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Contents

Computerised therapies: sacrificing effectiveness for wider access?

Acupuncture: potential value of a ‘theatrical placebo’

Can 12-step mutual aid bridge recovery resources deficit?


Computerised therapies: sacrificing effectiveness for wider access?

The prospect that computerised interventions could make help for problem substance use readily available to more people and for less money – with the promise of greater feasibility as internet access expands and becomes more convenient – has driven studies to test whether such approaches can retain the effectiveness of in-person interventions. If effectiveness is sacrificed, casting the net wider may not be worthwhile. Moreover, the idea that an automated response driven by a computer could help addicted patients overcome often desperate situations doesn’t quite sit right with everyone. Where is the humanity without the human-to-human contact? And where is the ‘therapy’ without the familiar cues of patient and practitioner? This reaction is in itself a reason why they might not work, because such therapies would fail to meet a basic criterion for effective psychosocial treatment, that it’s about what you do in that culture to get better – that to the patient, it looks like ‘treatment’.

Nobody is yet suggesting that computers can replace therapists for typical treatment populations, but further down the severity and complexity scale, there is growing evidence that computers and other forms of digital technology may add substance use reduction to its more familiar competencies. As web services permeate more of life including social and health-related activities such as dating, networking and distance learning, they too may take their place among culturally-accepted routes to overcoming unhealthy substance use.

Developing at a ‘fast pace’

Online interventions for gambling, drinking, and illegal drug-related problems have been “developing at a fast pace over the past decade”, with two distinct internet-based approaches emerging in the substance use literature: unguided stand-alone internet interventions; and internet interventions used as an add-on to conventional treatment. The former can support numerous substance users at the same time and have a low threshold for accessibility, while combined with face-to-face support, the latter offer more intensive treatment.

Overall, less is known about how (or how well) interventions work when provided entirely online. However, both approaches have demonstrated encouraging effects for nicotine, alcohol, and cannabis users in meta-analyses (1 2 3), with comparatively less known about their effects on users of opioids, cocaine, and amphetamines. Aiming to bridge this gap, a meta-analysis investigating the effectiveness of internet interventions in decreasing the use of opioids, cocaine, and amphetamines found that (free source at time of writing) they demonstrate small but significant effects in decreasing substance use among various target populations at the end of treatment and at follow-up assessments.

Another type of review, based on 18 eligible studies, found that evaluations of online interventions for drinking problems are more common than those for illegal drugs and gambling, and a large majority are delivered using a computer-based web platform, as opposed to a mobile platform (for example via an ‘app’ downloaded to a phone or tablet). Most are also based on motivational or cognitive-behavioural approaches, which are well-established therapeutic components in the field of addiction. In terms of effectiveness for people with problem drinking and/or drug use, more than three-quarters of the studies showed a short-term decrease in use that was maintained six months later, but only two studies included a 12-month follow-up. The participants in the studies were mostly adults between 30 and 46 years old (an age group presumed to be receptive to technology), with a high school education. While less than a quarter reported having previously consulted a professional for drug or alcohol-related problems, the majority presented with high risk or problem drinking and/or drug use. Outside the context of a trial, this profile was broadly replicated in a study of people accessing help for problem drinking via the internet, suggesting the results of trials may be applicable to people seeking help in the normal way.

While principles of cognitive-behavioural therapy are commonly found in computer-driven programmes, and have a high level of empirical support for the treatment of drug and alcohol use disorders in general, a phenomenon in research called the ‘implementation cliff’ means that a drop-off in benefit often occurs when interventions leave highly controlled (‘laboratory’) settings. In so far as this is due to the intervention becoming less well implemented, modern technologies may give scope to curb this by offering a flexible, low-cost, standardised means of disseminating cognitive-behavioural and other therapies in a range of novel settings and populations.

More than this, computerised support potentially opens up new opportunities for a range of intervention types, from education and information, to screening and brief interventions, feedback, and relapse prevention, without the stigma embedded in conventional treatment spaces, and to people in a range of circumstances, from those referred by helping professionals, to those motivated to pursue ‘self-help’ in private.

From ‘self-help’ to personalised professional help

Online self-help is an established resource for mental health problems within the UK National Health Service (NHS). Various services are already approved, with evidence of comparable outcomes between self-help therapies and face-to-face therapies for some types of mental health problems and disorders. In particular, the National Institute for Health and Care Excellence (NICE) recommends computerised cognitive-behavioural therapy for the treatment of depression, generalised anxiety disorder, and panic disorder – not just an interesting fact to note about a parallel field, but a resource that could be tapped into for the nearly three-quarters of clients of Britain’s drug and alcohol services suffering from mental health problems.

For substance use problems specifically, self-help websites or online resources are more likely to attract people lower down the severity scale ( image), and with more of the ‘recovery capital’ needed to lift themselves out of trouble without therapist intervention, such as problem drinkers who retain a stake in mainstream society in the form of relationships, jobs, families, and a reputation to lose. They may also complement national campaigns such as Dry January (previously run by the charity Alcohol Concern, which has now merged with Alcohol Research UK), which in the UK engaged an estimated five million people in 2017. However, experts were divided on “whether the initiatives help to change behaviour in the long term, and whether they were the right approach for many who regularly overindulge”.

