Awareness Month Feature Article by “The Fix” Explores The Topic: ‘AA Is not an Evidence-Based Treatment’

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AUTHORS NOTE:

“I am in no way demeaning or saying that The 12-Step Program and model is not a form of treatment, nor that it doesn’t help people recover from drugs, gambling, or alcoholism.  But more and more articles like the one I am sharing today and hearing many people talk about needing and wanting MORE than 12-steps to reach long-term recovery and have a well-balanced path from ADDICTION.”

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So please don’t leave me nasty comments as to such. What I am exploring is a more in-depth look into having “Wellness in Recovery.” Many are now searching for ways to obtain treatment AND learn the much-needed skills and tools to begin the “inner work” needed to a well-balanced recovery without relapse or slips in the process.

Let’s face it, if we teach new addicts coming into treatment BOTH, we just may cut relapse percentages in half or more and would mean MORE NEW addicts would be getting the help they need as well.

There are many ways to go about it this.

One new exciting way I have been using and venture I am involved with is for those working in the “treatment side and facilities” and those looking for recovery “AT HOME Recovery.”  Learn more about “Wellness in Recovery” and “Oak Valley Productions Educational DVD Series.” It is a fresh approach to having a well-balanced journey, learn to begin and process the underlying issues that may have you turned to addiction, and learn to release and let it GO!

It will help guide you on how to begin your “inner work” as you learn the educational side of recovery from addiction! See all the details of this non-12 step recovery series and have  “Recover in Wellness” of mind, body, soul and Spirit!

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FEATURED ARTICLE: AA, GA, NA, Is not Evidence-Based Treatment by, Laurel Sindewald 03/16/17

“Researchers have not been able to methodologically eliminate self-selection bias or utilize adequate controls in their studies of 12-step groups and Twelve-Step Facilitation.”

When I read Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, I was surprised to see Twelve-Step Facilitation (TSF) included as an evidence-based behavioral treatment for addiction. I had just done a literature review on the efficacy of 12-step-based interventions and found the evidence insufficient to support the prescription of 12-step groups as treatment. TSF is a standardized form of therapy where professional counselors try to engage their patients in participating actively in 12-step groups, in part by emphasizing 12-step philosophy during therapy sessions.

Twelve-step philosophy stipulates that addiction is a spiritual disease born of defects of character and that 12-step groups are the only cure, involving faith in a higher power, prayer, confession, and admission of powerlessness. In contrast, the National Institute on Drug Abuse (NIDA) defines addiction as a disease of the brain – a medical condition requiring medical treatment. A spiritual disease concept is not the same as a medical disease concept. Twelve-Step Facilitation treats addiction as a spiritual and biopsychosocial disease, retaining the spiritual emphasis of 12-step philosophy.

TSF was classified as a professional behavioral treatment in the Surgeon General’s Report. How can a professional, medical treatment be based on a definition of addiction as a spiritual disease? Baffled, I knew I would not be able to understand if I got stuck in bias against Twelve-Step Facilitation. I had studied the research on 12-step groups, but had only dipped my toe into the research on TSF. The Surgeon General’s Report cites hundreds of studies, and over a dozen in support of TSF. So, I did what all good scientists must do: I set aside my bias, knowing that if I want the truth, and I must assume first that I am wrong and dig deeper.

I conducted a preliminary literature review to investigate the effectiveness of TSF as a treatment, and then examined each of the sources the Surgeon General’s Report cited in support of TSF. I looked at the methodology, results, and conclusions for each. In this article, I define “evidence-based” to mean any treatment supported by numerous scientific experiments with rigorous methods that include control groups, randomization of patients to treatments, and bias-free samples. I use “12-step approaches” to refer to all 12-step-based rehab programs, TSF, and 12-step mutual help groups.

The key to understanding research on TSF is to know why the treatment was created in the first place. Researchers had documented a correlation between 12-step group attendance and abstinence, but correlation is not causation and research had been limited in several ways:

  • Studies evaluating the effectiveness of 12-step groups could not eliminate self-selection bias, which happens when group members are not randomly selected and participants opt in or select themselves, creating biased samples. The people participating in the studies had chosen to participate, and researchers could not determine whether successes observed were due to 12-step participation or qualities in the self-selected participants, such as greater motivation to enter recovery, more resources, or greater receptivity to messages of God, faith and/or acceptance. The people who chose not to participate, or who dropped out of the study, were not always accounted for. Researchers could not determine whether the correlation they observed was due to the treatment or to the characteristics of the people participating.
  • Twelve-step groups have no standardized methods or conditions. Leaders of the groups are often laypeople in recovery from addiction themselves. The quality of social support in the group depends on the people who are participating. The literature is interpreted by the members, who create their own cultures around the interpretation. Twelve-step cultures also pass around other information and advice, which may or may not permeate every group. Each sponsor is a different layperson in recovery from addiction, with different character traits. Researchers could not control for all of these variables all of the time.
  • Researchers struggled to maintain rigorous control groups throughout studies. At a minimum, to determine whether 12-step groups have an effect, researchers needed a no-treatment control group for each study. Ethically and logistically, they could not prevent people in the control groups from receiving treatment or from attending 12-step groups.

