Mention the subject of Alcoholics Anonymous (AA) effectiveness, in a room full of addiction counselors, and you are sure to start some kind of an impassioned debate. The debate usually centers on the program’s effectiveness. Although AA is not a formal counseling treatment (McClellan & McKay, 1998), one side of the argument generally maintains that there is limited research on the subject, and that makes the organization controversial (MacKillop, Lisman, Winestein, & Rosenbaum, 2003). The other side argues for validity via personal testimony and reports of thousands who deeply believe the organization saved their lives.

Second, the problem with the personal testimony is that it is personal testimony. For the individual, it can be quite validating. Yet, no matter how heartfelt and true for the individual, personal testimony is always subject to bias. And, trying to generalize personal feelings to others causes a lot of problems. That’s where science steps in. It can either validate the generalizing or not. Much more interesting than that old argument is the results of all the recent AA research. It has been enlightening. Simply put, AA works for those who are amenable to its principles and philosophy. Let’s look at some research specifics.

A summary of the AA research
Previous studies have investigated numerous elements of AA, including who is best suited for this program among others. The following list is based on literature that summarized a great number of recent studies:

• Miller (Owen, et al., 2003) notes what we reasonably know about AA today. The accumulated evidence tells us that we cannot ignore AA in understanding treatment outcomes. In other words, it is common for clients who seek or who are ordered into treatment to be also involved with AA — one simply cannot ignore that fact.
• When clients attend AA, the combination of treatment and AA predicts better outcomes.
• Continuous abstinence is most likely to be affected by AA.
• Yet, the message of abstinence does not seem to have detrimental effects on those who do not remain abstinent, as would be predicted by the abstinence violation effect.
• It is possible to facilitate AA attendance, and the treatment phase is the time to do it.
• Attendance of meetings does not mean involvement. Rather, notes Miller (Owen, et al., 2003), for many people there seems to be an internalization of the AA program that is not reflected by mere attendance of meetings. This has treatment implications.
• There is even international support for AA in terms of attending meetings and better outcome.

A recent article (Gossop, Harris, Best, Lan-Ho, Manning, Marshall, & Strang, 2003) found that from a sample of 150 subjects in a U.K. inpatient program, those who attended more AA meetings following treatment had superior outcomes to non-attendees.

Research notes that combining AA attendance and treatment seems to consistently be associated with better treatment outcomes. But, AA attendance without professional treatment does not routinely result in better outcomes (interesting). Moreover, treatments based on 12-step approaches are as effective as other approaches, and may actually achieve more sustained abstinence (10th Special Report to the U.S. Congress on Alcohol and Health, 2000).

Frequent AA meeting attendees report more use of behavioral change mechanisms, such as stimulus control, and behavioral management. They also report more use of helping relationships (9th Special Report to the U.S. Congress on Alcohol and Health, 1997).
Research-to-Practice Key: If you decide to introduce AA to a client, here a few research-supported practical clinical elements to consider (Owen, et al., 2003):

• AA attendance is associated with an increased confidence (self-efficacy) to avoid taking a drink. This finding tended to be applied to client social situations, negative emotions, and higher levels of abstinence.
• Progressing through the steps of AA adds to self-efficacy, which is related to higher rates of abstinence.
• The friendship quality of AA and support for abstinence influence the frequency of drug and alcohol use.
• AA participation leads to lifestyle changes that lead to greater levels of abstinence.
• Internalizing the AA program, not necessarily the amount of meetings attended, is a factor in abstinence rates.
• Support from AA members is related to more abstinent time than support from non-AA members. AA members seem to be able to offer practical help, be role models, and offer around-the-clock support.

One caveat
These research implications don’t mean that AA is to be applied unthinkingly to all clients. Counselors need to think critically about its use. Recall from earlier columns that no organization or treatment has ever been shown to effective for all people — now, this conclusion doesn’t sit well with some folks. They argue that all addicts should be referred to AA or some similar organization as soon as possible.