Moving into the realm of more dynamic or personalised support, brief advice following a short screening questionnaire is a broadly available first step or next step for non-dependent but clearly excessive drinkers. Here a computerised response has a clear role. Users are unlikely to seek face-to-face help, an inexpensive and short intervention would seem in line with the (non-)severity of their problems, and more extensive help might even be rejected as ‘over the top’.

A systematic review of ‘digital’ brief interventions from the Cochrane collaboration (which helps to facilitate evidence-based choices about health interventions) found that personalised advice using computers or mobile devices overall helps reduce heavy drinking better than doing nothing or providing only general health information, and, from a small pool of studies, may match the effectiveness of face-to-face conversations with doctors or nurses.

The 57 studies reviewed included people in workplaces, colleges or health clinics, as well as internet users. Information was insufficient to determine if advice was better from computers, telephones or the internet to reduce risky drinking, or to confirm which pieces of advice were most important. However, advice from trusted people such as doctors seemed helpful, as did recommendations for people to think about specific ways they could overcome problems that might prevent them drinking less, and suggestions about things to do instead of drinking.

Interventions across the severity scale

In Germany, a study testing whether people with different day-to-day drinking patterns benefitted differently from two computerised brief alcohol interventions, randomly allocated 1,243 job-seekers who were ‘at-risk’ drinkers to: (1) an intervention tailored to their motivational stage, (2) a non-stage tailored intervention, or (3) to a control group receiving assessment only. Four distinct day-to-day drinking patterns were observed. Those whose consumption was at the lower end were found to benefit more from stage-tailored brief alcohol interventions than non-stage tailored brief alcohol interventions and assessment only. As the authors identified, this is one core target population for brief interventions that is typically not reached. A key difference between the stage-tailored and non-stage tailored interventions was that the former reserved feedback about self-regulating drinking for those in later motivational stages of change, while the latter encouraged all participants to apply self-regulatory strategies. In line with the stages of change model (and broader transtheoretical model of behavioural change), the findings indicated that people in earlier motivational stages improved most when not encouraged to use self-regulatory strategies.

Prominent Dutch studies have reviewed evidence of computer-aided interventions across the severity scale, testing computer-delivered therapy via ‘text–chat’ conversations with a real therapist for problem and often dependent drinkers, an online cognitive-behavioural programme for excessive drinkers, and, at the lowest level of intervention intensity and problem severity, a 10-minute web-based brief intervention for risky drinkers.

For the typically very heavy and multiply problematic drinkers in the first study who volunteered for it in order “to reduce [their] alcohol intake or quit drinking”, text chats with a real therapist had the greatest and most lasting impact, but a fully automated process also worked substantially better than being placed on a waiting list and could be made more available with less resources. The less severe but still on average heavy drinkers in the second study who engaged with a web-based self-help programme and completed a follow-up survey had more often reverted to non-risky drinking than a control group. The still less heavy but nevertheless risky drinkers in the third study had been identified through screening or responded to ads and been allocated not to a self-help programme but a computerised version of a brief, single-session intervention. Again those who agreed to join the study and completed follow-ups had more often reverted to non-risky drinking than a control group.

Based partly on these results the Dutch team devised a mathematical model which simulates the health gains and costs of incorporating these new technologies into a health care system for problem drinking. For the Netherlands, the results suggested national health would improve and/or costs would be reduced if online brief interventions and therapy were added to or replaced conventional alcohol-related health care. However, the weak link in all the studies and therefore in the simulation was that few people joined the studies and completed follow-ups, raising doubts over whether impacts in these presumably atypical minorities would be matched on a larger scale.

The concern that routine implementation across a broad population might prove less effective than among the minority who join trials seemed validated in studies of computerised brief interventions in New Zealand and Sweden, seen as the most real-world trials to date of this type of intervention among college students. In both cases the study and/or the intervention appealed to only a minority of students and impact was at best slight and generally not statistically significant.

In finding (at best) small effects, these trials were typical of trials of computer-based brief interventions among students. Published in 2015 a study which amalgamated results from trials of (typically brief) computerised interventions found larger and more lasting drinking reductions among general adult samples of risky drinkers than among college students, among whom there was just a 12g per week reduction six months after intervention but no significant reduction after a year. Another review corroborated this disparity, but also argued that in some studies drinking amounts were so skewed that using the average to characterise them was misleading. After accounting for this the findings changed, and among students there was now no statistically significant reduction in drinking due to the interventions.

Stronger findings across non-college adult samples may be because, rather than for incentives or course credits, they join studies and access internet alcohol intervention sites in order to control a level and pattern of drinking which worries them. Drinking on average more heavily than students and having had longer to experience the ill effects, they have more reason and more scope to cut back. In a Canadian study it was only the higher-risk half of risky drinkers among a general adult sample who reduced their consumption and alcohol-related risk levels after being given access to a web-based brief intervention. Drinking less overall, and in a setting where heavy drinking is an accepted rite of passage and may be seen as a passing phase, it seems likely that students have less incentive to act on information and advice which would lead older and heavier drinkers – responsible for families and jobs, and facing the possibility of chronic diseases as they age – to cut back.

