Alcoholics Anonymous vs. other approaches: the evidence is now in

In the last decade or so, researchers have published a number of very high-quality randomized trials and quasi-experiments. Of the 27 studies in the new review, 21 have randomized designs. Together, these flip the conclusion.

That sounds impressive. If it turns out not to be so impressive, that's definitely on topic.

Addiction does vanish spontaneously with a wave of a wand. These are people of flesh and blood and free will that managed to overcome their addiction. They are making attempts at treating themselves. They might be reading blog posts with advice. They may avoid buying alcohol for fear they'll drink it all. They be taking detours around bars. They may be meditating or even self-administering cbt.

So calling it spontaneous seems a misnomer.

It’s been a while since I reviewed the literature for substance abuse disorder, but if I remember correctly it was highly disputed whether complete abstinence was necessary (or even beneficial) for treatment. Has this changed?

The argument was that by focusing on abstinence you are setting a significant part of your patience up for failure with all the psychological harm involved in knowing that they’ve failed, which might result in severe and frequent relapses.

EDIT: To conclude. I find it hard to draw conclusions if success is measured in “days of abstinence”. That means that a patient that has recovered from cognitive behavior therapy (CBT) that uses occasionally and non-detrimentally is not considered a success! Further AA or other 12-step programs do often stress abstinence while CBT does not, this creates a counting bias in favor of 12-step programs.

There are about 10 findings, and the only “high” quality finding is that there appears to be a significant increase in abstinence, especially long term abstinence from people who get treatments which get them in the rooms of AA (“TSF” treatments).

We can dive down in to the details about this finding (percent abstinent) on pages 88 and 89 of the report. They actually use six different studies, but only two of them provide information at the one-year follow-up, so only those two get listed in the summary on page 4 of the report.

Considering that they compared a number of things, and only percentage of subjects abstinent showed, with high confidence, a difference between AA/TSF and other treatments, I’m a little worried we may be seeing a multiple comparison fallacy. Then again, this is unlikely: They are seeing P values of 0.02 and 0.03 (1-in-30 to 1-in-50) for the abstinent numbers, but only look at about 10 factors.

Humphreys 2014, another meta-analysis of multiple studies, showed AA effectiveness which can not be attributed to self-selection, but it saw something different: A fairly small but significant increase in the percentage of days abstinent. While they did see in the 2020 Cochrane review, they did not see it with a high level of confidence (see pages 89-90).

Percentage days heavy drinking — I don’t have a copy of Brandsma 1980 handy, but I think that’s what the “Brandsma 1980 shows that AA results in increased binge drinking!!!111!!!!!” claim parroted by the usual anti-AA crowd talks about — might be increased in the short term after starting AA treatment, based on the one study which has 6-month follow-up figures for this; Brandsma 1980 only saw it at the 3-month follow-up and not later. Then again, the Cochrane study of those numbers show a pretty high P value (0.79, just glancing at those figures), which means we still don’t really know if Brandsma 1980 actually saw something. Scott Alexander dismisses it as an example of a multiple comparison fallacy, and the P values for it in Cochrane 2020 means we probably didn’t actually see something, but this may merit additional investigation.

Cochrane 2020, of course, didn’t look at the longitudinal studies showing really high abstinence rates for people who self-select to go to a lot of AA meetings, but even using only randomized studies, we are seeing a significant increase in number of subjects who get and stay sober when they engage in treatment which encourages AA attendance.

Another thing: There are no recent high-quality studies comparing AA to no treatment (“spontaneous remission”, an expression I see used mainly by people with a pretty strong anti-AA bias) because it’s been established for a long time that AA (or any other treatment you can think of) is better than no treatment. Even Brandsma 1980 saw that going to their AA-like meetings was significantly better than getting no treatment at all.

In summary, with some caveats, we are seeing solid scientific evidence that AA really helps alcoholics get sober and stay sober. Ten years ago, someone could still say “AA does not have a higher success rate than no treatment” with a straight face; today, to claim something like that requires ignoring a lot of scientific evidence.

https://hn.algolia.com/?dateRange=all&page=0&prefix=true&que...

https://news.ycombinator.com/newsfaq.html

https://news.ycombinator.com/item?id=10178989

That's unfortunate, and mostly in line with other experiences I've heard from friends, etc. AA seems like just another bullshit Christian recruitment/retention facility, that sometimes accidentally helps people who buy into it recover from addiction. Too bad.

I obviously don’t have your unique and nuanced understanding of the situation, but this seems like a common occurrence with all humans when they lack information.

In my experience when we don’t have information, our group tendencies lean towards filling gaps with the outlandish and dramatic.

Again, I don’t know much about AA but I’d question whether that situational behavior was driven by something unique to AA.

Though, their hostility to atheism is a problem they should have addressed long ago.

I have had nothing but positive experiences with these groups.

In my experience there are two types of atheists who go to AA: those for whom religion “isn’t their thing” and those who are actively hostile to religion.

