by Thaddeus Camlin, PsyD
A 2020 mega study from research juggernauts Cochrane garnered substantial attention when it concluded that “there is high quality evidence that manualized AA/[Twelve Step Facilitation] interventions are more effective than other established treatments, such as CBT.” Click-bait headlines proliferated touting things like, “AA Superior to CBT for Alcohol Addiction,” and, “AA Still Best to Beat Problem Drinking.” The 2020 Cochrane study conclusion was strikingly divergent from a similar Cochrane mega-study in 2006, which concluded that “no experimental studies unequivocally demonstrated the effectiveness of AA or [Twelve Step Facilitation] approaches.” Such discrepancies warrant further investigation.
Beyond the surface of the click-bait headlines, details help make sense of Cochrane’s contradictory findings in 2006 and 2020. The 2006 study measured treatment success based on recovery rates determined by factors like improved quality of life and reduced drinking in addition to abstinence. The 2020 Cochrane study measured success exclusively by continuous, unbroken abstinence. Odd, considering that factors like improved quality of life and reduced use are viable outcomes and important measures of success in addiction treatment.
As is often the case, experimenter bias may have been a factor in shifting the focus away from reduced drinking and improved wellbeing to continuous abstinence. Lead researcher of Harvard Medical School, John Kelly, is a vocal advocate for the brain disease model of addiction. Concepts like self-regulated use and self-efficacy do not align well with a model of irreversible brain disease. In addition to potential experimenter bias, the 2020 Cochrane results raise the issue that even if it were shown without equivocation that AA effectively helps 42% of people to remain continuously abstinent for one year as the study purports, why is the overwhelming majority of US addiction treatment 12-Step based? Shouldn’t it be more like 50/50?
Other findings of the 2020 Cochrane study received little-to-no press. As addiction pioneer Stanton Peele points out in his expert analysis, when looking at percentage of days abstinent rather than continuous abstinence the study concluded that “people in other interventions racked up, on average, just as many total days abstinent.” Why was continuous abstinence reported on so heavily rather than percentage of days abstinent? Is there any decent argument that continuous abstinence is somehow more desirable than percentage of days abstinent?
The results of the 2020 Cochrane study also showed that intensity of drinking was about the same in the first 12 months, but higher in AA than CBT and other interventions when people started drinking again after 12 months. The 2020 Cochrane study results seem to support the concept of the abstinence violation effect, and highlight a potential danger of focusing on continuous abstinence as the primary or sole measure of success in overcoming addiction. It is important to note that addiction treatment is arguably the only area in mental health where a 99% reduction in symptoms is considered failure. The time for the focus to shift from total abstinence to helping people build a rewarding life is long overdue.
A final issue worth noting about the 2020 Cochrane study is that the AA model examined does not parallel the AA experience of most members. The Cochrane study looked at manualized AA and Twelve Step Facilitation, which are generally completed one-on-one with a trained counselor. Most AA members complete the 12-steps with an untrained sponsor and do not follow the manualized protocol, making the Cochrane results difficult to generalize to the most common AA experience.
AA and 12-Step programs help many people and their dominance in US addiction treatment is a problem. The 2020 Cochrane results show that AA is more effective than CBT, can also help some people maintain continuous abstinence, and may be a factor in higher intensity drinking when continuous abstinence is broken. The focus on continuous abstinence as the best determinant of success in addiction treatment is a major factor in why the availability of various treatment approaches remains disproportionate to the needs of the consumer. Harm-reduction and moderation approaches are viable outcomes in addiction treatment, and the 2020 Cochrane study’s focus on continuous abstinence undercuts much needed efforts to broaden and expand access to a variety of treatment options.
