking entire fifths of whiskey in a night. I'd then sober up for a few days and do it again. The quantity drunk was increasing and the interval between binges was decreasing; the progression was clear. In 6 months or a year, I would have been unable to just stop without detox, I believe. That was 3 years and 4 months ago and I have not had a drink since. My mantra was: a better life is possible, not, a Higher Power can save me. Ironically, this experience made me a lot more understanding of AA, probably since I've spent a lot of time talking with 12 step people in online support groups. I have no interest in disparaging their experience or what is working for them. But I do agree that the culture has developed a demonstrably false belief that theirs is the only way.
posted by thelonius at 4:21 AM on March 18, 2015 [15 favorites]


My sample of one person indicates it works quite well.
I'd like to know how that success percentage rate is affected by the fact that many many people get "sentenced" to AA by the courts in the US, which completely goes against the tenets of AA.
Some groups I know of have quit signing court papers, good on them.
posted by rudd135 at 4:29 AM on March 18, 2015 [9 favorites]


A friend of mine has recently started in a 12-step program modeled closely on the AA model, including the religious overtones. He says that, while the support aspect of being/talking with others dealing with the same issue is something he really needs, he's very put-off by the faith/religious aspect of everything. They start each meeting, of course, with the Serenity Prayer, and they end each meeting reciting the Lord's Prayer, with everyone holding hands. He says it all with the others, but it makes him very uncomfortable, being a non-believer. He's not sure if he will stick with the program specifically because of the emphasis of faith and God.
posted by Thorzdad at 4:42 AM on March 18, 2015


The beautiful thing about AA that isn't mentioned in this article is that there are as many kinds of meetings as there are people who want to explore them. There are religious ones, agnostic ones, and every flavor in between. Very few people find a good fit in the first room they visit and with a small effort, anyone can find a room where they can feel comfortable talking about the things that are leading them to substance abuse or more importantly, just to listen and see that they aren't alone. I strongly agree that more exploration of pharmaceutical means to help addition needs to happen but AA, NA and the like create communities and support that are very difficult to deny to the addict who feels like he or she has no one else who understands their situation. That is a huge part of the road to recovery.
posted by pearlybob at 4:59 AM on March 18, 2015 [18 favorites]


Science of Us rebuttal.
Here and throughout the piece, Glaser is simply ignoring a decade’s worth of science.

“No, that’s not true,” said Dr. John Kelly, a clinical psychologist and addiction specialist at Massachusetts General Hospital and Harvard Medical School, when I ran Glaser’s argument by him. “There’s quite a bit of evidence now, actually, that’s shown that AA works.”
posted by wendyfairy at 5:05 AM on March 18, 2015 [12 favorites]


Jesse Singal of New York Magazine' Science of Us has published a rebuttal to the Glaser's piece. Glaser's work is based on an NIH publication from 2006, and there is much more evidence on the effectiveness of 12 step programs. Elsewhere, blogger Ed Platt has reviewed Glaser's other argument about the possibility of returning to moderate drinking, and reviewed the literature.

On preview: what wendyfairy says
posted by honest knave at 5:08 AM on March 18, 2015 [3 favorites]


Public Education also has a shitty success rate. Is there any way we can turn that industry over to pharmaceutical companies as well?
posted by Potomac Avenue at 5:10 AM on March 18, 2015 [21 favorites]


I just think it's hilarious that a person with no history of substance abuse can just take a pill, drink some wine, be bored about it, and then tell everyone that they've been doing it wrong and that instead of helping each other out for free, they should just take pills from the professionals if they want to be well-adjusted and sober.
posted by oceanjesse at 5:17 AM on March 18, 2015 [16 favorites]


Glasser is promoting her book (Why Women Drink). She is trying to bank money, not actually solve a problem.

Even if there was a better way than AA, to attack that organization as harshly as she does is insane.
AA broke ground. Opened a field that virtually did not exist before. Countless alcoholics and families have been helped.

It may not be perfect, but it has done a lot of good. Disrespecting AA as she does is low brow.
posted by Flood at 5:26 AM on March 18, 2015 [10 favorites]


There is an almost cult-like mentality to AA. The whole idea that you must admit that you are subject to a higher power takes all responsibility away from you and keeps you a victim. I understand that the point of getting together and talking about it is to get support but it just ends up being depressing listening to everyone else's sob story sometimes. The groups also tend to be a little incestuous. Alcoholism is often accompanied by other mental and emotional problems that are not fun to deal with in other people. I'm not perfect, but I found it didn't help me to be around other people whose lives revolve around not drinking. It's as odd to me as centering your life around not being a vegetarian. But then I have a good support system outside of any AA group so my perspective is particular.
posted by Schleprock at 5:46 AM on March 18, 2015 [12 favorites]


The rebuttal (for which, thanks) vindicates teponaztli's point about social networks.
posted by Segundus at 5:47 AM on March 18, 2015


It's as odd to me as centering your life around not being a vegetarian.

Vegetarians typically don't disappear for days on end to go on steak binges.
posted by jpe at 5:53 AM on March 18, 2015 [10 favorites]


AA is free. And there's most likely a meeting not far from any American every single day and evening.
posted by Miko at 6:01 AM on March 18, 2015 [12 favorites]


But you aren't ruled by your higher power, whatever that may be for you, God, Buddha, the tree in your backyard.... You turn things over to it. So when things go south, as they always do in life, instead of drowning your troubles in a bottle of vodka, you can tell yourself, "there is something bigger than me that will take care of this and I'm going to carry on." You get out of bed, pay your bills, buy groceries, one minute at a time, one day at a time, whatever it takes until it becomes your new normal and sobriety takes hold. You learn to not ignore life's obstacles but to deal with them in a healthy, adult manner that doesn't involve using. That is a very, very simple explanation but the higher power thing isn't about subjection. It's about realizing that you can't and don't control everything so don't try, you only control you. It's about taking baby steps to learn how to deal with the bumps in the road (that non addicts sail right over) without having to rely on a substance to cope. This takes more time and practice for some than others but worth the effort. As with everything, YMMV.
posted by pearlybob at 6:06 AM on March 18, 2015 [21 favorites]


G.O.D. = Group of Drunks

Problem solved.

The fact that Cochrane is probably going to reverse their findings... that's amazingly wonderful news. I deeply love Cochrane work but I've always thought that the quality of the data was insufficient to justify their 12 step study.
posted by anotherpanacea at 6:13 AM on March 18, 2015 [2 favorites]


So many people have this idea that AA is some kind of homogenous monolith. That's no more the truth for "AA" than it is for "Christianity" or "the United States educational system."
posted by The Underpants Monster at 6:15 AM on March 18, 2015 [8 favorites]


I've got an alcoholicrelative, and after going through several very bad things he tried AA. He has been dry for over a year now and he's not at all convinced that it is a good program.

He used the word cult several times when describing his AA experience. He says that they wanted his life to become AA centered, that on several occasions they urged him to go to AA events that conflicted with other, not AA stuff like museum programs.

He's split, he does think AA helped him at least some, but he says the whole thing is very creepy.
posted by sotonohito at 6:15 AM on March 18, 2015


He also points out that AA has a terrible success rate.
posted by sotonohito at 6:18 AM on March 18, 2015 [1 favorite]


The "rebuttal" piece is very thin on the central question of whether AA basically is taking credit for spontaneous remission, as far as the rates which are very handwavy (measuring days of abstinence is very misleading when comparing to non-abstinence based programs). There are other things I find curious; AA is one of very few treatments I can think of that has not advanced substantially since the 1930s.

But what I really find problematic is that I've never heard a defense of the big issue that I've seen cited with AA, and twelve-step programs in general: people in abstinence-based programs tend to engage in binge activity when they backslide. This is really nasty, as binge drinking is the most dangerous type of drinking, and Glaser repeats the charge that I've seen leveled against AA that its tenets encourage this mode of failure. By telling people they are helpless, AA makes it worse when they do go back to drinking (or the equivalent for the NA programs).

This doesn't mean that AA hasn't been part of people's individual successful recovery from addiction. But if we think of it as treatment, we have to ask if the side effects can be more damaging than it's worth.
posted by graymouser at 6:30 AM on March 18, 2015 [9 favorites]


The rebuttal doesn't address the Finnish treatment at all- which seems like the most compelling part of the article. I don't care about whether AA is helpful or not (I have no personal experience with it and limited second-hand knowledge), but it seems like ignoring a possibly effective drug treatment that is cost effective is a bad idea, no?

I do think the US really moralizes drug and alcohol issues in an unhelpful way. Abstinence is very difficult, and also seems to engender obsessive behavior. Wouldn't it be better to consider a drug that just removes the desire and frees up the addict's mental energy for something else? Like family or work or life?
posted by rainydayfilms at 6:35 AM on March 18, 2015 [9 favorites]


Thank you for posting this. It's a really useful and interesting article, even as someone who already knows a fair amount about this stuff.

One thing I wish they had found room to cover is some of the non-religious support-group alternatives to AA. I have a family member who has found SMART Recovery to be a very useful support for him where AA is not. As this person describes it, it's partly the non-religious focus but also the emphasis on science and evidence-based practice, and a significant de-emphasis on shaming and blaming the person with the problem.

I'd also love to see some focus specifically on dual-diagnosis drinkers. There seems to be scant science or focus on the particular issues and concerns of people with dual diagnoses, for whom the standard addiction framework seems to fall far short.
posted by Stacey at 6:35 AM on March 18, 2015 [3 favorites]


I remember when my wife and I were at her mother and stepfather's house for dinner. Two things were going on around this time: first, my wife, who's been in 12-step programs since the late-80s and before we met, was going back to school to become a registered dietitian and, second, Mom and Marv had discovered fen-phen. They couldn't understand why anyone would want to become a dietitian because soon everyone would just take a pill and lose weight. Just look at them! And they were losing weight. My goodness, they were at the gym, taking their pills, and the pounds were just falling right off them. Marv's calves belonged on a neo-classical statue.

And then the other shoe dropped. The pill was killing people and was taken off the market. And Mom and Marv gained all the weight back. It had changed nothing about them besides applying a cattle prod to their metabolism and playing dice with their hearts.

I have heard often about the abysmal success rate of AA and other 12-step programs, and as others have said better, I think the criticism misses an important part of AA, which is the community. I agree that depression can play a big part in someone's drinking, but isolation, another effect of depression, can be even more so.

The community is maybe the most important aspect of AA, and when the 92-95% of participants fail -- go out, fall off the wagon, what-have-you -- the community can play a big part in helping someone start over.

Pharmaceuticals and time logged in treatment don't offer that critical piece. The incestuous, proto-religious, old-timey, I'm Just an Old Lump o' Coal tent revival trappings of the program are not for everyone, but when someone fails, the community provides a great help in giving the lost lamb the chance to start over. A helping fucking hand to the 92 to 95% of screwups who can then come back in, get back on the wagon, dust themselves off, live their cliches and slogans, and try again.

