Further Reading

What do you make of the Stanford group's claim that continuing in 12-step aftercare helps people recover?

Dear Stanton:

I am two years away from earning my Ph.D. in clinical psychology. My graduate training has continually impressed upon me the importance of scientifically demonstrable outcomes for psychological treatments. I have been taught over and over again that therapies with little or no empirical support, whatever their theoretical appeal, need to be abandoned in favor of more effective therapies. Having read much of your impressive work in the area of alcoholism treatment, I am appalled and embarrassed about the current state of addiction treatment in this country. It seems that due to the religious nature of A.A., as well as the fact that scientifically trained professionals tend not to work with alcoholics, alcoholism treatment is immune from having to live up to the scientific standards that so rigorously apply to treatments for other psychological problems. Based on the tremendous number of individuals being treated for alcoholism each year, few issues seem more pressing in the field of mental health.

I am aware that all of the assumptions behind the disease concept of alcoholism have no empirical support. I also believe that the twelve steps are often counterproductive and may ingrain beliefs that are more harmful than helpful (e.g., powerlessness). Finally, the scientific literature on the effectiveness of A.A. suggests A.A. to be ineffective and occasionally even harmful. Given these considerations, I was very surprised to read a study in the October, 1999, issue of the Journal of Consulting and Clinical Psychology by Drs. Andrew Winzelberg and Keith Humphreys from Stanford University Medical Center. The authors studied the effects of twelve-step group attendance on 3,018 male abusers of alcohol and other substances at 15 V.A. medical hospitals. The results showed that twelve-step group attendance significantly increased abstinence and reduced substance abuse problems, even for patients who did not believe in God or who did not participate in religious behaviors (e.g., church attendance). The authors concluded that 12-step attendance was beneficial.

This study seems to offer clear-cut support for twelve-step attendance. Before jumping on the A.A. bandwagon, my knowledge of the true nature of twelve-step groups raises my suspicion that there may be other factors that accounted for the study's findings. I believe that many participants who are helped from twelve-step groups obtain their greatest benefit from the "non-specific" aspects of the program. In other words, working the steps is not as helpful as is receiving social support, empathy, an explanation for your problems, and the expectation of impending improvement. It may also be possible for some twelve-step attendees to receive these benefits without ever having to fully engage themselves in the religious aspects of the program. However, regardless of what aspect of twelve-step group therapy was responsible for the beneficial effects found in the study, the overall benefit of twelve-step attendance was clear. If I were currently in practice I would certainly not refer my substance-abusing clients to 12-step programs.

Stanton, my question is how can I reconcile the results of this study with the rest of my knowledge about the effectiveness of twelve-step programs? Thank you very much for your time and consideration.

Brett Deacon

Dear Brett:

Thank you for your thoughtful and challenging question. The current defense for AA is that, although it is not effective in clinical trials, treatment recipients who in addition enter and remain in AA as a concomitant to treatment show better outcomes than those who do not engage in AA.

There are a number of research, theoretical, and ethical issues to take into account in regards to this finding. In the first place, patients are self-selecting into AA — that is, those who continue to attend are those most likely to be serious about remaining sober — if you asked them to show up at meetings following treatment to simply fill out a card saying how they were doing, and gave them $5 for doing so, those who showed up would have better outcomes than those who did not. Although the most motivated individuals will be those who continue with AA attendance, these are the people who would generally have the best outcomes under any circumstances. In fact, it is those most likely to drop out whose outcomes therapy should be most designed to enhance — rather than "cherry picking" the "best" patients and counting them as signs for success of treatment and aftercare.

Those who continue in group sessions following treatment are, in fact, nearly always attending AA, with its 12-step, spiritual, group-confession emphasis. Ironically, the researchers who have most noted superior outcomes for those continuing to attend AA following treatment are at Stanford Medical Center, and are associated with Rudolph Moos. This group, under Moos, clearly established that success at treatment is do primarily to success over time at integration and resolution of long-term work, family, social, and other real-world involvements for the individuals concerned. Moos, R.H., Finney, J.W., and Cronkite, W.C. (1990). Alcoholism treatment: Context, process, and outcome. New York: Oxford University Press.

The issue would seem to be, then, to engage in therapy that was most oriented towards improving these real-world outcomes, and that focuses on external life management rather than on spiritual issues. In other words, in what way does AA (or 12-step therapy in general) better equip people to cope in their interpersonal, work, et al. arenas? In fact, AA and the 12 steps are not oriented towards such real-world functioning. It is thus not surprising that clinical research on effective treatments finds instead that programs which assist people in developing coping skills, in negotiating real-world involvements (such as community reinforcement therapy), and in building on and encouraging patients' own motivations to continue to develop outside the therapy site will be most helpful to people. This is the approach we develop in our book, The truth about addiction and recovery.

Of course, one other aspect of continuing attendance at AA et al. following therapy is how you get them to continue in post-care treatment. Why do so many fail to continue? We know for many the issue is that 12-step treatment, AA spirituality, and the group think and pressure that accompany AA do not sit well with them. What should we do about this? One answer — based on the Stanford group's research — could be to coerce people to continue post-treatment attendance. In fact, drug courts and court-ordered sentences generally require such follow-up, often with court-enforced abstinence (perhaps involving testing). In other words, rather than asking what would enhance follow-up to treatment by relating to patient needs, values, and preferences, a shot gun is taken to these individuals. Of course, the ethical-legal-therapeutic issues of such coercion are the focus of our book, Resisting 12-step coercion.

The goal of a real treatment system is not to note that those who are willing to jump through some highly specialized hoops will be the best patients. The goal is instead to create a facilitative treatment and post-treatment environment that supports people's integrity and values, encourages their self-reliance, and assists them to develop real-world skills required to function successfully. What the Stanford group's research does, in place of encouraging such a treatment environment, is to find those who survive current treatment practices the best and point to them as ideals of the treatment system. It is a sorry compromise for instead putting in place what we know to be effective treatment that respects the individual.