I think the latter group should find an alternative to AA.

each meeting can be quite different. i had to try 10-20 of them in my city to find a few that were on my wavelength.

i don't attend aa meetings as often as i used to in early sobriety, but i still go if i have a friend that's struggling and want to open this resource to them.

at every meeting, there are things that people say that resonate and things that are cringe-worthy or even inflammatory.

part of the meditation and process is being able to be hear and react to everyone's words with equanimity.

Sodium Oxybate (ie: incredibly expensive GHB) is on the market elsewhere, but not indicated for alcohol abuse and usually heavily controlled (ie: special doctors and pharmacies only).

The heavy control always surprised me while other powerful sedatives flow freely with little control.

It was the religious stuff that put me off completely. Being in a group of people all there with a common cause I felt was quite powerful. Hearing shared experiences from the community was helpful. I just couldn't pretend I was OK with peddling any form of faith.

I would be skeptical too and it can certainly have a negative impact on addiction groups. Although I would think these negative factors to be worse for people actually believing it. Some people classify them as a sect, but I wouldn't go that far to be honest.

But if it doesn't work for you, I think there are other groups or those that set the focus elsewhere.

I would obviously let it slide if I needed this kind of thing, but it is clearly cruft.

No cosmically, nothing about governance.

Should be loving and tolerant.

At least that’s my experience so far working the steps.

https://en.wikipedia.org/wiki/Serenity_Prayer#Use_by_twelve-...

I have witnessed _exactly_ what you're saying, and I've seen people feel so unwelcome that it hurts them more than helps them. It blows my mind the stranglehold that AA has on this industry, given how demeaning it can be to people who are looking for help.

I've seen more success with people going to SMART recovery meetings, which focus on providing a space to talk and seek help without the judgement level associated with AA.

The "Sinclair Method" is, basically, to promise to take naltrexone (or similar) 30 minutes or so before you ever take a drink. That way, if/when you drink, you never feel the "drink" and your mind can return to normal.

No drug will "make you stop drinking" (though disulfiram may make you want to do so); the Sinclair Method attempts to remove your interest in drinking.

Some basic googling found https://www.theatlantic.com/magazine/archive/2015/04/the-irr... from 2015, which covers most of my understanding of AA.

The measure of success should be relapse after treatment, but AA doesn't have the concept of stopping, and more importantly does not consider relapse after ceasing attendance to be a failure of their 12 step program.

This ignores the moral corruptness of praying on, and essentially mandating indoctrination, of people in need of help.

Then you presumably aren't aware of how abusive religious people can be towards atheists, and that includes in AA groups.

A few homeless shelters are "open", even when they don't have beds. They require mandated participation in multiple religious activities per day.

Boise statutes say "If a homeless shelter is open, you can be arrested and jailed for sleeping on the streets", and "but I don't want to be subjected to mandatory religious activities for only the _potential_ of a bed at the end of the day" is not considered an excuse.

My son's in Cub Scouts and we take this approach with the "duty to God" requirements (he doesn't have a duty to God, so duty fulfilled!) but some troops require a bit more than that.

That's quite cheeky.

Telling people to believe in a "higher power" simply translates into the gods in the mainstream religion in the society they live in.

There are people that can just say "from tomorrow I will believe in God/afterlife/spirits etc. It would be so easy to live knowing that your loved ones are not gone or that if you are good enough your problems will be solved soon but for some people(like me) it is like trying to convince me that 2+2=5 and giving cancer to children has a higher purpose that we are to stupid to understand but we still should worship that "bigger" thing.

When you contrast it to any other type of 'militant', there is typically violence involved..

However, personally, I think the closest thing I could believe in is a "best self". Not that anyone chooses their beliefs, but the rest would be pretty hard to digest for any good reasons.

Honestly, I just think giving up on the idea that you can do this by yourself (in the long term) is counter-productive. Especially if you have an existential crisis later in life and that 'higher power' was the only thing that kept you moving forward. Learning how to embrace self-respect/love/understanding/esteem would go so much further in the long run and would help in all aspects of your life. With each success, and learning to accept each failure -- you will be strengthening productive habits.

That being said, these smaller towns already pressure people to believe in a higher power in most social settings, so it’s less a case of AA imposing it and more society, which is kind of to be expected in a people driven effort.

Not that you're saying its not, but I'd grasp onto this to add a point that its valid and useful to debate whether that surrendering is the best path.

In my mind, what you're being asked to do is abstract and make a virtual externalization of your ego. The benefit is you can get some of the benefits of ego-depletion or ego-loss, but the side effect is that it risks further use of that mechanism to explain or stop caring about things that are more easily under one's control. This can lead to a cycle of ignorance - if every event that happens is "God's Plan", then why not give into nihilism? Its ends up being the answer to every question - if you don't understand something, then its not due to lack of effort, it must be ungodly.

Note that plenty of religious people don't fall into this trap. They don't have a problem expanding their knowledge, and they leave the dieties in the periphery of understanding. Growing up amongst some extreme fundamentalist people though and seeing the downsides of dealing with all problems through faith alone, I am really lax to recommend the surrendering that AA espouses as a universal/sole truth.

Within the 12 steps of AA, Bill W clearly laid out the answer to this very question. Below I've copied over the first 3 steps of AA.

