The study shows why we need more addiction treatment options in America.
For the past several decades, Alcoholics Anonymous and the 12 steps have dominated addiction treatment in America — boasting millions of adherents and turning into the standard option within most addiction treatment programs in the US.
A new study has found, however, that AA, the original 12-step program, and others like it don’t have to be the only answer for people seeking out mutual help groups to deal with alcohol addiction.
The study, in short, looked at how people’s self-reported outcomes with AA and 12-step programs compare with the three biggest alternative mutual help groups — Women for Sobriety, SMART Recovery, and LifeRing. It concluded that these other groups perform about as well as 12-step programs.
“This study suggests that these alternatives really are viable options for people who are looking for recovery support and don’t like AA for whatever reason,” Sarah Zemore, lead author of the study, told me.
The research is by no means the last word on this question — Zemore characterized the study as the beginning of a deeper evaluation into AA alternatives.
But this is important. There has been a good amount of research into AA and the 12 steps over the years, broadly finding that about a third of people maintain recovery from alcohol addiction due to 12-step treatment, another third get something out of the treatment but not enough for full recovery, and another third get nothing at all.
Researchers have long suspected, though, that the benefits found in 12-step treatment programs are not exclusive to the 12 steps. As Zemore told me, “The benefits of 12-step groups are not driven by the 12 steps’ specific philosophy or adherence to the 12 steps. It’s really more about general mechanisms like abstinence motivation and social support for abstinence. Presumably, you could get those by participating in alternatives to AA.”
In other words, these alternatives could help the one-third to two-thirds of people who don’t get anything or much out of AA. That would help deal with a big public health issue: Based on federal data, more than 20 million people in the US have a substance use disorder, and within that group, more than 15 million have an alcohol use disorder. Excessive drinking alone is linked to 88,000 deaths each year. So finding the right solutions for this problem is literally a matter of life or death.
The study, conducted by the Alcohol Research Group at the Public Health Institute in California and published last month in the Journal of Substance Abuse Treatment, surveyed more than 600 people with alcohol use disorder (AUD), who were divided by which mutual help group they primarily participated in. Researchers followed up at six months then 12 months, measuring involvement in the groups and various substance use outcomes, including abstinence from drinking and alcohol-related problems.
After controlling for several factors, the researchers concluded that “[Women for Sobriety], LifeRing, and SMART are as effective as 12-step groups for those with AUDs.”
“Essentially, that’s the story,” Zemore said. “We were really interested in whether the effects of involvement on recovery outcomes depended on which group [participants] were in. And we found that they did not.”
There were some differences in the data. People who reported SMART as their primary group seemed to have worse substance use outcomes, and there were lower odds of total abstinence among LifeRing members.
That might have something to do with differences in recovery goals. For example, AA really emphasizes total abstinence from drinking as the solution to alcohol addiction. Groups like SMART and LifeRing, meanwhile, can be friendlier to the idea of members moderating their drinking but not quitting altogether. That could affect substance use outcomes — and especially abstinence outcomes.
The study’s survey data suggests this is in fact what was going on: When researchers controlled for people’s recovery goals — meaning, whether they wanted to commit to lifetime total abstinence or not — the differences between the 12-step groups, SMART, and LifeRing went away.
“That suggests that people with less commitment to lifetime total abstinence are more likely to participate in SMART and LifeRing than they are to participate in 12-step groups,” Zemore said. “That’s why you’re seeing these associations between SMART and LifeRing affiliation at baseline and worse recovery outcomes when you control for involvement.” She added, “But I want to emphasize that these go away when you control for recovery goals.”
Again, the study is not the final word. John Kelly, an addiction researcher at Harvard Medical School who was not involved in the study, told me that the study is “good news, in general,” but pointed out that it’s limited by its methodology: It’s based on an online survey, not the kind of randomized trial that’s typically the gold standard in research. That may have led to some potentially biased results — perhaps participants in specific groups were less likely to report bad outcomes, for instance.
And since it’s only one study, it’s possible that the results were biased in some other way. So it’s up to future research to verify the findings.
One tricky thing with this line of research is you can’t really force people to participate in certain groups — so studies that randomly assign participants to AA, SMART, LifeRing, or Women for Sobriety may not be easy to do. But there are ways that researchers could get around these problems, such as only using participants who are willing to try different groups and actively following up with them to make sure they are actually participating.
Another big research question: figuring out why, exactly, these groups might work to help people stay alcohol- or drug-free. There’s good research into how AA works, but it’d be good to figure out if SMART, LifeRing, and Women for Sobriety work in a similar way. That, Zemore said, will be one of her goals in future studies.
In discussions about addiction treatment, AA and the 12 steps tend to prompt polarizing reactions — some people swear by the programs, others absolutely hate them.
There’s a good explanation for that: While the research shows that 12-step treatment can be as effective as professional treatment modalities like cognitive behavioral therapy, the research also shows that the 12 steps don’t work for everyone.
As one example, a prominent complaint about 12-step programs is the spiritual aspect. This is a big part of the 12 steps, with the final step even invoking “a spiritual awakening.” For people who aren’t religious or spiritual, this can be a big turn-off; that’s one reason SMART and LifeRing exist to begin with — they’re meant to be secular alternatives to the 12 steps.
The good news is that the research suggests the spiritual aspect doesn’t fully explain why the 12 steps are effective for some people. Instead, it seems other traits are just as, if not more, important — such as the social support that AA meetings provide and the lessons that participants can pick up at meetings.
That’s long led researchers to suspect that alternative mutual help groups could work. If so, that would let some people go to AA meetings if they prefer the 12 steps, while others could find SMART, LifeRing, Women for Sobriety, or something else that works for them. Basically, everyone could find a workable solution.
Providing these alternatives would essentially move addiction treatment closer to other kinds of medical problems. As Keith Humphreys, a drug policy expert at Stanford University, previously told me, “We don’t have anything that works for everybody. There’s very few places in medicine where you do.” So there need to be as many alternatives as possible.
The US is far from that at the moment. Most treatment facilities in America are, according to the survey data and research, at least partly based on the 12 steps — making it the only option for many people. While alternatives like SMART or LifeRing do exist, they’re not nearly as available as AA — and they certainly aren’t built into professional treatment programs in the same way as the 12 steps.
As Albert, a pseudonym for an AA member in Georgia, previously told me, “There’s just not a lot of widely advertised options available.” AA and 12-step treatment are “the most well-known and most recommended option, so that’s kind of where you tend to go.”
Zemore’s study begins to peel away at this problem. By showing that there really might be other effective options out there, the research provides hope that there may be a better — or at least more complete — solution out there for alcohol addiction.
For more on the research into AA and the 12 steps, read Vox’s explainer.
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The study shows why we need more addiction treatment options in America.