Statistically, AA is a god damn mess. But I see it working for a lot of people, even when they blow it, and in some cases especially when they blow it.
posted by mcdeeder at 6:35 AM on March 18, 2015 [14 favorites]


I don't really get why people feel a need to bad mouth AA, but I wonder if science can tell us if that group contains a higher percentage of Gandhi critics, for instance, than the normal population. The need to put down and characterise as a cult something that generally helps people is fucking bizarre. The goD thing is always used in the pejorative sense by these same people when it may as well have been an elephant or lightning, but the higher power expression is probably most helpful. They use the gOd word so people who are hurt and dulled by abuse can see something that they can recognise and which is known to all humans. It's not really god in the sense of a giant religious saviour-type in the sky (although that would do) because it's more about being a representation of a sort of mirror held up to one's own destructive behaviour. That drinking and drugging belongs in the world of psychiatry or psychiatry by way of causation and one of the common factors shared by alcoholics is the idea of self will run riot. A goD or higher power or elephant or whatever is merely a mean for the alcoholic to see by way of comparison, for them to begin to understand that the concept of their illness begins with the way that they think and that thinking revolves around fear and self centeredness. So being able to recognise something, anything, as being more powerful than oneself is a very big step on the way to declaring one's diagnosis as alcoholic or addict. It can be religious. It can be cultish. It can be casual. It can be handholding and comforting. It doesn't really matter what sort of relationship to AA in the hurricane you manage, as long as you don't pick up a drink or a drug for another day. Eventually you'll settle on your own level of connection to the fellowship (which is the true and accurate description of this secret society) and the fact that it is utterly up to the individual as to the manner and extent to which they meld with this bunch of twisted folks really undermines most of the ignorant criticism that has been hurled at it by what I can only regard as hurtful or ignorant or nasty individuals who only wish to prevent some poor sod from finding out that they are not gOdalmighty and that sharing with a bunch of likeminded drunks and addicts actually *might* help them get through the day or week and year and allow them to live again with dignity.
posted by peacay at 6:42 AM on March 18, 2015 [12 favorites]


There is an almost cult-like mentality to AA.

From the Science of Us link ...

It’s worth pointing out that while critics of AA paint it as a bit cultlike and out-there, what with its reliance on “higher powers” and such, to the researchers who believe in its efficacy, there’s actually very little mystery to the process. “We have been able to determine WHY these 12-step facilitation interventions work,” said Kaskutas in an email. “And we have also been able to determine WHY AA works.”

Simply put, “People who self-select to attend AA, or people who are randomized to a 12-step facilitation intervention, end up having people in their social network who are supportive of their abstinence,” she said. Reams of research show that social networks, and the norms contained therein, are powerful drivers of behavior, so to Kaskutas — who noted that she is an atheist — the focus on AA’s quirks and spiritual undertones misses the point. “When you think about a mechanism like supportive social networks, or the psychological benefit of helping others, well, they have nothing to do with faith, or God — they have to do with the reality of what goes on in AA, with people meeting others in the same boat as they are in, and with helping other people (for but two examples of these mechanisms of action),” she said. So it can be the case both that AA rests on overly judgmental moral language, takes the unlikely view that God himself (or “a higher power”) is what cures people’s alcoholism, and has various other flaws — and that it still works for a lot of people, simply by connecting them to others going through the same struggles.

posted by philip-random at 6:43 AM on March 18, 2015 [12 favorites]


We have to assume that there is some rate of recovery among people who have no treatment or therapy at all

If you believe this source - a national survey - most alcoholics who recover, do so with no treatment at all. And a significant chunk of them (25-50% or so, depending on what definition you go by) return to moderate levels of drinking, which supposedly cannot be done. It's a survey, so grains of salt should be taken and so on. But if it is believed, never treating is better than getting any treatment in terms of avoiding long-term dependence.
posted by mrbigmuscles at 6:50 AM on March 18, 2015 [9 favorites]


AA as a whole has no opinion about much of anything, doesn't care whether people join it or not, and doesn't make any money off new members or growth. (Twelve Traditions) Some of the groups are definitely off-the-wall, others are relentlessly sane and ordinary, and the occasional one goes into territory that is non-AA.

But it's supportive, friendly, self-supporting, and reliable and if you get fed up with one group you can go to another one.

Disclaimer: I used it 41 years ago to stop drinking, stopped going for about twenty years when I was about twenty years sober because I was too darn busy, and started going again last summer because I'm older and have time and, even though I still have a very busy life with sports, profession, and friends, missed the fellowship of AA.
posted by Peach at 6:58 AM on March 18, 2015 [4 favorites]




Yeah, "never treating" is a real good idea for someone who is throwing up blood :) Dang.
posted by Peach at 7:06 AM on March 18, 2015


Pardon what must be a reading failure on my part, but that rebuttal piece appears to read like:

"Her conclusions are wrong because she used an old study; here is a link to it. Newer studies say the opposite; here are some crickets chirping."

So are there links/citations for the newer studies? They might not have any serious flaws, but that doesn't seem to be a safe prior assumption.

AA studies appear to have some notorious design difficulties. Glaser mentions the one with no control group, but doesn't mention that that's a hard problem to avoid: if you really don't refer an alcoholic to any treatment then you have ethics problems; and if the patients choose their own treatment-or-lack-thereof then you have selection bias problems. Even "no control group" isn't as tragically funny as the studies where "subjects in the “not attending Alcoholics Anonymous” condition attended Alcoholics Anonymous more than subjects in the “attending Alcoholics Anonymous” condition".

That whole link is worth reading, by the way - even if the studies there turn out to be outdated, the writing about them is hilarious.
posted by roystgnr at 7:12 AM on March 18, 2015 [12 favorites]


One thing I did not know before reading this article was that the religious content of Alcoholics Anonymous was inspired by a vision of God that Bill W. experienced in 1938 while taking the hallucinogenic drug belladonna, which was used at the time as an alcoholism treatment. Bill W. would later go on to advocate LSD as a treatment for alcoholism and possibly even tripped balls on LSD with Aldous Huxley.
posted by jonp72 at 7:16 AM on March 18, 2015 [9 favorites]


Public Education also has a shitty success rate. Is there any way we can turn that industry over to pharmaceutical companies as well?

...what?

"Oh, new evidence suggests that [thing] isn't the best possible way to do things and may actually cause harm in some cases? Sounds like the rhetoric of pill-popping sheeple to me!"
posted by showbiz_liz at 7:32 AM on March 18, 2015 [10 favorites]


AA studies appear to have some notorious design difficulties

For starters, there's no objective criteria for who is an alcoholic, as far as I can see. It's a socially constructed category.
posted by thelonius at 7:33 AM on March 18, 2015 [6 favorites]


I lost a good friend, who was a struggling alcoholic, three years ago to suicide; AA didn't help him. I don't know if anyone offered him naltrexone, but of course, here in the great free country of 'Murca, he didn't have health insurance or a steady income, so it might not have helped if they did.

Still, it's hard to think about what could have been, if he'd have had support and maybe pharmaceutical help, he could still be with us. His daughter could still have a dad. I'm pretty sure the people who loved him wouldn't care what kind of pill he had to take if it meant he could stay around and get better.
posted by emjaybee at 7:44 AM on March 18, 2015 [3 favorites]


I always thought meetings were a good thing. There was a good feeling there. It was people who were trying to be better. Trying to be better people. I found that heartening.

I'm an atheist pretty much, but I found that feeling of people aspiring, and being honest with themselves about having lost control, in a way it was a holy thing.
posted by Trochanter at 7:45 AM on March 18, 2015 [5 favorites]


The rebuttal doesn't address the Finnish treatment at all- which seems like the most compelling part of the article. I don't care about whether AA is helpful or not (I have no personal experience with it and limited second-hand knowledge), but it seems like ignoring a possibly effective drug treatment that is cost effective is a bad idea, no?

I gotta agree with this. AA is not effective for lots of people, & the treatment "industry" (blech) needs to come to terms with this and look at all the possible medical solutions as they become available. There are people who need help that are not getting in through in-patient treatment programs.

The thing about "rock bottom" is that is the point at which you become willing to admit you're ready to quit drinking. People that come in to AA after finding that point may have a better success rate than people conigned by courts or shuffled off by treatment programs because they're motivated to try it, and it appeals to them.

It was a good thing for me to find a room full of people who had recovered & wanted to help me do so. I let the group carry me for quite a while until the cravings subsided & I got on my feet. But again, I was motivated, am not a strict atheist, etc.
posted by Devils Rancher at 7:56 AM on March 18, 2015 [2 favorites]


I always thought meetings were a good thing. There was a good feeling there. It was people who were trying to be better. Trying to be better people. I found that heartening.

Well they are. But they're good in that they provide the person with a support network of people who aren't centered around addiction (which is the problem for many addicts, as they often have few if any relationships not based on addiction.) Which is why I don't find that Science of Us piece to be nearly the rebuttal it portrays itself as - it's so focused on one aspect of the criticism of the traditional 12 step model that not only does it ignore the other parts of that criticism, it doesn't even really look at what the one point they're making is really saying.
posted by NoxAeternum at 7:59 AM on March 18, 2015 [2 favorites]


naltrexone - This sounds like a powerful aid. I'm looking forward to the expansion of this use and for it to be looked at for obesity issues as well. I like stuff that feels good, to the point of detriment. If alcohol were one of those things, it'd be alcohol. If I didn't have asthma, it's likely it'd be smoking.

Food is cheaper than drugs, so for a long time it was my drug. Now I'm getting to a place where I can fight my way down through the pounds (Weight Watcher's style tracking got me rid of 25 pounds pre-babies).

But if I can't "fight my way" through consumption reduction/changes on my own, it's nice to know there'd be a step before surgery that wasn't Alli.

Whoops, just looked up Naltrexone. I guess that's out for me, like Alli, for liver issues. But there's probably people who can benefit from it for obesity issues (in conjunction with retraining how to eat and maintain balance in their habits in that arena).
posted by tilde at 8:03 AM on March 18, 2015


LSD therapy for alcoholism. It was effective. Bring it back.
posted by Liquidwolf at 8:05 AM on March 18, 2015 [2 favorites]


As a longtime Al-Anon member, I've heard all the criticisms of 12-Step programs, and even agree with some of them.

Still, you know what? It's been exceedingly helpful to me. The program is only one arrow in my life quiver, but I'm glad it's there.
posted by k_nemesis at 8:08 AM on March 18, 2015 [6 favorites]


The reason I think the more overlooked criticism – that people in abstinence-based programs tend to have worse relapses – is so important is that it says that the program can actually hurt people when it fails. Saying that the meetings helped you doesn't change that, and the calculus of whether AA should be recommended becomes very different.
posted by graymouser at 8:15 AM on March 18, 2015 [16 favorites]


By the way. I went to a number of different meetings in different places, and I never found any that were especially bible thumpy. Really at all. I don't remember the lord's prayer ever happening. This is in Canada, don't know if that means anything.

