Abstract from the Journal of Alcohol and Clinical Experimental Research, 1987; 11 [5]:

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1 I would like to state from the outset, that I have no concerns when it comes to questioning the efficacy of 12-step-based treatments in the treatment of addiction. However, I have great concern when the information presented is clearly biased and inaccurate. In a discussion of the data presented in Chapter 3, Does AA Work? of The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry authors Lance Dodes, MD and son Zachary refer to several key studies to support their opinion that Alcoholics Anonymous is ineffective. If one takes the time to go back to the original source, it is clear that they have distorted the overall findings of the studies by selecting tidbits in isolation and out of context, to support a biased perspective. To illustrate my point I will review the six abstracts related to these studies in their entirety. The Dodes state: To understand what can actually be known about AA s success rate, we must attempt a deep dive into the best data available. Let s start with the controlled studies. Study 1: J.M.Brandsma study, Two thirds of the patients were court referred outpatients. The results of this study suggest that the dropout rates in the Alcoholics Anonymous stream were higher than other treatments and control group. The results suggested that Alcoholics Anonymous was not as effective as the alternatives. These statements appear consistent with the original article. Study 2: C.D.Emrick. Dr. Emrick reviewed a number of research papers which were completed between 1976 and 1989 to determine the effectiveness of Alcoholics Anonymous. The authors suggest that this review demonstrated that Alcoholics Anonymous was not effective. The Dodes continue with: The effectiveness of AA as compared to other treatments for alcoholism has yet to be demonstrated. Reliable guidelines have not been established for predicting who among AA members will be successful Caution was raised against rigidly referring every alcohol troubled person to AA. However, the original source states: Abstract from the Journal of Alcohol and Clinical Experimental Research, 1987; 11 [5]: " recent findings from the empirical literature on Alcoholics Anonymous suggests that no clear exclusionary criteria for this organization exist, except that alcohol dependent individuals who become non-problem drinkers appear to be less likely to affiliate with or maintain involvement in AA. Of those alcoholics who become long term, active AA members, about 40 50% enjoy several years of total abstinence, with about 60 68% improving to some extent, drinking less or not at all during their participation. More active 1

2 AA participants do as well as or better than those who participate respectively. Compared to professionally treated alcoholics, AA members seem to achieve abstinence at a higher rate. (Italics mine). Consideration is given to the apparent unsuitability of AA for problem drinkers who choose the goal of non-problem drinking. Dr. Emrick s study is worded as follows: Dr. Emrick Recent Developments Alcohol. 1989; 7: Alcoholics Anonymous: Membership characteristics and effectiveness as treatment. "Reports published since 1976 were reviewed with respect to the characteristics of alcohol dependent individuals who affiliate with Alcoholics Anonymous. No "AA personality" was identified in as much as systematic differences have not been observed between affiliates and non-affiliates. Evaluation studies were reviewed with regard to data on AAs effectiveness as treatment, leading to several observations. When "alcoholics" participated in AA in addition to professional treatment, their outcome on drinking and other indices is no worse, and may be better, than that of patients who do not involve themselves in AA. (Italics mine) AA involvement tends to be associated with relatively high abstinence rates but with only fairly typical total improvement rates. The effectiveness of AA as compared to other treatments for alcoholism has yet to be demonstrated. Reliable guidelines have not been established for predicting who among AA members will be successful. And alcohol involved persons chances of participating in AA are related to the type of drinking outcome achieved. Caution was raised against rigidly referring every alcohol troubled person to AA." ******** Study 3: D.C. Walsh, 1991 (This study was designed to compare more expensive in-hospital treatment of patients with alcohol abuse identified in the workplace, compared to outpatient treatment of Alcoholics Anonymous only, and the third group was allowed their own choice of treatment.) Study 3: D.C. Walsh, 1991 New England Journal of Medicine. Of the 71 subjects in the choice group, 29 elected hospitalization, 33 went directly to Alcoholics Anonymous, three chose outpatient psychotherapy, and six opted for no organized help at all. Of those assigned to compulsory hospitalization, Alcoholics Anonymous meetings were held at the hospital and abstinence was established as the goal of treatment. The hospital stay was followed by a year of job probation, during which attendance at Alcoholics Anonymous meetings on a regular basis at least three times a week, sobriety at work and weekly checks with the employee assistance program staff were required. The major finding was that the extra cost of in-hospital treatment was cost 2

3 effective compared to the outpatient treatments that often required readmission to hospital for treatment at a later date. In their book, the Dodes imply that the AA group was least effective. They either ignore, or are unaware of, the fact that the hospital program was in fact an AA-based program, both inpatient and in the aftercare component. They also make no mention of the fact that of that choice group, 29 elected for hospitalization (which is essentially an AA stream) and 33 went directly to Alcoholics Anonymous. In other words 62 of the 71 members of the choice stream are actually attending Alcoholics Anonymous. (Italics mine). While the authors later spend a whole chapter debunking Alcoholics Anonymous-based treatment, the major result of this study is that inpatient Alcoholics Anonymous base treatment was better than outpatient Alcoholics Anonymous treatment. Study 4: The Cochrane Collaboration, 2006 ******* The Dodes partially quote the Cochrane Collaboration by saying: Their conclusion was unambiguous: No experimental studies unequivocally demonstrated the effectiveness of AA or 12 Step Facilitation approaches for reducing alcohol dependence or problems Again, returning to the original and complete document, one finds the following: Study 4: The Cochrane Collaboration, 2006 The "plain language summary" included in the report states: " the available experimental studies did not demonstrate the effectiveness of AA or other 12-step approaches in reducing alcohol use and achieving abstinence COMPARED WITH other treatments, but there were some limitations with these studies. Furthermore many different interventions were often compared in the same study and too many hypotheses were tested at the same time to identify factors which determine treatment success." "More efficacy studies are needed". In my opinion the actual conclusion is that this is a poorly studied area and "unequivocal" conclusions cannot be drawn based on the absence of solid research. This does not conclude that the treatment is ineffective, in fact based on their summary it appears comparable to other treatments. Not surprisingly, The Sober Truth authors ended their sentence before the addition of compared with other treatments giving it an entirely different meaning. 3