 

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Twelve-Step Facilitation was developed by researchers working on Project MATCH, a well-known and extensive study funded by the National Institutes of Health. Project MATCH compared TSF to Motivational Enhancement Therapy (MET) and Cognitive Behavioral Therapy (CBT), seeking to establish what patient characteristics corresponded with the best results for each treatment. The study found there “was little difference in outcomes by type of treatment” based on the primary outcome measures of percent days abstinent and drinks per drinking day.

By standardizing methodology for TSF, Project MATCH made some headway on strengthening the quality of evidence, but they did not find a way around self-selection bias and they did not have a control group. Many patients, however, did drop out of the assigned treatments early on in the study. Two researchers later examined the outcomes of the zero-treatment dropout group, and found that “two-thirds to three-fourths of the improvement in the full treatment group was duplicated in the zero-treatment group.”

This means that the people in Project MATCH’s treatment groups did not have significantly better abstinence outcomes than the people who dropped out of the study. Importantly, we do not know whether the dropout group sought treatment on their own, and it seems probable that they did. Based on their analysis, none of the interventions in Project MATCH seem to be effective, but without an actual control group, the results are equivocal regardless.

Some researchers have sought to re-analyze other parts of the Project MATCH data, but their findings, while supportive of TSF, are subject to the same methodological limitations of the parent study. Many other studies cited by the Surgeon General’s Report seem to support TSF as effective for improving abstinence outcomes and/or for relatively increasing 12-step participation compared to treatment as usual (TAU), but none of these studies had control groups. The Surgeon General’s Report cited one source in support of TSF that was actually an article reviewing information about 12-step programs to educate social workers, not an experimental study. The Report also cited a study in support of TSF that examined two active referral interventions, 12-step peer intervention (PI) and doctor intervention (DI), compared to no intervention (NI). The study found that while the active referral interventions significantly increased participation in 12-step groups compared to no intervention, “abstinence rates did not differ significantly across intervention groups (44% [PI], 41% [DI] and 36% [NI]).”

This study was the only one cited in the Surgeon General’s Report in support of TSF that approximates a control group, and it does not actually support the efficacy of TSF in increasing abstinence outcomes. The NI pseudo-control group still received a list of 12-step group meeting times and locations, but was not encouraged to attend. The PI group attended meetings twice as much as the NI group, and yet the researchers found no significant difference in abstinence outcomes. The DI group, essentially TSF, was less effective than the PI group at increasing attendance, and again, did not significantly improve abstinence.

My own literature review turned up articles the Surgeon General’s Report did not reference, both in support of TSF and not supporting TSF, but none of the studies I found had control groups either. Results of my literature review, including my assessment of the Surgeon General’s report sources, were therefore as ambivalent as the 2006 Cochrane Review, a systematic meta-study of all 12-step-based programs that found “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems.

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In medical science, if a treatment is ineffective or faces prohibitive methodological challenges, the treatment is either revised or abandoned. Twelve-step philosophy prohibits either approach. Twelve-step literature is comparable to the Bible for Christians or the Qur’an for Muslims; if the literature is removed, the identity of the group goes with it. The same basic text has been used for AA since the publication of its “Big Book,” Alcoholics Anonymous, in 1939. Twelve-step literature also explicitly states that “Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves.

There are such unfortunates. They are not at fault; they seem to have been born that way. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average.” Twelve-step philosophy, by taking this position, is asserting that its methods can never be wrong. If the 12 Steps do not work for people, 12-step philosophy explicitly states it is their fault, and that the fault is inborn and irreversible. The 12 Steps and attendant literature, however, are not modified.

Research does support the concept that changing “people, places, and things” and finding a network of people with a culture of abstinence can improve chances of recovery. However, mutual help groups other than 12-step groups do exist that may provide the social support needed by people in recovery. People who are not religious may be able to make 12-step groups work for them as social support if they have no other choices, but other options will most often be available.

A study in 2001 by Humphreys and Moos found that TSF may reduce health care costs for people in recovery by emphasizing reliance on free 12-step groups, as opposed to cognitive behavioral therapy. Yet their conclusions that the study indicates people should be diverted from CBT to TSF because it is ultimately cheaper amounts to advocating malpractice. TSF itself is not free and is not decisively supported by evidence; twelve-step groups, while free, are not evidence-based treatment, and other available mutual help groups are equally free options for social support. Even if TSF were demonstrably effective at promoting abstinence for some people, 12-step philosophy is heavily spiritual (specifically Christian-based) so it would be unethical to recommend TSF simply because it might save money.