Also by the way. I am not much on any level of AA beyond those small meetings. The national body has made a lot of dumb claims and, cynic that I am, I don't see why it would avoid the propensity to stupidity and corruption that overtakes any human endeavour. But that never had much at all to do with the meetings I attended.

I also don't particularly endorse anything beyond step one. After that it's personal.

And further, I wouldn't say AA was essential to my sobriety. Definitely not the 12 steps. But those meetings were a comfort and a positive thing early on.

I forgot to use the word "humble". These were people who had been humbled. In a way it was seeing the best of people.
posted by Trochanter at 8:41 AM on March 18, 2015 [3 favorites]


LSD therapy for alcoholism. It was effective. Bring it back.

I've seen a guy who was tripping pass out with a beer in his hand. It's not a magic bullet. Of course what we were doing was pretty far from "therapy".

we replaced it with an empty can, and drank it
posted by thelonius at 8:43 AM on March 18, 2015 [3 favorites]


OK, this is going to be a pretty long rant about the misconceptions that people have, and promulgate, about AA. Disclaimer: I've been going to meetings regularly since becoming sober over three years ago, so that's either a qualification, a bias, or both, take your pick.

First, as has already been noted, Gabrielle Glaser is selling a book, and has written a number of articles for the New York Times (here and here) and the Daily Beast (here and here). You might note that, in the first NYT article, she speaks approvingly of Moderation Management, while in the second, she still speaks approvingly of them, but notes parenthetically that Audrey Kishline (the founder of the group, not "one of its founders" as Glaser would have it) killed two people while driving drunk well after she founded the group. Note also the first DB link, in which she uses the alcoholism-related death of Elizabeth Peña to plug her book. Her credentials for writing these articles seems to be limited to her having written a book about it.

Based on my own experience both in and out of AA, here are some myths that I'd like to address about the program:

It's a cult. Not in any meaningful sense of the word, unless your definition of "cult" is basically "any organized or semi-organized group of people who use rituals, vocabulary and literature that's largely impenetrable to non-members, that I don't belong to personally." (This, of course, includes just about any fandom or hobby that you could name.) Just about every anti-AA site gets this wrong, and will usually dedicate quite a bit of time, space and effort in disparaging Bill Wilson, AA's founder and the author of the principal section of the "Big Book". This misconception isn't helped by clubs that post pictures of Bill W. and Dr. Bob (Smith) as if they were this guy. But lots (most, in my experience) don't, which points toward the main reason why AA isn't a cult: it's too anarchic. Some clubs (and individual meetings within clubs) are run very tightly; some aren't. Some clubs and meetings insist that everyone take a turn speaking even if it's just to say their name, some don't. Some end with the Lord's Prayer (although every one I've been to has made it optional; if they hadn't, I probably would have just walked out), some end with the Serenity Prayer, or with something else from AA literature; when I chaired a meeting I'd end with the AA Promises. [PDF] One of the things that I encourage people new to the program to do is not only to do the "90 meetings in 90 days", but to make as many of those at different clubs and meetings within clubs as possible. In particular, it helps keep people away from rogue meetings where the chairperson is pushing their own personal brand of sky king (i.e. religion) or ranting about how AA is the only way for anyone.

It's a program of first resort. It's really the program of last resort; this is the main problem that I have with both the studies that treat it as if it is a first-resort program, and with courts and other parts of the justice system that force people to go. When I first tried sobering up, after my first DUI, I went to a few AA meetings, didn't like 'em (because I didn't try another meeting--see above--or I just wasn't ready yet), and lone-wolfed it for the next 2 1/2 years. Some of the studies that rank and compare methods of achieving sobriety would have put AA under the "fail" column and unsupported abstinence under the "success" column for me; thing is, it didn't last, and when I went back out (i.e. started drinking again), I picked up pretty much where I left off, and eventually got a second DUI. Even then, it was nearly three months before I stopped drinking, and another several months before I started taking the program seriously; after over three years of sobriety, I am now on Step 6. (There's a reason why it's called working the steps.) Nobody really wants to do "a searching and fearless moral inventory" of themselves, or make amends (which, with the path of devastation that hardcore drunks can leave behind themselves, can be considerable). "How It Works" [PDF], the part of the Big Book that's read at the beginning of every meeting, even hints at this: "Half-measures availed us nothing" and "We thought we could find an easier, softer way. But we could not."

So why, then, if it's such a tough program, is it one of the first things that people in rehab and in the justice system for DUIs and other alcohol-related offenses get shoved into? Because it doesn't cost them anything; because no AA meeting chairperson (at least that I've ever heard of) will turn them away (see the Twelve Traditions, and while I'm at it, I should note that these sort of anti-AA articles seldom ever acknowledge the Traditions, let alone seem to understand how they affect what AA does and doesn't do as an organization); and, of course, because they may perceive drinking itself as a moral failing. I am absolutely not opposed to someone trying SMART or naltrexone or anything else that they think might work; I might have given naltrexone a shot myself, before my second DUI. (I'm really hesitant to do so now, simply because, if it doesn't work and I get a third DUI, I'm severely fucked. Although I don't want drunk drivers on the road--even if one of them is me--I've more than once, during my journey through the judicial system, had opportunities to reflect on the bitter truth that no politician has ever lost an election by proposing or voting for more stringent penalties for DUIs.)

The God thing, which was a big hangup for me as it is for a lot of people; many other commenters in this thread have already addressed it, but I'd also like to add that I think the real hangup for a lot of people attempting recovery is that the only thing that they believe any more is that they can't live without alcohol (or whatever their drug(s) of choice is/are). Also, something that someone said at a meeting once that really rang true for me: the most important thing to realize about my Higher Power is that I'm not it. As I noted above, if someone is trying to foist the idea that their own brand of Sky King is the one true H.P., find another meeting or another sponsor, and if you want Batman as your Higher Power, awesome, if you're willing to turn your life and your will over to the care of Bruce Wayne as you understand him.

Oh holy shit I have to tell a room full of strangers all the embarrassing shit I did when I was wasted are you fucking kidding me. Again, no. Some of my regular meetings have/had people who have never spoken; other people have spoken maybe once. As I've already said, if the person chairing the meeting tells you that you have to speak, you can get up and walk out, find another meeting, and if you'd like, tell the people who are the current officers of that club that the chair of the first meeting isn't running their meeting very well. (As also noted above, AA is pretty loosely run, and per the Third Tradition, "the only requirement for A.A. membership is a desire to stop drinking," but most clubs will regularly hold a meeting (a "group conscience") at which they may discuss whether a certain person who's being disruptive, or a chairperson who's being overcontrolling or apparently working a different program from everyone else, should be asked to stop.) What tends to change people's minds about speaking at meetings is the shock of hearing someone say out loud what I thought I'd never say to another living being, and later realizing that I can help a newcomer as I'd been helped.

Anyway, that's my experience; as we sometimes say, take what you like and leave the rest.
posted by Halloween Jack at 8:46 AM on March 18, 2015 [33 favorites]


Audrey Kishline (the founder of the group, not "one of its founders" as Glaser would have it) killed two people while driving drunk well after she founded the group.

She was going to AA when that happened.
posted by thelonius at 8:53 AM on March 18, 2015 [8 favorites]


I think one of the problems with the twelve-step method is that once it became established as the most successful method for treating alcoholics, it was adopted as a treatment method even in areas where it’s clear that the program is a bad fit. For example, AA and NA programs are often set-up in prison settings where participation is mandated. So a program that is supposed to work because it is voluntary and anonymous instead features meetings with a group of people who are required to attend and everyone knows who is going.

My favorite AA story from prison is from a guy whose incarceration was closely tied to his alcoholism, who was committed to recovery, and who found the 12-step method helpful. He shared a cell with a guy who regularly made pruno but who also attended the AA meetings along with him. Often the guy would crawl under his bunk and take a swig of homebrew as soon as they’d returned from the meetings (which, like many AA meetings outside of prison, featured a large urn of coffee with packs sugar and powdered creamer available for members to share).

After several weeks of this, my friend finally asked his cellie why he kept going to AA meetings when he clearly had no interest in staying sober. “Where do you think I get the sugar to make this stuff?” the other inmate replied.
posted by layceepee at 9:09 AM on March 18, 2015 [16 favorites]


It's funny this thread would come up just now. I don't remember the exact date of my being sober, but I've always used St. Patrick's day -- it's within a few days.

So, I'm right around my twelfth or thirteenth birthday in that sense. And those meetings and the memory of the feeling in those meetings has always sort of been there for me.

I'm not really white knuckling it though. Never have been. I was just ready. I was full.
posted by Trochanter at 9:09 AM on March 18, 2015 [3 favorites]


If AA helps some people, that's great, if it helped you, that's great too.

Neither of those truths answers the criticisms in the piece, though. There's no reason a non-AA program couldn't have the good parts the current program has (support system) while also having actual qualified, trained counselors. You could take naltrexone or other aids and still go, or go to a similar program. You don't have to drink in moderation; you can abstain if that works for you.

It's possible to have a program that is well-studied, and founded on newer research, that still helps people.

What would be really great is if AA as an organization decided to move forward, and make it clear that medical assistance/drugs that dampen your cravings are ok, encourage its counselors to get credentials, and let go of the religious stuff, or at least make it optional for each group. Even if they refused to go along with the idea of moderation, they could help their members a lot.
posted by emjaybee at 9:11 AM on March 18, 2015 [28 favorites]


What would be really great is if AA as an organization decided to move forward, and make it clear that medical assistance/drugs that dampen your cravings are ok

Is AA officially against this? It doesn't seem like the national org goes on the record about very much, judging by the article.
posted by dr_dank at 9:21 AM on March 18, 2015 [3 favorites]


[Kishline/Conn] was going to AA when that happened.

Note the author of that piece and the date (relative to the articles that I linked to above). I'm detecting a certain amount of vindictiveness in how she's handling Conn's suicide. I'd also note, again based solely on my personal experience with the group, that simply going to meetings isn't enough, in the long run; I'm either actively working on my recovery or passively working on my relapse.

What would be really great is if AA as an organization decided to move forward, and make it clear that medical assistance/drugs that dampen your cravings are ok, encourage its counselors to get credentials, and let go of the religious stuff, or at least make it optional for each group.