4 The authors go on to discuss two other studies by Moos in 2005 and Fiorentine in 1999 which found Alcoholics Anonymous to be favorable. They then raise the question: Why do large observational studies such as that of Fiorentine and Moos seem to suggest that AA is effective, while smaller controlled studies like those of the Brandsma, Walsh and others included in the Cochrane Reviews do not? In my opinion, it is the misinterpretation of the study s conclusions (as noted above) which leads to this apparent discrepancy, not the effectiveness of AA. Study 5: Kaskutas, The Dodes quote Kaskutas as follows: Rigorous experimental evidence establishing the specificity of an effect for AA or 12 Step Facilitation (criteria 5) is mixed, with two trials finding a positive effect for AA, one trial finding a negative effect for AA, and one trial finding a null effect. Studies addressing specificity using statistical approaches have had two contradictory findings, and to that reported significant effects for AA after adjusting for potential confounders such as motivation to change. The authors interpretation of this is: The strong evidence that one would expect if AA were clearly effective is simply not present. Not surprisingly, if one goes to the original document, one will find the authors have been extremely selective in their focus. The full abstract states the following: Kaskutas from the Journal of Addictive Disease, 2009; 28 [2]: , Alcoholics Anonymous Effectiveness: Faith Meets Science. "Research on the effectiveness of Alcoholics Anonymous is controversial and is subject to widely divergent interpretations. The goal of this paper is to provide a focused review of the literature on AAs effectiveness that will allow readers to judge the evidence for AAs effectiveness for themselves. The review organizes the research on AAs effectiveness according to six criteria required for establishing causation: 1 magnitude of effect, 2 dose response effect. 3 consistent effect. 4 temporally accurate effects. 5 specific effects 6 plausibility. 4

5 The evidence for criteria 1, 2, 3, 4 and 6 is very strong (italics mine): rates of abstinence are about twice as high among those who attend AA; higher levels of attendance are related to higher rates of abstinence; these relationships are found for different samples and followup periods; prior AA attendance is predictive of subsequent abstinence; and mechanisms of action predicted by theories of behavior change are present in AA. Even in light of these positive findings, the authors persist in their negative representation of AA. The following lines are those exclusively quoted by The Sober Truth s authors. "However, rigorous experimental evidence establishing the specificity of an effect for AA or twelve-step facilitation is mixed, with two trials finding a positive effect for AA, one trial finding a negative effect for AA and one trial finding a no effect. Studies addressing specificity using statistical approaches have had two contradictory findings and to that report significant effects for AA after adjusting for potential con founders such as motivation to change." Study 6: R.D. Weiss:Drug and Alcohol Dependence 2005, Vol.77, No.2 (2005) pages: The authors quote the R.D. Weiss study stating: the authors uncovered a strong indication that attendance alone did not seem to help people with addictions, but that "active twelve-step participation" was predictive. This was confirmed again in a study he quotes by J Majer in 2011, J.Majer: Journal of Substance Abuse Treatment, Vol.41, 2011, pages: " participants who were "categorically involved" in all twelve-step recommended activities reported significantly higher levels of abstinence and self-efficacy for abstinence at one year compared with those who are less involved, whereas averaged summary scores of involvement were not a significant predictor of abstinence." This is like saying that having a gym membership will only get you fit if you actually attend the gym and workout on a regular basis. This information should not be a shock to anyone. One cannot help but question the authors motivation for presenting such a selective and obviously biased discussion of these studies which, when examined in their entirety, clearly demonstrate the effectiveness of Alcoholics Anonymous. As well, the authors have no problem dismissing the rise of the biologists or the geneticists with volumes of supporting research by world experts yet promote their own theory with virtually no evidence other than their own experience, as fact. 5

6 This fact leads to one of the important parts of a modern treatment of addiction: if addicts can learn to address their rage at helplessness directly, then it manifests simply as an assertive act. When people act directly, there can be no addiction. Naturally, not a shred of evidence is presented to support this hypothesis, other than Dr. Dodes own clinical experience. He justifies this omission in his last chapter with the explanation: Most people who do good work in education or the humanities know that deeply significant truths cannot be measured. Great teaching for example is hard to quantify. Most good, worthy and verifiable ideas don t belong in a spreadsheet. Yet as a result of insecurity or ignorance, the majority of scientific publications today won t even consider paper that isn t larded with numbers from top to bottom. Finally I believe Dr. Dodes asks what I think is the most appropriate question in the book: How do I know that my own bias toward a psychological perspective isn t pushing me towards the same flawed and unfounded worldview? Given the evidence, this question is sobering indeed! 6

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