1. We admitted we were powerless over alcohol - that our lives had become unmanageable. 2. Came to believe that a Power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

The gist of step 1 is acceptance. Acceptance that our lives are controlled by alcohol. This one is pretty easy for any true alcoholic to admit.

The gist of step 2 is surrender. Step 2 states, "Came to believe a power greater than our selves could restore us to sanity." Coming to believe in something is not the same as flipping a light switch and a light coming on. Surrender here in step 2 deals with admitting that we need the help of something greater then ourselves to restore us to sanity. That power could be the love of your family, wife/husband, kids, the energy that moves the cosmos, or a fucking Zagnut bar. As long as it is a power greater then self, you're good.

The gist of step 3 is faith. The key to not getting hung up here is the statement "God as we understood him". This ties directly back to "a power greater than ourselves". Seeing how the Big Book was initially written in the 1930's, and Bill W himself was a Christian, the word God appears a lot. Before the first edition was published, there was an internal fight between the founding members and contributors to the Big Book on the wording of step 3 in particular. They made a deliberate decision to say "God as we understood him" to include as many people as possible.

I share this with you all because I have been and always will consider myself a non religious person. I have needed to work on the concept of a higher power time and time again. When I first started attending AA meetings I let the God/higher power thing get in the way of my recovery and relapsed many times. Only once I surrendered to the idea that a power greater than myself could alleviate my suffering, was I able to start the road to content sobriety. I hope this helps clear the air for some of you, and if there is anyone out there suffering from alcohol or drugs please find a local AA or NA meeting raise your hand and ask for help.

My uncle Guus plays viola in an orchestra and once noted to me that there is something similar that happens in attitudes towards other people who are dissatisfied with us. When we are young we ask “what is wrong with me, how can I change myself?” and as we grow older we start to ask instead “What's wrong with them?” but without trying to change anybody. They will find their way—or not; and we may be able to help them—or not.

The higher power is not "thrown in" to AA, it is the critical foundation.

Also the people who are most critical of this concept or most aggressively reject AA based on a perceived religious foundation also tend to be the ones who have the poorest understanding of what the higher power means.

I'll admit it's not an easy concept to grasp. For many/most fellows AA the principles of AA take a good amount of time to begin to understand, and alcoholics sometimes bumble their way in and out for years before this happens. It's a learning process. Pushing back on these principles, especially the existence of one's higher power, correlates highly with continued active drinking. Acceptance of this is the whole point of the program.

Sure, we can crunch numbers and test hypotheses faster, but they were doing that with far more primitive instruments, in most cases even without writing and simply using their minds, for centuries well before the so called Enlightenment period. It seems the more "enlightened" we become the worse off the condition of the human soul becomes, and the more we favor vices and all the things our fathers and mothers tried to warn us against for centuries. Our Science, which in of itself has become a religion, in my view has lead us all to cultures of indulgence, where utilitarianism is the only value to be regarded. I wish you could say at least we aren't slaughtering ourselves anymore in the name of Religion, but sure enough, human slaughtering has increased by entire factors these past two centuries, than the previous 100 combined, "Enlightenment" or not.

The notion of man gaining reason and "growing out of" religion during this period is in of itself such a hilariously cliche, Western-centric viewpoint of history but this is another issue of itself.

But if that were really the intent of the program then why do they have a prayer where they ask capital-G-God for help every meeting?

Alcohol qua alcohol is a pretty terrible drug, toxic in reasonable doses, very addictive, affects judgement, and so on and so forth. I happen to think in a culture with a sane attitude towards drugs in general, alcohol wouldn't be a favorite.

Mormons, Muslims, straight-edgers, teetotalers, and alcoholics, all manage to socialize and conduct business just fine while never touching alcohol. Literally all you have to do is order soda water. Anyone who gives you crap for not drinking is going to turn out to have other bad habits, bet money on this.

GP is right: the absolute best way to avoid problems with alcohol is to not drink it. Considering GP was a problem drinker, and that has a genetic basis, you are being arrogant as hell telling him how to raise his children.

That's pretty problematic though, isn't it? At some point, you're dropping below placebos, not everything works for everyone, but should we still put weight on it? Homeopathy and intense praying works for some as well, but we don't say "I guess it's not effective for everyone". Psychotherapy (not the behavior therapy kind) gets a pass for some reason.

it's really hard to taper down! it takes a lot of willpower not to just take more since you have it sitting around. i wonder if would be more successful with like a 1 month taper for in patient program.

Yet at the same time I think dang has the ability to move any post up or down/re-prioritizing or re-ranking based on his intellect, instead of a natural, organic ranking. It becomes a forced therapy session by dang. We also cannot know if this happens, since those moves would be invisible to everyone else on the site (except to other admins/moderators). I do not think it’s far fetched to think he has this power, seeing as karma scores are conveniently hidden for all posts (except for the author of each individual post).

I’m a little disturbed that dang seems to ‘steer’ conversations based on his own interests. There’s a bunch of smart people here and I don’t understand why he goes past his role as administrator to interject into certain threads. It’s ‘bad hosting’ in my eyes.

With my questions I’m trying to understand what the rules of the game are, to see whether I like them or not and whether I want to keep playing (engaging on HN).