AA doesn't have counselors; it's a group of recovering alcoholics that get together to share their strength, hope, and experience. And there's no reason why someone can't go to AA and be on naltrexone at the same time. As many people in AA say, the disease is 10% drinking and 90% thinking.
posted by Halloween Jack at 9:21 AM on March 18, 2015 [6 favorites]


The relapse problem associated with the AA model is especially bad for heroin, because sobriety lowers tolerance. People who relapse on heroin often go back to taking the same amount as when they stopped, but because their tolerance is lowered, they're ingesting dramatically more than they can handle, and so they overdose and die. Relapsing on alcohol doesn't have the same inherent harm. AA alone, without any medication, might be an appropriate treatment for some alcoholics, but it's inappropriate for certain other addictions.
posted by Small Dollar at 9:25 AM on March 18, 2015 [3 favorites]


I am just a guy who went sober a few weeks ago and have no authority to speak to these issues. I have non-religious friends who think AA is great. I just have a hard time saying "I am an alcoholic." That doesn't feel like my identity. I'm a guy who had problems with substances. I've been to groups, Rational Recovery, AA, NA, and Kaiser. Not sure any of them helped a lot.

Being tired of coping with anxiety/stress/problems/depression by feeding my brain chemicals--with the usual dismal side effects--has been more helpful than anything else.

By the way, my friends in Berkeley and NYC tell me about AA groups for artist, Buddhists, etc., and if I had one of those in flyover country, I would go, but I don't.
posted by kozad at 9:30 AM on March 18, 2015 [4 favorites]


I'm not really white knuckling it though. Never have been. I was just ready. I was full.

I feel much the same. It was easier than I had feared. When it was hard, it was really hard, but it wasn't that way all the time, and it's just gotten to be the new normal for me. There was a big drawback to my method, though - drinking until middle age. If you have problem with alcohol, do yourself a big favor and do something about it NOW. I lost some good years there.
posted by thelonius at 9:47 AM on March 18, 2015 [1 favorite]


As a clinician (I am not your therapist and none of this should be seen as therapuric advice) the best thing I've seen about 12 step programs is the ability for 24 hour contact. Got cravings at 3 in the morning? Some sponsors or other members will meet you at waffle house for some waffles and distraction. Sometimes there are meetings to go to at 4 am. Outpatient programs run on the 8 to 5 schedule and don't allow for support off hours.

A lot of what she is talking about is harm reduction. People can and do reach a place where they are comfortable with their use of whatever drug they choose. Safety is relative but I work with all kinds of substance use.


I do want to comment that therapies with fluffy sounding names like equine therapy are actually secret ways to engage clients in normal types of therapy. I've experienced equine therapy as a part of my eating disorder treatment in a ritzy residential center. And honestly it was focused on active provlem solving and the very concrete rule making that people with anorexia tend to do. It was complete cbt based when it came down to it but engaged in a different way. I was actually very impressed.

Of course, not all threatment centers are the same and everybody does things differently.

I think a big part of addiction treatment it's the large subgroup that needs trauma therapy. This article ignored that treatment centers are really a place where lots of stuff comes out but there really isn't an outpatient structure to deal with that. Group therapy helps address this in substance abuse treatment.

I want more medical interventions and more doctors willing to try these medications. I also want treatment centers and outpatient programs not to deny treatment because someone is "in" their addiction by using. Or bouncing them between different agencies and levels of care.

Sorry fot the disjointedness but I think I got my points across.
posted by AlexiaSky at 9:55 AM on March 18, 2015 [6 favorites]


AA ain't all bad. In the 80s, it was the best place to find other dykes to date in towns that didn't have gay bars.
posted by Dreidl at 9:58 AM on March 18, 2015 [9 favorites]


while also having actual qualified, trained counselors

And then people can spend weeks and months navigating a costly system of referrals instead of finding a free meeting happening in some church basement that very day. My knowledge of the ways of AA is only through having parents who were members for over 40 years, but it has always seemed to me a remarkable community organization for being able to maintain its accessibility everywhere while having an extremely loose hierarchy, without having any (as far as I know) professional staff, or any staff at all. A lot of the criticism in the article can be directed on those more professional bodies piggybacking on AA - private sector rehabs that charge tens of thousands but offer little else but AA meetings, public sector courts that mandate people to attend meetings. AA isn't constraining them from offering other options.
posted by TimTypeZed at 10:01 AM on March 18, 2015 [6 favorites]


LSD therapy for alcoholism. It was effective. Bring it back.

I've seen a guy who was tripping pass out with a beer in his hand. It's not a magic bullet. Of course what we were doing was pretty far from "therapy".


Yeah i wouldn't call that a therapeutic use of LSD.
Of course it's not a magic bullet, it doesn't work that way. It doesn't change your relationship with alcohol directly , it makes you see the harm you're doing to yourself and others and THAT makes you change your own behavior ( in many cases).
posted by Liquidwolf at 10:16 AM on March 18, 2015


if you are stuck on the 'higher-power' issue, you might take a look at yourself. as many here and elsewhere have noted, the HP concept is very, very fluid and personal. yes, some meetings are "doing it wrong'. so find another one.
posted by j_curiouser at 10:16 AM on March 18, 2015


+1 on the fact that the rebuttal article provided no citations.

"The study is likely to be overturned" is gossip; not science, unless Dr. Kaskutas has actual evidence (in the form of published and peer-reviewed studies) to support the notion that findings of the original paper are invalid.

While others have made some great points in support of AA above, I'm very weary of the seeming lack of efforts to improve or optimize AA through evidence-based medicine. Even many of the legitimate researchers seem to treat AA as a monolithic and immutable entity.

Even if AA can be proven to be effective (and I lean toward the side that it probably can), I see very few attempts to incorporate scientific findings into AA/NA. Even if the basic premise is sound, I find it difficult to endorse any organization that so vehemently considers its practices to be beyond reproach.
posted by schmod at 10:40 AM on March 18, 2015 [8 favorites]


I highly recommend that people check out this link that roystgnr already linked to. It is a thorough, insightful, and even hilarious examination of the methodological flaws of various studies of the effectiveness of Alcoholics Anonymous and other treatments for alcohol dependency. The tl;dr is that almost none of the studies, whether cited by pro-AA or anti-AA partisans, can withstand the most basic methodological objections. The other tl;dr is that asking people nicely, "Would you cut out drinking so much booze, mmmkay?" for five minutes is about as equally effective in getting people to abstain from alcohol as AA or psychotherapy or inpatient treatment.

Here's the juiciest part of the linked post if you want to skip ahead:

Alcoholism studies avoid control groups like they are on fire, presumably because it’s unethical not to give alcoholics treatment or something. However, there is one class of studies that doesn’t have that problem. These are the ones on “brief opportunistic intervention”, which is much like a turbocharged even shorter version of “motivational enhancement therapy”. Your doctor tells you ‘HELLO HAVE YOU CONSIDERED QUITTING ALCOHOL??!!’ and sees what happens.

Brief opportunistic intervention is the most trollish medical intervention ever, because here are all these brilliant psychologists and counselors trying to unravel the deepest mysteries of the human psyche in order to convince people to stop drinking, and then someone comes along and asks “Hey, have you tried just asking them politely?”. And it works.

Not consistently. But it works for about one in eight people. And the theory is that since it only takes a minute or two of a doctor’s time, it scales a lot faster than some sort of hideously complex hospital-based program that takes thousands of dollars and dozens of hours from everyone involved. If doctors would just spend five minutes with each alcoholic patient reminding them that no, really, alcoholism is really bad, we could cut the alcoholism rate by 1/8.

posted by jonp72 at 10:48 AM on March 18, 2015 [13 favorites]


We have to assume that there is some rate of recovery among people who have no treatment or therapy at all

Yeah, I lived with one of those for a long time. Even when he was in periods of abstinence or limitation, I wouldn't have referred to him as "recovered." There were more times than I care to mention that I wished he would just get drunk because he was just so f***ing miserable during the "self-management" periods.

It didn't help that all his male relatives, going back to a grandfather I'm not sure if he ever met, were all alcoholics, too. They rant the gamut from mean to sad to brilliantly functional, but the common factor was not knowing how to relate to themselves, other people, or the world in general, without alcohol being a factor.
posted by The Underpants Monster at 10:49 AM on March 18, 2015 [2 favorites]


if you are stuck on the 'higher-power' issue, you might take a look at yourself. as many here and elsewhere have noted, the HP concept is very, very fluid and personal. yes, some meetings are "doing it wrong'. so find another one.

I'm not in AA, and thankfully I don't crave alcohol myself, so I don;t need a higher power for those purposes. But, as an atheist, I still consider biology, psychology, and the laws of nature to be a higher power than my own Ego.
posted by The Underpants Monster at 10:53 AM on March 18, 2015 [3 favorites]


Then, Underpants Monster, if you ever do need AA, biology, psychology and the laws of nature could be your higher power. It's a personal choice. Everyone has his/her own. Whatever works.
posted by pearlybob at 11:03 AM on March 18, 2015 [2 favorites]


Technically speaking, AA is for alcoholics. Somewhere along the line, the definition of "alcoholic" was broadened to include those who are technically not alcoholic. Divorces, DUIs, loss of employment and houses does not an alcoholic make. What makes one an alcoholic is if one cannot quit on their own, no matter the HONEST desire to stop and plentitude of genuine reasons.

Alcoholics as a whole are notoriously dishonest and evasive with psychiatrists and physicians, but can quickly identify, relate and find common ground with someone who has been through the wringer.

There are other paths to sobriety, some easier than others, but it relies on the extent to which one has lost the power of whether they will continue drinking or not. For many, AA is in fact, the last house on the block. Treatment, therapy, and medication has come first. To try to condemn that house as unsuitable for recovery is to try to doom those people to a lonely, pitiful, death... Simply out of contemptuous ignorance of what the program of action really calls for.
posted by Debaser626 at 11:08 AM on March 18, 2015 [3 favorites]


I've never been to an AA meeting, but in my experience quitting drinking (five years ago) was the easy part. Dealing with the reasons I was drinking is an ongoing process. I don't foresee a drug-based treatment ever working for a drinker like me, for that reason.

My view is that AA provides a peer support network which is certainly going to be somewhat effective, but the 12 steps don't interest me in the slightest so the program would never have worked for me personally, although I'm very glad for the people it has worked for.

What did work for me was talking therapy and doing some voluntary work, the combination of which allowed me to develop a sense of self worth and forgiveness.
posted by walrus at 11:09 AM on March 18, 2015 [3 favorites]


Debaser626: Technically speaking, AA is for alcoholics. Somewhere along the line, the definition of "alcoholic" was broadened to include those who are technically not alcoholic. Divorces, DUIs, loss of employment and houses does not an alcoholic make.

