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New book offers accessible look at 12 Step's research base

January 12, 2015
by Gary A. Enos, Editor
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12-Step treatment and recovery support likely will never be able to shed all criticisms directed its way. But one clinical psychologist and retired college instructor believes no one should be able to argue successfully that Alcoholics Anonymous (AA) and its principles have not undergone rigorous research.

That certainly had been true in the late 1980s when the Institute of Medicine (IOM) pointed out the lack of an evidence base for 12-Step approaches, but Joseph Nowinski, PhD, says that analysis from IOM would end up fueling substantial research inquiry that now forms the content of his new book, If You Work It, It Works! The Science Behind 12-Step Recovery.

The Hazelden Publishing book, officially out Feb. 1, is targeted largely to a general-interest readership, but Nowinski believes its straightforward accounting of major studies will prove useful to addiction professionals as well.

“It can help them to understand why they are sending someone to AA,” says Nowinski, who operates a private practice near Hartford, Conn., and formerly taught at the University of Connecticut and the University of California-San Francisco. “I don't like to go to a doctor who wants to give me a particular treatment and can't explain why he thinks it's going to work.”

Seminal study

Nowinski himself played an integral role in one of the most prominent studies that compared 12-Step and other approaches in the treatment of addiction.

Yale University researchers in 1990 asked Nowinski to design an alcohol treatment program based on the 12-Step model. His “12-Step facilitation” intervention would be used in one of the three treatment arms in Project MATCH, a highly cited study in which nearly 2,000 individuals with an alcohol use disorder received either 12-Step facilitation, cognitive-behavioral therapy (CBT) or motivational enhancement therapy (MET).

The Project MATCH researchers found that all three treatments succeeded in promoting abstinence and reducing overall drinking at periods from 3 to 12 months post-treatment. In addition, 12-Step facilitation was reported to be as helpful to persons with an alcohol abuse problem as it was for those with more severe alcohol dependence. “In other words, the Twelve Step model seemed not to be limited in its effectiveness to those who had bottomed out,” Nowinski writes in the new book.

12-Step facilitation is included on the Substance Abuse and Mental Health Services Administration's (SAMHSA's) National Registry of Evidence-Based Programs and Practices.

Critical components

The first section of Nowinski's book plainly states the highlights of numerous research studies in support of 12-Step approaches. He focuses a great deal on crucial elements that enhance the success of 12-Step treatment and/or support once an individual decides to pursue that route. He considers these factors particularly critical to success:

  • Consistent attendance at some 12-Step meetings. Research has shown that attending two to three meetings a week will yield a 70% probability of maintaining long-term sobriety five years post-treatment, Nowinski says.

  • Having a 12-Step sponsor, with particular importance on securing one in the first few months of recovery.

  • One's perception of one's place in the 12-Step group. Research has indicated that the most actively engaged group members who truly identify as being part of the group tend to have the best outcomes, Nowinski said.

Research also has demonstrated that 12-Step support and formal treatment together tend to produce better results than either of the two alone, he said.

Facing criticism

Nowinski, who also pens a blog for Psychology Today, says he becomes the target of criticism on many occasions when he writes about the 12 Steps. He sees several reasons why this remains such an incendiary topic.

“One is that AA has grown and grown—it is ubiquitous,” he says. “Anybody who feels they have a different approach sees it as competition.”

Another reason involves AA's practice never to respond directly to criticism, based on its traditions that reinforce anonymity. “AA does not have a public relations office,” Nowinski says. “It is an easy target.” In addition, the spiritual underpinnings of AA often become the subject of attack, he says.

Nowinski points out that combining 12-Step approaches with cognitive or other modalities often has merit. He adds that just as not all treatment facilities are created equal, 12-Step support meetings have different characteristics and should be examined closely by clinicians so that they can make thought-out recommendations to their patients.

Also, other support group models such as SMART Recovery and Women in Sobriety should be considered, he says. “I'm certainly in favor of any support group where the goal is abstinence,” Nowinski says.

He concludes about his book, “I'm hoping it can be a counterbalance to a lot of the baseless criticism that's out there, so that people can make an informed decision.”