After exhaustive research, I assert with confidence that 12-step approaches are not evidence-based treatments. They may be strong recovery support for people to choose in addition to a medical treatment plan, but 12-step approaches—including TSF—are not established as evidence-based for treating addiction.

Due to the methodological limitations identified in this article, I question continuing to spend thousands of dollars, hundreds of hours, and invaluable expertise on researching a spiritually-based treatment for addiction that cannot be proven to be effective for most people most of the time compared to “spontaneous,” or natural, remission rates. It is time to relegate 12-step approaches to the realm of recovery support services (RSS, as defined in the Surgeon General’s Report), and allocate our research resources to promising treatments that can be studied rigorously and without such crippling methodological limitations.

** Laurel Sindewald is a writer and researcher for Handshake Media, IncorporatedAnne Giles contributed to this report. ** 

 

Sharing Some Recovery News and Humor From Around The Web …

Hello Recovery Friends and Visitors,

Happy Holidays Too!

 

“I enjoy sharing interesting stories I read on the many recovery sites I come across and get permission to share. There are two I have read that I thought they were worth sharing.”

 

The first is from The Fix, addiction and recovery, straight up. It is an article about having HUMOR in our recovery and no one had more humor than the late, Robin Williams . . . .

“There’s nothing funny about hitting bottom with your addiction. But once you’re on the other side, there’s so much laughter in recovery communities you could almost forget how grim the life and death stakes really are. Humor may not be the best medicine, but being light about our darkest hours is one approach that makes sobriety that much more livable and attractive. Most of the following were written by working stand up comedians. Not everyone gets the joke, but if you’ve been through hell, and come up for air, the following needs no explanation— “

-The Fix Staff

Robin Williams: You Know You’re An Alcoholic If…
By The Fix staff 05/26/14

Robin’s checklist of tell-tale signs you have a problem with alcohol. Below that, the brief 2011 interview with him after one of his rehab stays: “Rehabbed and Ready to Roar.”
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“I went to rehab in wine country, just to keep my options open.” 

About four years ago, Robin Williams started drinking again after 20 years of abstinence from alcohol and cocaine. That in itself is a sobering thought, and a grim reminder of the chronic nature of addictive disorders. But Williams dealt with it, emerged sober, and is now starring as a tiger in the hit Broadway play, Bengal Tiger at the Baghdad Zoo. Time magazine caught up with him and did a Q&A session with the savagely sardonic comedian. Here, Williams briefly discusses his addictive past:

You made headlines in 2006 when you went to rehab for alcoholism. Did you find material there? Or is it all secret?

Well, secret–hence the name Alcoholics Anonymous. I went to rehab in wine country, just to keep my options open. But it was important for me to do. I had to. I was really out of control.

And yet you own a vineyard.

I do, actually, which is weird. It’s like Gandhi owning a delicatessen.

We see a lot of stars with substance-abuse issues. Why?

I think celebrity itself is a drug. There’s withdrawal, because it comes in waves. You’ll be hot, and then you’re not, and then back again. Even now, with an Academy Award, it’s still, “Mork!”

Billy Crystal says stand-up is how you process the painful. Do we have to wish more painful things on you?

You don’t have to.
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*Now I still can not believe that Robin Williams is really gone. He made so many of us in recovery learn that we can laugh at ourselves once in a while. Laughter is good for the ‘Spirit’ when you have been to hell and back. My next share is an important one from my friends over at UNITED To Face Addiction.

It is a new video series for parents to help “change the conversation” and help talk to your teens about alcohol and drugs. Here is what they are doing!*

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*Changing the Conversation*

Addiction to alcohol and other drugs is the most pressing health and human rights crisis facing our country today, impacting more than 45 million Americans and is now the leading cause of preventable death – more than motor vehicle accidents.

Fortunately, much can be done to turn the tide against addiction – in prevention, early intervention, treatment and recovery, and research. But in order to make significant progress against these critical initiatives we need your help.

Scores of millions have joined the movements to battle cancer, heart disease, and diabetes. But because of the shame and stigma surrounding addiction, no movement of that scale has ever been created to change the conversation and create better solutions for this crisis. Until now ..  ..  ..
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Together we can begin facing addiction and save a great deal of lives. PLEASE JOIN THE MOVEMENT TODAY at: Join Us At Facing Addiction & Save Teen Lives   . . . .

Now let us remember how the holidays can be full of stress and triggers in recovery. So humor can fill some of that void of “No Party Fun”…

My humor quote?
“You don’t have to use to have fun in recovery, and it doesn’t mean the party is over…It just means you’ll remember what the hell you did LAST NIGHT!”

Recovery Advocate & Author, Catherine Townsend-Lyon
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