This is an interesting point. Aside from plea bargainers who are compelled to go to AA under threat of jail, I'd be curious to know how many are there because they screwed up while consuming alcohol and AA attendance looks like a good thing to clean up their image. Does AA dissuade those who are there to look good rather than commit themselves to sobriety for their own self-improvement?
posted by dr_dank at 11:29 AM on March 18, 2015


The only requirement for membership is an (honest) desire to stop drinking. The diagnosis of alcoholism is a self admission, so it is up to the individual to determine whether they can stop on their own or not, or even whether they really want to or not. The point of the program is to provide one solution for those who need it, and to provide an ear and some words of hope to those who don't or may not currently want to.
posted by Debaser626 at 11:45 AM on March 18, 2015 [1 favorite]


I still consider biology, psychology, and the laws of nature to be a higher power than my own Ego.

This is largely how I work it. I consider the vast scale of the universe, my very, very, very, very small place in it, and realize it is very much more powerful than me. When I wake up every morning, I ask myself some variation of the question "what causes us to exist?" I don't know the answer to that, but I want to find my place in it, fit into the stream as it were, and I ask for the strength and the clarity to help figure out what that entails, and for help in not resisting the flow and trying to own too much of my little universe for myself. I try to remain humble before all of creation. Most days I fail miserably, but it's better than it was when I was trying to drink away all my disappointment in my unrealized expectations of what the universe should have been doing for me. I've turned it around 180º thanks to help from others on a similar path.
posted by Devils Rancher at 12:28 PM on March 18, 2015 [5 favorites]


...there are as many kinds of [AA] meetings as there are people who want to explore them. There are religious ones, agnostic ones, and every flavor in between.

Interesting set of boundaries there. "Agnostic" is the polar opposite of religious?
posted by QuietDesperation at 12:40 PM on March 18, 2015


I don't really get why people feel a need to bad mouth AA

I think there's a lot of us who have experienced people in the program dismissing other folks as dry drunks - particularly if they assert non-program approaches to quitting - or judging others as alcoholics in denial. It's not a good reason to dismiss an entire scheme but it explains a lot of bad blood. The downside of a very decentralized and undefined movement is that you can end up with people speaking for it who really have no business doing so.
posted by phearlez at 1:24 PM on March 18, 2015 [7 favorites]


Even if AA can be proven to be effective (and I lean toward the side that it probably can), I see very few attempts to incorporate scientific findings into AA/NA. Even if the basic premise is sound, I find it difficult to endorse any organization that so vehemently considers its practices to be beyond reproach.

All the calls for AA to become more evidence-based strike me as really odd. You might as well go to Metatalk and demand that Metafilter become more evidence-based. 12-steps programs aren't medicine, they don't bill themselves as medical professionals, and they don't charge you money or take responsibility for your treatment.

Drug courts should be evidence-based. Judges sentencing folks for DUIs should be evidence-based. Prisons and sociall workers should be evidence-based. But AA should be exactly as evidence-based as its members want it to be. And if you want it to be more evidence-based, join a group and present the evidence!
posted by anotherpanacea at 1:24 PM on March 18, 2015 [8 favorites]


I didn't read the article as bashing AA. I read it as bashing an entire treatment paradigm that's unquestioningly accepting of AA as the main road.

Yes, there's some information about when and how it's most effective, and that is not applied to practice.

It's entirely possible that AA can be a good thing, and courts ordering people to attend AA can be a bad thing.

Especially when it actively interferes with better scientific research into treatment of addiction.
posted by entropone at 1:43 PM on March 18, 2015 [13 favorites]


Pardon what must be a reading failure on my part, but that rebuttal piece appears to read like: "Her conclusions are wrong because she used an old study; here is a link to it. Newer studies say the opposite; here are some crickets chirping."

+1 on the fact that the rebuttal article provided no citations." The study is likely to be overturned" is gossip; not science, unless Dr. Kaskutas has actual evidence (in the form of published and peer-reviewed studies) to support the notion that findings of the original paper are invalid.


So, I followed the links. For me, they're they orange contrast text in the article. (I find on the internet that links are often highlighted in a contrasting color to the rest of the text.) Here are some cites I found (you can click on these titles to go to the articles' abstracts):

Encouraging Posttreatment Self-Help Group Involvement to Reduce Demand for Continuing Care Services: Two-Year Clinical and Utilization Outcomes

Alcoholics anonymous effectiveness: faith meets science.

Effectiveness of Making Alcoholics Anonymous Easier: a group format 12-step facilitation approach.

Alcoholics anonymous careers: patterns of AA involvement five years after treatment entry.

Social networks as mediators of the effect of Alcoholics Anonymous.

Toward an Enhanced Understanding of the Psychological Mechanisms by which Spirituality Aids Recovery in Alcoholics Anonymous

Young adults with co-occurring disorders: substance use disorder treatment response and outcomes.

Young adults, social networks, and addiction recovery: post treatment changes in social ties and their role as a mediator of 12-step participation.

There does indeed appear to be some new work on this question since the Cochrane study was published.
posted by anotherpanacea at 1:43 PM on March 18, 2015 [3 favorites]


Dealing with the reasons I was drinking is an ongoing process.

I can't emphasize how important I think this is. The desire to abuse shit is often a symptom of other, deeper issues, and I think that failing to address those root-causes is the reason we see the lack of optimal outcomes that people complain about.
posted by mikelieman at 1:51 PM on March 18, 2015 [3 favorites]


Flood: It may not be perfect, but it has done a lot of good. Disrespecting AA as she does is low brow.
"Disrespecting" is nonsense. Many potentially lethal medicines have been tried, sometimes backed by science and sometimes not. Those that are not the best at what they do should generally be discarded. Why should AA be afforded some holy place of "respect", when it's simply a medical treatment that is very likely sub-optimal for most people?

I'll respect people, and use medical treatments without regard to the latter's self-esteem.
posted by IAmBroom at 1:52 PM on March 18, 2015 [11 favorites]


thelonius: SD therapy for alcoholism. It was effective. Bring it back.

I've seen a guy who was tripping pass out with a beer in his hand. It's not a magic bullet. Of course what we were doing was pretty far from "therapy".
Thank you for that completely irrelevant anecdote.
posted by IAmBroom at 1:58 PM on March 18, 2015 [2 favorites]


when it's simply a medical treatment that is very likely sub-optimal for most people

It's not medical treatment. It's gatherings of people who have similar struggle joining together to attempt to help one another. Community. Doesn't work for everyone but then nothing does. For those whom it does help it makes a tremendous difference. Medicine is free to explore other approaches, and should.
posted by TimTypeZed at 2:05 PM on March 18, 2015 [2 favorites]


So, it attempts to treat a medical issue, but is not a medical treatment? OK.
posted by IAmBroom at 2:31 PM on March 18, 2015 [3 favorites]


I am a alcoholic. I have aways drank to get drunk and achieve oblivion. I have never drank for effect, to be cute and relaxed at parties. I always wanted to be "outta here". I have no interest in Naltrexone's chemically induced governor. If science comes up with a pill that allows me to drink all I want with no consequences, I'm all in. Until then, I am happy with my spiritually (not religiously) induced abstinence and the freedom of expression (with no governor) I find at 12 step meetings.

The author, the NYT, big pharma, and the alcohol industry are desperate to win the trifecta of a chemical cure for alcoholism and addiction. I see the 12 step community as being a thorn inside the skin of the medical model. They scratch and scratch but can't get rid of the damn thing.
posted by Xurando at 2:38 PM on March 18, 2015 [2 favorites]


The blog Slate Star Codex links to an amazing paper (How to have a high success rate in treatment: advice for evaluators of alcoholism programs) that's a bit like the How to Lie With Statistics of alcohol addiction research. I'm finding at an excellent antidote to the unusually high degree of woo (for Metafilter, at least) in this thread.
posted by jonp72 at 2:55 PM on March 18, 2015 [6 favorites]


If science comes up with a pill that allows me to drink all I want with no consequences

Robin Williams had a joke that went something like: you know what alcoholics would say if there was a pill that cured alcoholism? Hmmm, what if I take two of them?
posted by thelonius at 3:19 PM on March 18, 2015 [8 favorites]


Doesn't work for everyone but then nothing does. For those whom it does help it makes a tremendous difference.

This is what's frustrating about discussing AA. The real, and as far as I'm concerned the biggest, issue with AA is the relapse problem. It is well documented that people who relapse from abstinence-based treatment for addiction have a higher tendency to engage in harmful binge behavior. But advocates for AA do not talk about this problem. It's always about the good it does for the currently sober people, which is a completely separate thing. The question is whether that benefit outweighs the relapse problem sufficiently to recommend AA (or any other abstinence based program).

I have to think that AA's rather harsh attitude toward people who fall off the wagon is one factor preventing its advocates from even acknowledging that this is a problem. I say that not out of hostility to AA but because I think it's a flaw in a sincerely well-meaning program.
posted by graymouser at 3:46 PM on March 18, 2015 [4 favorites]


Since members of AA on metafilter are using their personal experience to defend AA. I will tell a little bit of my story. I went to AA meetings off and on for nearly 20 years. I had long periods -5 to 7 years - of sober time. I used the "steps" of AA, I went to meetings as suggested, working with others and with a sponsor. I have seen countless people come and go, a few by suicide. Usually the suicides are blamed on the person by the group. I have been to 50 or 60 different groups and thousands of meetings of AA. Any failure of the " program" is blamed on the person, and the groups never question the effectiveness of the treatment i.e.. faith healing through AA.

I left AA to never return after reading about alternatives, trying SMART and basically designing my own "program". I have never had a happier time of abstinence, ever, which has been almost 5 years now. AA for me was horrible. The stories I could tell about the abuses in AA could fill a book. Just a few things that were not anomalies in the groups I went to: Newcomers with mental illness being told not to take their meds, 13th stepping(sex with new members) by older men with long term sobriety with younger vulnerable women, financial predation, outing of other group members 5th steps on a group level etc...
posted by yertledaturtle at 3:49 PM on March 18, 2015 [14 favorites]


People who relapse in AA are welcomed back with open arms, no judgement and renewed support. I have no idea where people are getting that AA has a harsh attitude toward relapse. I've followed the thread pretty closely but missed that one. It just isn't true. At all.
posted by pearlybob at 3:51 PM on March 18, 2015


Welcomed back with open arms and gossip about why they did not "make it".
posted by yertledaturtle at 3:52 PM on March 18, 2015 [4 favorites]


That has not been my experience, I guess I've been fortunate.
posted by pearlybob at 3:54 PM on March 18, 2015


--It is well documented that people who relapse from abstinence-based treatment for addiction have a higher tendency to engage in harmful binge behavior.--

You mean they're alcoholics and haven't finished drinking, so they return to what they were doing previously (AA has nothing to do with it) Sure they may have walked out the door with a bit more guilt, but that's gonna be pretty insignificant compared to the great scorecard of wreckage they left in their wake while they drank alcoholically.

One thought that may help the ambivalent and sceptics is that this is said that it's the only disease that requires self diagnosis. You can rain science down on the head of someone who's actively drinking but unless they convince themselves that THEY are the problem, then any gains are short term and surface-deep. People can sometimes decide for themselves that they are alcoholics by going to AA and listening to the parts of other people's stories that make them go "shit, I did that too!"; that other people have similar tales of desperation, life carnage and emotional wreckage.

