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Can 12-step mutual aid bridge recovery resources deficit?

Paralleling the heightened profile of abstinence-based recovery from addiction in UK national strategies (1 2) has been a rise in the profile of probably the best-known and most widely implemented programme for achieving this goal – the 12 steps of the various ‘anonymous’ mutual aid fellowships such as Alcoholics Anonymous (AA). They don’t suit everyone and – as this expert Findings review makes clear – other mutual aid models less reliant on a ‘higher power’ and abstinence have filled the gaps. However, 12-step approaches remain by far the dominant model.

For UK commissioners, mutual aid spearheaded by 12-step fellowships offers a way to reconcile diminished resources with the desire to get more patients out of treatment without precipitating relapse threatening lives, health, and communities. The interest at national level can be judged from the resources made available since around 2010 to aid implementation. How much has trickled down to local service level is unclear. Judging by a 2014 report on the alcohol-related content of joint health and wellbeing strategies from 25 English local authority areas – including 15 of the top 25 for alcohol-related harm – fostering mutual aid seems not to be a priority. However, when managers of adult drug and alcohol treatment services were surveyed in 2014/15, peer support including mutual aid groups were thought by nearly a quarter to have increased in availability since the previous year and by just 4% to have become less available, and most responding services actively promoted access by referral and by hosting or facilitating groups. It was however not specified whether these were free-standing groups open to anyone or (for example) peer support groups for users of the service.

Methodological Catch 22s impede unbiased evaluation

Nearly all the research on 12-step groups and allied treatments comes from the USA, but the US record – where the 12 steps are deeply engrained and widely accepted – is not necessarily a guide to their impact in societies like Britain.

For example, from the huge US Project MATCH alcohol treatment trial came the seemingly puzzling finding that 12-step therapists had been no more directive than therapists who implemented a motivational approach. Presumably as a result, unexpectedly these therapies had similar impacts on angry patients who react against direction. How could it be that practitioners of a codified set of steps – with prescribed beliefs about addiction, prescribed activities and prescribed ways to recover – were no more likely to lead, teach and instruct their clients than practitioners of a method designed above all to avoid being explicitly directive? Possibly the answer is that in the US context, and in particular with these patients, 12-step based therapy was ‘second nature’: there would be little need to direct and teach.

Another difficulty is that the classic randomised trial format fits mutual aid badly. Most fundamentally, participating in mutual aid groups is something someone does, not something done to them which can be expected to work regardless of whether they chose that route to recovery or embraced it once experienced. At a deep level that is, some say, true of psychosocial therapies in general, but with mutual aid it is the explicit essence. Researchers can randomly select people to be coerced by courts or employers to attend mutual aid groups, but cannot make them actively contribute to their own recovery and that of the other attendees, or make other attendees accept and interact productively with those forced to attend. And unlike ‘gated’ professional services, it is impossible to deny someone access to a free and open-access mutual aid network, and people prepared to deny themselves are not necessarily typical dependent drinkers or drugtakers. But without randomisation, results are vulnerable to the possibility that people who choose to participate in mutual aid groups do better than those who choose not to, just because they are keener to achieve abstinence rather than due to any impact of the groups – so-called ‘self-selection’ bias.

Reviews inconclusive

With just three randomised trials (all involving coerced attendees) among its collection of studies, a review published in 1999 synthesised the results of trials comparing AA groups against other approaches or no treatment at all. Findings from the three randomised trials suggested that people forced to attend AA do no better and possibly worse than when coerced instead into professionally run treatments or left to sort out their own ways of overcoming their problems. In contrast, the non-randomised studies in which (with one partial exception) alcoholics chose whether or not to attend AA meetings recorded statistically significant advantages over other treatments. This pattern of results suggests that AA looks better in some studies because those who attend are more motivated, and that people coerced into attending AA meetings might do worse than those coerced into other treatments, perhaps because existing members resent their presence and are under no professional or occupational obligation to try to engage the newcomers and promote their recovery from their drinking problems. However, the three randomised trials were deeply flawed as assessments of AA as usually accessed and attended, and in two of the trials methodological features meant they were poor indicators of relative impacts on drinking.

These two trials were omitted from a later review conducted under the rigorous Cochrane procedures, which included studies not only of patients allocated directly to 12-step groups, but to interventions to promote attendance at and affiliation to these groups. It found no convincing evidence that AA-based approaches were superior to other approaches at controlling drinking, but with just eight trials to go on, often trialling very different approaches with different comparators, evidence was lacking rather than conclusive.

If AA does work, it does so not primarily because of features which distinguish it from other approaches, but because of what it shares with those approaches. A review of how Alcoholics Anonymous works highlighted these shared mechanisms including heightening confidence that one can resist drinking, bolstering motivation for abstinence and commitment to recovery, developing coping strategies such as avoiding high-risk situations, and stronger social support. Particular importance was placed on “perhaps its most potent influence” – social group dynamics in the AA meeting, the broader fellowship, and social support. In contrast to these generic mechanisms found in other approaches, there was less support for spirituality, adherence to AA beliefs and philosophy, or following recommended AA practices.

Accounting for self-selection bias

Given the limitations of direct randomisation, the ideal is to mimic ‘randomisation’ by natural means – for example, to compare outcomes for drinkers who differ in their AA attendance because AA meetings are more or less available to them, not because they are more or less motivated and able to overcome their drinking problems. Three US studies have used statistical techniques to simulate this situation.