Be cautious of those who state AA is superior to all other forms of intervention. That is not quite an accurate statement. As stated, no form of treatment (cognitive, behavioral, motivational, solution, etc.) has been able to achieve that status (Institute of Medicine, 1990). If one of them had shown to be superior, science would have discovered it by now. But, it hasn’t. To insist on one form of intervention, when in fact something else might work better, is a poor clinical decision. It is time to move beyond this old argument, and proceed to what it is in AA, or any program, that clearly works for a particular client in a particular set of circumstances.

The “try it yourself” section: The research emphasis is beginning to move away from the question of whether AA is effective (outcome research), to what in AA makes it effective (process research). Here’s your chance to be a contributor to that effort. Your research question might be: What is it within AA that promotes abstinence for your clients?
Many of you already know what in the program works for you. Individuals in the fellowship can highlight parts of the AA program that were especially important to their recovery. Essentially, they know what works for them. For our experiment, why not use the same process for clients? For example, clients who go to AA meetings may find a certain something(s) that rings true for them — it will be different for people. That difference needs to be identified.
It is important to tease out what the “rings true” is. Once identified, the plan is to encourage the client to repeat what works — so, what would it be? Working the steps? Or, the behavioral components of AA? The support? Some combination? What?

One way to conduct this research is to ask clients to keep track of their abstinent days (dependent variable) and correlate that time to AA attendance or use of AA principles (we will keep the dependent variable simple in light of the fact that others argue for examining factors other than abstinence). Then, simply ask clients who remain abstinent and attend AA which element(s) of the program they use in their daily life. Probe to find out what element or set of elements in AA are being used with success.

Now this may sound like regular ol’ addiction counseling, but collecting all this data from say 20, 30, or more clients, and putting it into a rough spreadsheet will begin to show a pattern. You may find that certain types of clients will find more appeal with working the steps, while other clients will find certain appeal with the fellowship. Whatever the result, a pattern will emerge and that will begin to shed light what is working for whom. This is simple qualitative (grounded) research.

Start with the grounded research or some similar version, and your project is underway. Once some conclusions are attained, they can then be tried out on future clients to see if they work with those groups of clients (quantitative research).

Should you begin to show clear connections between certain clients working and certain elements in AA, contact me or a researcher near you — because it will be time to step up to a more rigorous design to test your theory. If the results are significant, you might get published.

Michael J. Taleff, PhD, CSAC, MAC, is the Coordinator of the Center for Substance Abuse for the University of Hawai’i at Manoa. He can be reached at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
Gossop, M., Harris, J., Best, D., Lan-Ho, M., Manning, V., Marshall, J., & Strang, J. (2003). Is attendance at Alcoholics Anonymous meetings after inpatient treatment related to improved outcomes? A 6-month follow-up study. Alcohol and Alcoholism, 38, 5, 421-426.
IOM (1990). Broadening the base of alcohol problems. Washington, DC: National Academic Press.
MacKillop, J., Lisman, S.A., Winestein, A., & Rosenbaum, D. (2003). Controversial treatments foe alcoholism. In S.O. Lilienfeld, S.J. Lynn, J.M. Lour (Eds.). Science and pseudoscience in clinical psychology, (pp. 273-305). New York: Guilford.
McClellan, A.T. & McKay, J.R. (1998). The treatment of addiction: What can research offer practice? In S.Lamb, M.R. Greenland, & D. McCarty (Eds.) Bridging the gap between practice and research: Forging partnerships with community-based drug and alcohol treatment. (pp. 147-185). Washington, DC: National Academy Press.
9th Special Report to the U.S. Congress on Alcohol and Health. (1997). NIH Publication No. 97-4017. Washington, DC: National Institutes of Health.
Owen, P.L., Slaymaker, V., Tonigan, J.S., McGrady, B.S., Epstein, E.E, Kaskuatas, L.A., Humphreys, K., & Miller, W.R. (2003). Participation in AA: Intended and unintended change mechanisms. Alcoholism: Clinical and Experimental Research, 27, 524-532.
10th Special Report to the U.S. Congress on Alcohol and Health. (2000). NIH Publication No. 00-1583. Washington, DC: National Institutes of Health.

This article is published in Counselor,The Magazine for Addiction Professionals, December 2003, v.4, n.6, pp. 40-41.

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