--I have to think that AA's rather harsh attitude toward people who fall off the wagon is one factor preventing its advocates from even acknowledging that this is a problem.--

graymouser, where do you get this shit from? I think you should go to a meeting or 3 so you can edumacate yourself. Maybe try a couple of venues. Because I reckon you have to face the possibility that you are doing some damage yourself by going around sprouting hearsay bullshit that many many many many people with direct knowledge can refute. Might one encounter a dickhead who comes out with the "tsk tsk tsk" towards a comrade returning from the storm? It's a possibility, sure. Is that representative of the fellowship in general? NO FUCKING WAY!
posted by peacay at 4:13 PM on March 18, 2015 [1 favorite]


Welcomed back with open arms and gossip about why they did not "make it".

I'll say this as a full-fledged 17-year, continuously sober member of AA: There is an evidence-based reason some people refer to it as Assholes Anonymous. I hate that kind of gossip, don't engage in it, and when someone announces to me they're going to take a stab a drinking again, I just say "you know where to find us if you need us." Some people do gossip, though. I hear it from time to time. I wish they wouldn't. But you know, a lot of us are kinda damaged people. We're by and large doing our level best to repair the damage by whatever means seem to help. I try to forgive other members & relapsers, for being human and thus imperfect, and take care of my own business, part of which is being there for relapsers with open arms should they wish to return.
posted by Devils Rancher at 4:19 PM on March 18, 2015 [7 favorites]


Graymouser, I would love to see those studies. Not because I doubt them as some of the recent comments seem to, but because they very much line up with my family member's experience and he was very interested when I mentioned your comment to him.

His experience has very much been one of the AA community having a harsh and judgmental stance on relapse, and of the medical community pushing AA as the One True Way and being very dismissive and patronizing toward his interest in finding alternative support models. Which is not to doubt others' experiences, just to reiterate that AA as practiced in some groups is not the right fit for some people, and it's a problem when someone gets lesser medical care because of that.
posted by Stacey at 4:21 PM on March 18, 2015 [2 favorites]


This is a description of the original study showing that AA members who relapse are more likely to engage in binge drinking than either CBT or control group drinkers. The OP discusses the phenomenon as well, and I think it deserves a good deal of attention.

I think what peacay said:

You mean they're alcoholics and haven't finished drinking, so they return to what they were doing previously (AA has nothing to do with it)

shows exactly what I mean by AA being very harsh on individuals who relapse. It's extraordinarily judgmental, in a way that I think should be avoided when talking about addiction. The central tenets of AA blame failures on individuals and not on AA, which I think is harmful, and also makes certain that AA's methods can't be analyzed or improved based on empirical results.
posted by graymouser at 5:39 PM on March 18, 2015 [5 favorites]


graymouser, my stating a fact is not me being harsh on individuals. A someone is an alcoholic and goes to AA and then doesn't return --- unless they are finding an alternative method for ceasing their drinking then I can state with some certainty that they have returned to drinking. I may be somewhat terse in the description here but that's because it's a fact. As to the poor bastard who is struggling, I have enormous empathy and would never trash them for leaving and returning and leaving and returning.

And this whole 'central tenets' thing is misleading. You're right, it's up to the individual to grasp some straw of identification from the stories they hear or the camerarderie they encounter. It's got fucking zero to do with blame though. It's just that each individual has to get it in their own way for AA to be of help. Some people never do fuckall about steps but they turn up to a few meetings and chill out some hours per week that gives them some peace of mind. It's this whole individuality that makes AA fairly impervious to real scientific analysis (apart from the anonymousness and the transient nature of many of the attendees). All kinds of people have all kinds of relationships with AA. As has been well described here by a bunch of nice people, yes there are aholes about, but they are not the norm.
posted by peacay at 6:06 PM on March 18, 2015 [3 favorites]


I'll say what I always say which is that I have no problem with AA/NA but I do have a problem with those being the places people get sent by the courts. I think the idea of some kind of free support group is much, much less bullshit than $10,000 rehabs offering a quick fix, regardless of the validity of equine therapy.

As far as moderation versus abstinence I think there's way too much all-or-nothing framing in general in popular ideas about addiction - if you're not completely "clean" of everything it must be only a matter of time before you're back down the spiral. But there are particularities of alcohol - its inhibition-lowering effect and the ease of going to the store and picking up a bottle - that contribute to turning a few into a binge for a lot of people.
posted by atoxyl at 6:25 PM on March 18, 2015 [2 favorites]


So, it attempts to treat a medical issue, but is not a medical treatment? OK.
posted by IAmBroom at 5:31 PM on March 18 [2 favorites +] [!]


I'm not sure what this means, except that the comment seems very sure about categories, and what fits into them, that are pretty unstable. Running a marathon causes a massive inflammatory response, is running a marathon a medical issue? Driving a car may result in an accident requiring medical treatment, is driving a medical issue? Exercise can positively affect depression and the propensity to develop Type 2 diabetes, is it a medical treatment? Scurvy can be kept at bay by eating limes or drinking pine needle tea, are they medical treatments? Hypothermia can be avoided by staying in your heated house, is staying inside a medical treatment? What if it leads to Vitamin D deficiency, which can be cured by going out into the sun?

The insistence that alcoholism is a "medical issue" requiring "medical treatment" is already a judgement not supported by evidence. It is a decision. It is biological determinism. I don't know, ultimately, if it's right or wrong, but it isn't necessarily right.
posted by OmieWise at 6:33 PM on March 18, 2015 [3 favorites]


AA's methods can't be analyzed or improved based on empirical results.

What intervention are you calling for, here? What method do you want to see changed in the 12 steps group dynamic, and how?

It's so weird that people keep calling for rationality and empiricism in such a generic way. It's like "evidence" is just your version of "woo." How would you treat alcoholism and addiction, in your world where AA sees the error of its ways and begins submitting to analysis and empirical results?

Do you want to see AA abolished or banned? Do you want AA groups to be required by law to avoid mention of God? Do you want to force AA members to drink or use drugs so they can't claim that abstinence is working for them? Do you want AA groups to be led by licensed professionals with a continuing education requirement so that they update their methods in light of new evidence? What should we do when people stop taking their naltrexone and go back to drinking or substance abuse?
posted by anotherpanacea at 6:35 PM on March 18, 2015 [3 favorites]


AA absolutely does not blame the individual. It blames the disease of addiction. It may be called "stinkin thinkin" or a handful of other terms coined over the years but it all boils down to the disease. The disease of addiction is cunning, baffling and powerful and relapse can hit someone with 30 days in or 30 years. I really encourage anyone who is so invested to have such strong opinions about something they obviously know very little about to go find a meeting and sit in. You'll be welcomed...you won't have to thump a bible or sacrifice to the big man in the sky or even utter a word if you don't want to. Stay after, have a cup of coffee and, I don't know, maybe talk to people. See what you think in person. Take what you want and leave the rest.
posted by pearlybob at 7:15 PM on March 18, 2015


There are gossips and assholes in any sufficiently large group of people. Look in any workplace, church, or amateur theatrical society.
posted by The Underpants Monster at 7:35 PM on March 18, 2015 [2 favorites]


The beautiful thing about AA that isn't mentioned in this article is that there are as many kinds of meetings as there are people who want to explore them.

This is true up to a point, but I've heard from people in certain areas (a gay man in a rural part of the Bible Belt, say) who really felt strong religious overtones and felt judged in many of the meetings they attended. On the other hand, in meetings in Manhattan or many other places, any mention of Jesus or overt preachiness may draw dirty looks and audible sighs. AA groups are made up of people who are much like many of the non-AAs in their communities.

I'm curious about the statistics that show such a high failure rate for AA, and the fact that they often lead people who are skeptical of the program to posit that it may be actively harmful to attend. How is the data derived, given that the program is anonymous? Are people who attend AA meetings tracked in some way? Are cognitive-behavioral or dialectical behavioral therapy more reliable? I would think that if someone attended CBT or dialectical-behavioral therapy to treat his/her alcoholism and stopped attending short of the recommended number of sessions, it would not be seen as a failure of the therapy per se. I would guess that a substantial portion of the people for whom AA fails are drifting away from the program before really investing in it. Even if the program were not anonymous it would be difficult to measure precisely who AA works for and why, unless you did some kind of regression analysis looking at frequency and duration of meeting attendance, the acquisition of a sponsor, work done on the steps etc. Then again, I don't want to blame the alcoholic and say that if s/he does everything by the AA book, s/he won't drink, just that the numbers are likely more favorable for those who are more committed.

As others have said, the bottom line is it is very difficult for some people to stop drinking, or even want to stop, even if they are ruining their lives. If there were some reliable method that could help them and it were being denied them in favor of shunting them into AA, that would be a travesty. Articles like Glaser's would help rectify this. But I'm not sure the reality is that straightforward. We can find plenty of hopeful anecdotes about people who either stopped drinking or stopped drinking dangerously in any number of ways, but I am unaware of any clear-winner methods that work for a broad cross-section of problem drinkers.
posted by callistus at 7:54 PM on March 18, 2015


to the 13th steppers, thieves, liars, backstabbers and gossips which can rear their heads in the various xA groups. First reaction is anger, than the dawning realization that this is, in fact, a fundamentally specific group of people who due to severe issues with substances and the often requisite mental instability are primarily comprised of sexual "weirdos", thieves, liars, gossips and selfish, self-centered assholes, and at that, not all are working to not be those things. It's amusing that the presumption exists that years, and sometimes decades or of abhorrent behavior can be undone completely in a year or two, or even at all for some who choose not to see certain behavior as an issue.

I mean, it isn't Volunteers Anonymous, it is, by its nature a place for some pretty fucked up people who have done some pretty fucked up shit. The fact that it still exists is a testament to its efficacy.
posted by Debaser626 at 8:41 PM on March 18, 2015


I'll say it again: any study attempting to compare the efficacy of AA with that of other programs will need to compare AA with other programs that are also completely free and nearly universally accessible. Perhaps such a study will discover a better completely free and nearly universally accessible program, or perhaps we will one day develop such a thing, as a society, in the form of something like universal single-payer health care. Until then, I think there will be room for, and need for, AA.

It doesn't matter if you have the most powerfully designed system and effective in the world if people can't afford it and can't access it.
posted by Miko at 9:34 PM on March 18, 2015 [4 favorites]


What intervention are you calling for, here? What method do you want to see changed in the 12 steps group dynamic, and how?

It's so weird that people keep calling for rationality and empiricism in such a generic way. It's like "evidence" is just your version of "woo." How would you treat alcoholism and addiction, in your world where AA sees the error of its ways and begins submitting to analysis and empirical results?