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Comments

I don't think he's offering anything new here. So if someone attends AA three times a week they are more likely to be successful. Well, that established a correlation but not causation. It could be argued that if someone is so dedicated as to attend AA "religiously" (no pun intended) then that person is clearly dedicated to their sobriety. I find it hard to appreciate the scientific argument that AA works because the people that go really want to quit. He's basically saying it works completely for those it works for. What? That makes no sense and I'm sure if I did research I could find a logical fallacy in that reasoning. I think AA works for the same reason people who go to church do so well in recovery: the interpersonal connection and support. It's a strong tool in the toolbox - it's that simple. That said, I always suggest it and support anyone who gets something from the rooms. But don't pass these findings off as science; or if you do, call it what it is: a correlation.

I value the openness of Yale University to include Alcoholics Anonymous (AA) being effective. However, what is missing is why it truly is effective by 'doing the work' in AA. The crux of the problem in AA today is that being sober has replaced being 'recovered.'

In other words, the long term recovery rate for people in AA is 80-85% when they are taken through the 12 Steps in the AA text book (affectionately called the Big Book). This process is someone who is recovered partnering with individuals or in groups and reading to book to them, answering questions, encouraging discussion and doing the work (the steps) articulated so well. For example, they do the third step together. The fourth step is a written inventory covering resentments, fears and personal and sex relations.

AA meetings, sponsors and even fellowship cannot keep a person sober for the long haul. The meetings, sponsors and fellowship are all bridges that need to take the alcoholic to the center of AA which is the recovery process in the AA Big Book.

I know hundreds of women and men who have achieved long term permanent recovery by 'doing the work.' This is what the founders of Alcoholics Anonymous did. It's just gotten watered down. The blessing and curse for AA is the human condition, which happens in many cases inside and outside of AA. No one is really to blame. We must just embrace what really works.

Thanks for your comment. We agree that research supports a correlation between AA meeting attendance and recovery. Beyond that, the research that has emerged on AA over the past two decades does indeed suggest a causal, not just a correlational, relationship.

The AA 12-Steps have certainly made a difference in the lives of thousands, there can be no doubt about it. Is it the treatment of choice? For many, it is, but it is not for everyone.
An issue of discontent presents itself at many of the meetings when addicts with a different DOC speaks among the group. There are still old timers in AA that fiercely defend what they believe to be true - that they are "alcoholics", not "addicts". It can and often does make addicts of something other than alcohol (and/or newcomers) uncomfortable and therefore less likely to return and maintain some sobriety. They somehow do not understand or accept that alcohol is not only a drug, but one of the worst drugs we indulge in.
Then you have NA, an option for all addicts, that often belittles people in recovery that use medication assistance. It can become contentious.
Lastly, I would love to know a physician who checks out support groups for their patients.

The information that NA belittles those who must use medications is outdated. NA has published a booklet entitled "In Times of Illness." That booklet covers all needs for medications from surgury to mental illness and makes it clear that every recovering addict may have times in which medications are required. It is a very useful for aftercare patients. Even the Basic Text of NA does not condemn the use of medications, and also sets the standard that an addict need feel no guilt after taking a minimum amount of medication prescribed by an informed physcian.
It is true that there are the those recovering addicts who are "old school," many of whom began their recovery in AA or in NA before literature was published, who will say that they belong to the "no matter what club" and refuse all narcotics, even though the Basic Text says that to do so also presents risk for relapse, because the pain (mental or physical) may become overwhemning.

I agree that personally checking out meetings is not feasible. So I ask a lot of questions of my clients who attend groups like AA or NA. (and not all do) They often will share their experiences, good and bad, and I dont think its out of line for me to periodically ask about the diversity or size of a particular meeting and if its more open or more old school, the latter being rare in my area. I might ask, which meeting do you recomend as most welcoming for atheists/agnostics, someone with opiate dependence, socio-economic factors, etc. Over time I get a feel for some of the local meetings just by seeing the growth some of my clients experience from 12 step experiences such as service.

Over time I get a sense for which meetings are mostly millenials so I mention that to a middle age client who might feel out of place. I also learn about the womens and LGBT specific meetings as well as which ones seem more meeting focused and which ones seem to attract the type of client who also needs more social outlets such as onse where its customary for some members to do coffee afterwards, informally arrange golf outings, concert trips, biking, yoga, volunteering, etc.