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Alcoholics Anonymous, a worldwide support fellowship with a goal to achieve sobriety, may be the most effective path to abstinence for people struggling with alcohol use disorder, according to a comprehensive analysis published Wednesday.
Since its inception in 1935, Alcoholics Anonymous and its effects were hard to study in the absence of adequate study methods, said Dr. Keith Humphreys, study researcher and professor of psychiatry and behavioral sciences at Stanford University's School of Medicine. AA may have also been contentious among professionals who were trained to address the same issues through established therapies.
The researchers evaluated 35 studies -- the work of 145 scientists and more than 10,000 participants -- to determine the effectiveness of AA on alcohol use disorder. They also examined the efficacy of the program's 12 steps, that include accepting one's inability to control their drinking by themselves, and helping others stay sober by becoming a mentor.
AA, especially when combined with Twelve-Step Facilitation in which a counselor encouraged adherence to the steps, was found to be more effective than psychotherapies such as cognitive behavioral therapy in achieving abstinence, according to the research.AA was also found to be at least as effective as professional treatments for other alcohol-related outcomes such as drinking consequences, drinking intensity, addiction severity and healthcare costs.
With more than three million alcohol-related deaths globally, and its misuse as the leading risk factor for death (PDF) and disability among 15- to 59-year olds worldwide, studies for treatment responses to these issues are needed, the review said.
"An advantage that AA has over the kind of therapies I was trained to do, is that people can persist in it a very long time, which gives them a better shot at recovery because you could literally go to AA everyday for years and years and years if you wanted to," Humphreys said.
"That may be better matched with chronic disease than short-term interventions the health care system usually gives."
Alcoholics Anonymous in combination with the 12 step facilitationmay work for achieving and sustaining sobriety by the social support, inspiration and availability it can provide.
When people embark on a lifestyle of abstinence, they might begin to feel lonely because they no longer have their friends who were drinking with them, Humphreys said. AA groups can provide the insular resilience members may need when situations arise that could potentially trigger them, so they can continue on the path to sustained sobriety.
"I care about the people I've taken care of, but I can't be their friend," Humphreys said. "I can't stick with them through the years and the troubles and divorces and all the things that happen in life, and AA is there for people as long as they need it, potentially for a lifetime."
AA can also instill hope in members in a way that is different than what professionals can do, Humphreys said.
"I can say to someone, 'Believe me, you can have a better life than what you've got right now,' but it's pretty powerful when someone says, 'I'm not just telling you that, I had your life. Look at me -- I'm also an alcoholic, and I'm having a really good life. If I could do it, you could do it,' " Humphreys said.
The fact that AA is free, widely available and doesn't require any forms or health insurance may also contribute to its efficacy. Members can attend as many times as they wish, as there are no financial or scheduling barriers that reside within having to attend therapy appointments.
Though the social benefits of AA are helpful for recovery, there still exists the need to overcome the brain's addiction to alcohol as a reward.
AA can "help people create senses of worth and value that occur in the brain and don't center around alcohol, retraining the brain to live differently" and replacing alcohol as an immediate reward, Humphreys said.
There are a number of factors the review doesn't address, such as psychological well-being, overall health, efficacy for adolescents and whether a person was struggling with a co-occurring, serious mental disorder along with alcohol use disorder, said Dr. Jennifer Plumb Vilardaga, clinical psychologist at Duke University Health, who was not involved with the review.
"We don't know whether AA is tackling those in a better way, the same way or worse than other programs," Vilardaga said. "As a psychologist myself, my read of the literature is that if you have a significant mental health issue, you're still better off seeking professional counseling to address your alcohol as well as your mental health concerns."
Combining the professional counseling from cognitive behavioral therapy with the social support of AA could be helpful for people in these circumstances, Vilardaga said.
AA was slightly more effective for women than men, which might be surprising since AA was developed by men, and the population of people struggling with alcohol problems is more male than female, Humphreys said.
"If you look at the steps, in a lot of ways it is not an endorsement of stereotypical male traits -- it's just the opposite," Humphreys said. "It says stop being so selfish and arrogant, do a better job in relationships, be responsible for other people, be honest about your emotions. And those are messages that, broadly speaking with lots of exceptions, may resonate more with women than men."
Previous studies suggest AA may have an "abstinence violation effect," in that if members slip up and drink again, they'll overindulge and backtrack in their progress. The review, published in the Cochrane Database of Systematic Review, found otherwise, that AA was just as effective as reducing drinking or harms of drinking.
"I think the take-home message is that if you feel like an AA approach works for you and you want a community of people who can help you focus on abstinence, this is the way to go," Vilardaga said.
"But if you do not prefer this model, the concept of a higher power or any of the other elements of AA aren't a good fit, I don't want people to be discouraged. There are many good treatment options available and there is really good evidence to support things like medication."