I am fine with all-volunteer support groups for people struggling with a personal problem, but I don't think that they should be the primary treatment for those problems, and I would prefer if those groups were open to communication with medical professionals and cooperated and honed their methods to match the scientific understanding of these problems.

AA tells people things about alcoholism. Those aren't the things that doctors and psychologists studying addiction are saying. When people in a 12-step framework talk about "the disease of addiction," are they telling people about an actual medical condition? Because they kind of are, and they're certainly trying to treat it, but not in a way that is paired with a current understanding of that condition. The AA understanding of alcoholism is a fixed thing, rooted in the late 1930s. You can't say that about any other area of medicine.

I would not be concerned if what I saw didn't suggest that there are flaws in the approach. And I say this thinking that the people in AA really want to fight addiction. If science tells us that what AA teaches is wrong, and possibly harmful, I'd prefer that AA adjust to the science instead of circling the wagons. And if you look through this thread, it's happened the whole time.

The U.S. is in a situation where the most readily available help available for people with drug and alcohol problems is not in a dialogue with the people trying to scientifically understand those problems. I think that is unfortunate and possibly dangerous, and would prefer that there be dialogue, and that the volunteer groups learn from the science, and vice versa.
posted by graymouser at 9:42 PM on March 18, 2015 [9 favorites]


If science tells us that what AA teaches is wrong, and possibly harmful,

I don't think it's necessarily wrong, however it appears to me that the unregulated and perhaps outdated content and delivery might the cause of a lot of potential harm. I've seen discussion of groups populated with predators. And I presume most aren't. But if your biggest variable in a successful program is "Luck", then there are issues that need to be addressed. Circling the wagons, and Sobriety Calvinism feels good, but ultimately doesn't help anyone.
posted by mikelieman at 1:48 AM on March 19, 2015 [1 favorite]


Is interesting that AA is nowhere near as popular outside the US, in my experience. I think this can be attributed to, yes, a higher level of religiosity and also the cultural history of alcohol and morals in the states, but also, having functional welfare systems I think.

It's fucking horrible that AA is the only, or main resource for alcoholics in the US.
posted by smoke at 4:57 AM on March 19, 2015 [6 favorites]


If science tells us that what AA teaches is wrong, and possibly harmful, I'd prefer that AA adjust to the science instead of circling the wagons.

Let me try one more time. You keep saying AA is wrong. What is wrong about it? What should they do differently?

So far, I've seen lots of vague denunciations, but not a single specific methodological change. Notice that to demand a methodological change, you have to know what 12 steps groups currently do, and what would be better. Look: here are some studies of these groups. Maybe one of them would help you make your case?
posted by anotherpanacea at 5:26 AM on March 19, 2015


anotherpanacea: I don't know how much more clear I could be. Studies have suggested that AA's insistence on abstinence and its tenet that alcoholics are powerless may lead to increased binge drinking from individuals who attend AA and then relapse. (The study I've seen says that it is worse in AA than in control groups.) I think that AA should investigate that more deeply, and work with doctors and psychologists to ensure that this doesn't happen.
posted by graymouser at 5:36 AM on March 19, 2015 [4 favorites]


I talked to my family member last night to ask if I could relay a little more of his situation and got permission to do so, so here's perhaps an illustrative example of how it causes a problem when the medical establishment views AA as the One True Way to stay sober:

A while back, he was in an intensive outpatient program. It was a dual-diagnosis program, although the staff was completely uneducated about his specific dual diagnosis. This program was very serious about AA - AA posters everywhere, part of the morning check-in was "how many AA meetings did you go to this week?" etc. He was not interested in AA specifically for some of the reasons noted above and other personal reasons, but he knows the research on how a support network is really helpful for getting and staying sober, so he definitely wanted to explore other support alternatives. No one there knew of anything, but he went off on his own and did research, and came back with information about SMART Recovery and about a local support group for his specific diagnosis. He got very involved in both online and offline SMART groups, and started attending the diagnosis-specific support group weekly. He's really serious about support groups.

Several other people in the group had no idea other support groups existed and asked him to share some information about them and about how they were working for him. This was shut down and belittled by the support group facilitators - basically no one was supposed to talk about anything but AA. They ended up like huddling outside the building on smoke breaks secretly trading information about other helpful tools. Which is ridiculous - at a place specifically meant to support people in getting and staying sober, the medical professionals were closing off discussion of ways that people might do that. And patronizing and belittling him for choosing other support methods - every single day, starting the day with a variant on "Well, did you finally break down and go to AA this week? Have you figured out yet that's the only way you're going to stay sober?" Did not make it a supportive or healthy environment for him.

Even more concerning to me, when the time came for him to graduate, he was told he might not be graduated from the program because he wasn't attending AA. Even though he had the best attendance record of anyone in his cohort. Even though he knew so much more about CBT, DBT, and mindfulness tools for sobriety that he had been asked to explain them to others in the group as well as to the facilitators. Even though he was actively participating in two other support groups that were not AA. The facilitators, therapists, and psychiatrist all had major doubts about letting him go unless he would commit to AA. IOP is not cheap - every week he was there was a big suck of time, of money, it was time he was not able to work with his long-established treatment team but instead was stuck with a therapist and psychiatrist who did not understand his diagnosis and wanted to make inappropriate changes to his medications. It was also a big blow to self-confidence - he had and has a sobriety plan and a variety of good supports in place, and is doing great at staying sober using a lot of different tools. But he still struggles with the fact that the medical professionals who are supposed to be the experts on this were so dead set that everything he is trying to do is wrong, and that he is doomed to failure without AA. Yes, this was just one program, but it is a well-respected program run out of a hospital that generally offers extremely excellent care, and I have to believe it is not that much of an aberration.

All of this makes me furious on his behalf. I have no problem with AA on its own, it absolutely works for some people and I'm glad it's there for them. But it is not the only available treatment option, it is not necessarily a great fit for people who have dual diagnoses or other situations that may not fit into the standard AA rubric, and it is infuriating that the medical establishment too often does not admit any other possibility.

The changes I would like to see are not necessarily in AA itself, but in our medical and cultural dialogue around addiction. I would like to see exploration of other support group models, I would like to see medical professionals educate themselves on these models, I would like to see the medical profession support patients' desires to actively participate in their own sobriety plan, I would like to see the culture as a whole become aware that AA is one tool in a toolbox and that other tools may work better for other people.
posted by Stacey at 5:44 AM on March 19, 2015 [18 favorites]


Studies have suggested that AA's insistence on abstinence and its tenet that alcoholics are powerless may lead to increased binge drinking from individuals who attend AA and then relapse. (The study I've seen says that it is worse in AA than in control groups.) I think that AA should investigate that more deeply, and work with doctors and psychologists to ensure that this doesn't happen.

You've only done half of your task. You've described (sort of) an element in 12 steps groups. You haven't described an alternative. (You're actually describing the elements you mention pretty badly, anyway, because you don't describe how those ideas are operationalized. But whatever.)

So let's try one more time: do you think that AA groups should promote moderate drinking and self-esteem? Is there a lot of evidence that moderation always works better than abstinence? Is it possible that some people should use addictive substances moderately and others should abstain? (What would those people who need abstinence do if AA stopped advocating abstinence?) And should NA groups also promote moderate heroin use and self-esteem?

Or perhaps your alternative is: "investigate." But 12 steps groups are not research universities. They don't conduct randomized controlled trials on human subjects: they ARE the human subjects. They don't even act in concert with other groups. Your other alternative is "work with doctors and psychologists." But of course, many individual alcoholics and addicts already do this, and those doctors and psychologists prescribe lots of different therapies, sometimes including abstinence-oriented 12 steps groups.

So it doesn't look like you actually have a policy proposal or change to suggest. That's fine: this is Metafilter, so no one who comments is obliged to know what they're talking about, but maybe tone down the rhetoric of empiricism if you're going to be so non-empirical yourself.
posted by anotherpanacea at 6:08 AM on March 19, 2015 [1 favorite]


You can't talk about a problem unless you provide a whole solution is pretty weak sauce
posted by phearlez at 7:26 AM on March 19, 2015 [10 favorites]


From what I can see, an idealized program of treatment might work like this:

Out of a 1000 people, about 300 would have substance abuse problems. (cite)

Out of those 300 people, 160 would respond well to encouragement and short cognitive behavior therapy to moderate their use. (cite)

Out of the 140 remaining people, about 40 would be able to use naltrexone to moderate or cease drinking over a long period. (Cite)

The remaining 100 people avail themselves of various group therapies, including 12 steps groups that advocated abstinence. 12 steps groups encourage new members to try moderation, therapy, and naltrexone before attempting abstinence. Because of selection effects, relapse among this group would be more severe than among the others groups.

Some subset (probably about 10) of the 100 remaining people would suffer from multiple diagnoses: schizophrenia or major depression combined with substance abuse. This group would need a combination of the above therapies, and would be badly served by 12 steps groups that discourage multi-phase treatment, going off meds, etc. So 12 steps groups should be instructed not to advise dual diagnosis members off their meds.

There's probably also some room for residential rehab programs in all of this, but I am suspicious that it's anything like the current usage rate.
posted by anotherpanacea at 7:27 AM on March 19, 2015 [1 favorite]


One thing to remember is that the "alcohol is a disease" thing, while dated, was an attempt to lessen the moral judgments around the condition. I find/found it overstated a bit in my time, and then AA seemed to come out with that whole "five generations" thing, which jumped the shark for me.

Like I said, I don't know too much, or care too much about the organization nationally, internationally, whatever. All I know is that the meetings themselves were good things. I'd recommend them to anybody who asked.

They were good, too, in the sense that it's a way to take some sort of action -- to do something about what you feel is causing grief in your life.

As to kozad, who said:"I just have a hard time saying "I am an alcoholic." That doesn't feel like my identity. I'm a guy who had problems with substances."

To that, I would say, just think of it as shorthand. I mean I know that feeling, for sure.
posted by Trochanter at 7:49 AM on March 19, 2015


having functional welfare systems I think.

Exactly. If we're not going to have a safety net, we can expect to have voluntary self-help associations, and they will not be regulated.
posted by Miko at 9:31 AM on March 19, 2015 [1 favorite]


So 12 steps groups should be instructed not to advise dual diagnosis members off their meds.

This is an important and salient point. I suffer from acute anxiety and am being treated for that by a psychiatrist with a phd after his name. The prescribed medicine I'm on controls my anxiety enough that I have no need to look towards alcohol to self-medicate. I do not & would not belong to an AA group that would contra-indicate a patient's following their doctor's advice, and I'm horrified that it happens in any groups.

It's hard to push this sort of thing from the top down becuase it's such a bottom-up organization, but it should be pushed, whatever direction.
posted by Devils Rancher at 10:04 AM on March 19, 2015 [1 favorite]


So 12 steps groups should be instructed not to advise dual diagnosis members off their meds.