The first sampled patients encouraged to attend AA following 12-step based inpatient treatment. Standard analysis found a significant positive effect of attending the meetings. Though it remained, the effect was halved and became statistically insignificant when the study adjusted for self-selection. The second study instead recruited previously untreated alcoholics who had contacted the alcoholism treatment system via an information and referral centre or detoxification programme, and selected those who (apart from detoxification) did not go on to start professional treatment but might have attended AA groups. In contrast to the first study, it found that allowing for bias due to self-selection in to AA doubled its apparent positive effect on the severity of drinking. In the first study, self-selection bias had worked in favour of AA, possibly because promising clients most engaged with the 12-step inpatient programme continued to access 12-step support on leaving. When the second study investigated an untreated sample, the reverse was the case: perhaps appreciating their difficulties, patients least likely to moderate their drinking chose AA rather than attempting to go it alone.

The third and most recent analysis was able to capitalise on studies which had randomly allocated patients not to AA meetings, but to treatment interventions which did versus did not systematically promote AA attendance. The thinking was that extra attendance promoted in this way could not be due to the greater motivation or resources of the patients, so would offer an unbiased estimate of the impact of AA attendance on abstinence. As in the first study, when AA followed inpatient treatment, attendance made no extra contribution to abstinence. But across the remaining studies the results implied that going to an additional two AA meetings each week would be associated with an additional 3.3 days of abstinence per month. Though in some ways an advance on previous estimates, it seems possible that the presumed impact of attending more meetings was in fact a gradient reflecting how well patients responded to the AA-promoting intervention itself. The better they responded to it, the more meetings they would attend and the more they would remain abstinent, making it look as if meeting attendance cause the extra abstinence, when in fact both were caused by the professional intervention. One way to disentangle this would be to see if abstinence rates were similarly affected by the intervention when AA was simply unavailable. If the AA-promoting intervention still promoted the same extra degree of abstinence, it would indicate that attending meetings was not an active ingredient. However, such a study would seem a nonsense both to staff and patients, who would find themselves promoting or being encouraged to attend a non-existent resource.

Facilitating attendance

In respect to mutual aid, the main role of treatment services is to encourage and enable patients who want to and can benefit from this resource to access it, without undermining the independent mutual aid ethos. Particularly important for Britain is a US study which showed that 12-step philosophy can be de-emphasised during treatment, and the emphasis instead placed on encouraging patients to tap in to the social support offered by these groups – potentially important for people who find it hard to embrace this philosophy, but would benefit from repeated and extended contact with committed abstainers. For the relatively secular UK, the ‘higher power’ steps and references to God seem the least appreciated and most off-putting of the 12 steps, the more so in one study among drinkers in treatment (the majority held these views) than drug users. In this study almost half the drinkers said the 12 steps would deter them from attending AA/NA meetings.

The US study cited above is not the only one to have suggested that – if they prioritise this – treatment services can promote mutual aid attendance and thereby improve substance use outcomes for their patients. Perhaps the most influential of these studies randomly allocated 345 US patients starting non-residential treatment to standard or intensive referral to 12-step groups. Compared with patients who received standard referral, intensive referral patients were more likely to attend and be involved with 12-step groups and improved more on alcohol and drug use outcomes over the follow-up year. This was, however, a demonstration of what can be done in relatively ideal circumstances unlikely to be duplicated outside the context of a research project.

That study was broadly replicated in a UK inpatient addiction unit, a country where 12-step groups are less well known and intensive referral may have the scope to be more effective than in the USA. However, the referral option tried was considerably less intensive than in the USA and did not involve arrangements for a 12-step group member to accompany the patient to their first meeting. Especially when delivered by someone who had themselves recovered from addiction via 12-step groups, the single session substantially encouraged post-treatment attendance, but only modestly and insignificantly increased the proportion of patients who sustained abstinence from their main problem substance. The contrast calls in to question the degree to which in the UK context post-treatment 12-step attendance ‘artifically’ elevated by special efforts during treatment generates abstinence. Instead the pattern of outcomes seems consistent with attendance being largely a sign of the patient’s ability and determination to sustain abstinence rather than an active force in generating that ability and determination.

Gains in substance use reductions were also modest in Norway but they were statistically significant, roughly an extra four days of not using drugs and about the same for alcohol over the last 30 days of a six-month follow-up. This extra reduction was generated by an intervention to encourage 12-step group affiliation among patients completing inpatient detoxification, which had the intended effects of bolstering affiliation and (though not statistically significant) attendance after leaving the ward. However, total abstinence over the last 30 days of the follow-up did not differ and nor did the severity of drug or alcohol use problems.

Standing in the way of treatment services facilitating 12-step group attendance may be a conviction that this has to be left entirely to the choice of the patient. Around 2010 that attitude was evident in responses to problem drinking offenders in north east England. In most areas criminal justice agencies were not directly linked to self-help groups, and though information on Alcoholics Anonymous was available in most probation services, direct referrals were not made because it was felt offenders should attend “of their own volition”.

Running this search will help you appreciate the degree to which the worldwide popularity of the steps is matched by evidence of effectiveness. One thing to look out for is the basis on which 12-step approaches are compared with others. When abstinence is the criterion the gap is sometimes more apparent than when substance use reduction or problem resolution are the yardsticks. Abstinence-focused evaluation plays to the 12 steps’ aims and strengths, but abstinence does not tell the whole or only story about recovery.

Thanks for their comments on this entry to Keith Humphreys of Stanford University in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 26 June 2015. First uploaded 01 March 2011

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