The problem here lies in the passive voice. I'm not sure who's supposed to do this instructing, but since the chain of authority between doctor and patient is much stronger and more accountable than any chain of authority within the AA association, why do we not ask that it be doctors who be instructed to advise their patients not to quit their meds regardless of what they hear in self-help groups (or online, or anywhere else?) After all, the doctor-patient interaction is the only one in the picture that we have a hope of regulation over.
posted by Miko at 10:11 AM on March 19, 2015 [2 favorites]


All of this makes me furious on his behalf. I have no problem with AA on its own, it absolutely works for some people and I'm glad it's there for them. But it is not the only available treatment option

Your anecdote has nothing at all to do with AA! It has plenty to do with the crappy IOP treatment your relative received, but nothing whatsoever to do with AA. You could as easily have written that comment with SMART in the place of AA, and it would be just as egregious.

Poorly trained addictions treatment professionals are poorly trained addictions treatment professionals. AA is something other than that. There is plenty to say about how crappy much substance use disorder treatment is, but that is neither here nor there when it comes to AA.
posted by OmieWise at 10:34 AM on March 19, 2015 [1 favorite]


Your anecdote has nothing at all to do with AA!

Except that no other program is as huge and dominant as AA, and no other program simultaneously holds the top spot and insists that its abstinence approach is the only one that works. Unless you're really going to contend that AA's assertions about its approach play absolutely no role in those counsellors pushing it as a treatment mechanism.

Yeah, that treatment organization has final responsibility for sucking. But we've got no problem pointing a finger at McDonald's for their harm despite people having their own final call on whether to walk through the doors or not. I am sure some people think there's a blanket pardon that comes with being not-for-profit and having a humanitarian mission, but I don't think that's an absolute.
posted by phearlez at 11:04 AM on March 19, 2015 [3 favorites]


Unless you're really going to contend that AA's assertions about its approach play absolutely no role in those counsellors pushing it as a treatment mechanism.

I don't know, this thread is really weird. People really have it in for AA, and I'm not sure why. The evidence of harm seems pretty slight.

No, I don't think you can hold a volunteer, decentralized, support group responsible for the irresponsibility of supposedly trained professionals with no official connection to the group. The McDonald's comparison doesn't fit, because we know that McDonald's maximizes the things about its food that lead people to want to eat it, and that are damaging. And it does that for profit and market share.

The thing is, and I think this is pretty important, the folks talking about how great AA are, the people pushing the importance of AA as an intervention, are people who have presumably been helped by AA. There is no nefarious ulterior motive that I can think of or that fits with the structure of the "organization." So, perhaps AA is not effective, and perhaps in some ways and in some cases it increases the risk of harm, but the people who are talking about how great it is are the people who were helped by it. In other words, for those people those things are not issues.
posted by OmieWise at 11:20 AM on March 19, 2015


No, I don't think you can hold a volunteer, decentralized, support group responsible for the irresponsibility of supposedly trained professionals with no official connection to the group.

The problem is that most of the counselors do have a connection to AA or NA as members of those groups. Not only that but a significant proportion of those counselors do promote the AA line that it is the best and or only way to maintain abstinence from x and to maintain that abstinence. This is definitely a problem. The harm done by AA is much greater than perhaps you know. I have seen it first hand going to thousands of meetings and seeing the social dynamics and power structure that develops in some groups. I have even seen large groups that are cults of personality where the leaders of the group take advantage of members to their benefit financially and in other ways.

I left after I found an alternative in SMART Recovery- which is free and run mostly by volunteers. Where there is at least a semblance of accountability for leadership in the group i.e. ...the facilitators are trained.
posted by yertledaturtle at 11:30 AM on March 19, 2015 [1 favorite]


The problem is that most of the counselors do have a connection to AA or NA as members of those groups. Not only that but a significant proportion of those counselors do promote the AA line that it is the best and or only way to maintain abstinence from x and to maintain that abstinence.

So? That's the problem of the treatment programs, and not AA.

I've got some little bit of knowledge of all this, both as an individual treatment clinician who has worked a lot with people with addictions, many of whom were in or struggled with AA, and on the macro level. My job for the past 18 months has largely involved writing the regulations governing substance use treatment services by a single state agency. In other words, I've been writing all about the necessary program structure, credentials, etc etc for providing appropriate SUD treatment services. We would not countenance AA or NA as a treatment service, nor would we expect it to be an overt or covert requirement of treatment.
posted by OmieWise at 11:38 AM on March 19, 2015 [1 favorite]


All this has me thinking....where I participate in group support online, we are constantly urging people who are on the verge of seeking recovery from alcohol to see a doctor and be honest about their drinking. This is, of course, because of detox and withdrawal concerns - we cannot provide medical advice at all, or speculate about if it is safe for a particular individual to cease drinking abruptly. Suppose they do that, take our advice - what happens then? Do they just get a prescription against seizures and get sent on their way? Maybe a referral to a clinic or rehab? How much followup do doctors provide to people who self-report substance abuse concerns? I wonder how much time is devoted to addictions in medical school? I bet it used to be, barely any, but has increased some over the last few decades.
posted by thelonius at 11:44 AM on March 19, 2015


So? That's the problem of the treatment programs, and not AA.
Perhaps it's not an either or but both AA and the treatment programs where AA is the main treatment offered?
posted by yertledaturtle at 11:44 AM on March 19, 2015 [1 favorite]


Perhaps it's not an either or but both AA and the treatment programs where AA is the main treatment offered?

No, it's not. Look, it's fine to hold AA accountable for its culture and its failings. It is not appropriate to hold it accountable for the failings of treatment programs that have been set up precisely as different from AA. I don't hold the Southern Baptists responsible for the prayer group that one of the treatment programs associated with a Baptist church I know of runs. I do hold the treatment program and the charlatans posing as substance use treatment providers accountable.
posted by OmieWise at 12:03 PM on March 19, 2015 [1 favorite]


Well within AA culture any association with outside hospitals and or institutions is prohibited by Tradition 6: An A.A. group ought never endorse, finance or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property and prestige divert us from our primary purpose.

Any group that is associated with a treatment facility is by definition violating the "rules" of AA. So, any group that does this is responsible according to the rules of AA.

I have to be honest here and say it is challenging for me to talk about and criticize AA. I was introduced to the program by my family when I was a teenager and I have experienced a lot of damage from AA as a person. It hindered me from dealing with being abused as a child and I experience the same feelings talking about AA as when I experienced being beaten as a child. There are a lot of apologists in AA for child abuse - I know this because I had more than one sponsor who tried making me see "my part in it" .
posted by yertledaturtle at 12:27 PM on March 19, 2015 [2 favorites]


That sucks, and I'm really sorry. I can't imagine how infuriating that must be.
posted by OmieWise at 12:29 PM on March 19, 2015


Thanks,
I am trying to be civil and not let any of my anger about my treatment in AA and as a child influence my interactions with the good people here at metafilter. I understand and empathize with the defense that AA inspires. I too loved and defended AA. For many years I thought the program could do no wrong. But I am glad that I opened my mind to the possibility that it could actually be harmful for me and dealing with my problems with alcohol. I also know that my experience is only one experience of millions and I cannot judge the whole of AA by that experience. But at the same time I do not know why it needs to be defended so adamantly by so many.
posted by yertledaturtle at 12:39 PM on March 19, 2015 [1 favorite]


I definitely sometimes struggle here with either a personal investment, or a lack of a personal investment, and how that affects my tone. In this case I have no personal investment really (I mean, many people I know have been helped by AA, but I don't primarily think of AA as the thing that helped those loved ones), which can be its own problem. The arguments for me are not academic, exactly, because this is my field, but they are more abstract. Consequently my tone can be analytical and dismissive when I don't remember that others have personal experience that may be raw or painful or make it feel like I'm talking about them. I'm still regretting comments in that regard in another thread, so I should have been more gentle here.
posted by OmieWise at 12:54 PM on March 19, 2015 [2 favorites]


I surmised that from your posts. I do not feel it is your tone in particular that I find challenging just the subject matter itself due to my former membership in AA and the harm I experienced being a part of it.
posted by yertledaturtle at 1:23 PM on March 19, 2015


I see more defense of AA here than criticism of it.

Every medical condition has evidence-based treatment/therapeutic/remedial options. Almost all medical conditions have an implicit, or sometimes explicit, decision tree. If this, then that. It's a flowchart with many possible end points.

But with addiction treatment (professional or support-group, at least in the U.S.), there is this one huge end point to every possible move in the flow chart. It's not a decision tree, it is a funnel.

That's
the problem.
posted by yesster at 3:55 PM on March 19, 2015 [9 favorites]


There is no nefarious ulterior motive

Why does it have to be nefarious? There doesn't have to be malice or even subterfuge for something to cause harm.
posted by phearlez at 10:17 PM on March 19, 2015 [3 favorites]


> I don't really get why people feel a need to bad mouth AA,

Perhaps the single-digit success rate, coupled with a general attitude that AA is the only possible treatment (often court-enforced)?

The religious part of it might also be a turn off to people. I've been helping a friend with alcohol issues, and he had a very bad religious upbringing, and so finds AA intolerable...
posted by lupus_yonderboy at 8:36 AM on March 22, 2015 [1 favorite]


Perhaps the single-digit success rate

Umm... try about 50% success rate. Of course, that still leaves half the substance abusing population in need of an effective treatment. And it's clearly wrong to make attendance court enforced. But it's weird to keep pretending that 12 steps groups don't work at all.
posted by anotherpanacea at 3:00 PM on March 22, 2015


Except the very study you posted notes:

However, rigorous experimental evidence establishing the specificity of an effect for AA or Twelve Step Facilitation/TSF (criteria 5) is mixed, with 2 trials finding a positive effect for AA, 1 trial finding a negative effect for AA, and 1 trial finding a null effect. Studies addressing specificity using statistical approaches have had two contradictory findings, and two that reported significant effects for AA after adjusting for potential confounders such as motivation to change.

Notably, if you flip over to Figure 4, you'll see that the best data the authors have indicates that AA does not provably lead to better outcomes than other treatments.

But even all that aside:

Abstinence is not coterminous with successful treatment for addiction. Nor is 2-year outcomes. One of the criticisms levelled at AA upthread and in the linked article is that short-term abstinence (as opposed to choosing less-destructive use of alcohol) may set up recovering addicts for even worse long-term outcomes, so the metrics used in that article can't answer that question at all
posted by thegears at 4:24 PM on March 22, 2015 [1 favorite]


The figure doesn't say that. Not does the article it comes from.

I mean, it's right there. Read it.
posted by anotherpanacea at 5:08 PM on March 22, 2015


The religious part of it might also be a turn off to people.

...that was a big part of this thread, if you care to read it.
posted by Miko at 5:29 PM on March 22, 2015


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