Adding another string to the bow of relapse and overdose prevention

Most existing educational interventions for preventing opioid overdose focus on the provision of naloxone and are conducted in-person, presenting certain logistical barriers that may limit wide-spread implementation. One study developed and evaluated an easily-disseminated opioid overdose educational intervention and compared computerised versus pamphlet delivery. While the computer-delivered intervention may have advantages in terms of cost and reach as a delivery method, it was not found to have any benefits over pamphlet delivery on the outcomes measured. Knowledge increased across the board and was well-sustained at the one and three-month follow-ups among people receiving the computer and written pamphlets, and there was a significant reduction in the risk factor of ‘using opioids while alone’.

Testing the acceptability of an opioid relapse prevention intervention, a small US study found conflicting evidence supporting an automated text message providing relapse prevention support for treatment-seeking individuals with opioid use disorder discharged from the emergency department. Patients seeking care were invited to enrol in PIER1 (which stands for Preventing and Interrupting Early Relapse), after which they received text messages including instructions to text the keyword ‘crave’ for immediate support, and to text ‘quit’ to stop the programme at any time. Every morning thereafter, participants received a text message aimed at increasing their positive thoughts about success in recovery, for example:

“Begin by visualizing yourself as a nonuser. Think about what that person would look like, act and do. You may only have to change a little to accomplish this!”

Twice a day, participants were texted a query asking them to rate the severity of their cravings. Based on this, they received feedback about their level of craving, and further queries about whether physical withdrawal symptoms, mood or anxiety, or immediate environment (including people) may be contributing to cravings, followed by tailored advice. Every evening participants were asked whether they had used any opioids in the past 24 hours. If participants responded that they had not used, they received a positive feedback message. And if they had used, they received a message attempting to limit the break in abstinence, followed by a query about whether they would be willing to commit to a goal to stay sober for the next 24 hours. For all PIER1 queries, if a participant did not respond within one hour, they received a prompt. If a participant did not respond within one hour of the re-prompt, the window for responding closed. Any text sent by participants outside the two-hour window prompted the reply message, “We are unable to respond to you right now. If you have a medical emergency, please dial 911 or contact your doctor.”

The overall response rate to text message queries was low (30%), suggesting to the researchers that “participants did not have the ability or interest in interacting with the program in the context of their daily lives”. One explanation was that some treatment programmes didn’t allow private mobile phone use.

Although from the outside the number of messages and expected responses per day seemed potentially onerous, those who participated and interviewed afterwards found it easy to use:

“… you can just text a couple words and you don’t have to put people in your business or like get really stressed out to the point where it’s a conversation.”

Furthermore, the feeling of connection with someone was almost universal – important among this cohort as social ties were typically frayed or non-existent. Overall, the findings indiciated that the intervention could be useful, but that its acceptability would likely be enhanced through personalised ‘human’ support including the ability to communicate through text messaging with another person about their struggles.

Run this search to get more of a feel for what we can expect from digital interventions.

Last revised 04 April 2018. First uploaded 01 May 2012

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Acupuncture: potential value of a ‘theatrical placebo’

Acupuncture is a key component of traditional Chinese medicine, and practiced by some professionals such as those in the Acupuncture Association of Chartered Physiotherapists under the umbrella of evidence-based western medicine. While there are certainly many patients receptive to complementary and alternative therapies, the question for this hot topic is whether these therapies can or should be recommended within mainstream healthcare spaces for their effectiveness in treating acute substance use problems and disorders, or relieving symptoms of withdrawal.

How acupuncture works

An extract from the NHS choices website

“Western medical acupuncture is the use of acupuncture following a medical diagnosis. It involves stimulating sensory nerves under the skin and in the muscles of the body.”

“This results in the body producing natural substances, such as pain-relieving endorphins. It’s likely that these naturally released substances are responsible for the beneficial effects experienced with acupuncture. […]”

“Traditional acupuncture is based on the belief that an energy, or ‘life force’, flows through the body in channels called meridians. This life force is known as Qi (pronounced ‘chee’).”

“Practitioners who adhere to traditional beliefs about acupuncture believe that when Qi doesn’t flow freely through the body, this can cause illness. They also believe acupuncture can restore the flow of Qi, and so restore health.”

In medicine generally, whether acupuncture can be considered a bona fide treatment has been hotly contested. Cynical of the benefits of acupuncture, pharmacologist David Colquhoun and neurologist Steven Novella argued in 2013 that “the benefits of acupuncture [were] likely nonexistent, or at best … too small and too transient to be of any clinical significance”; and in what became the headline message of their editorial, that acupuncture may be “little or no more than a theatrical placebo”.

The pro-acupuncture counter-argument published in the same journal, written by Shu-Ming Wang and colleagues, concluded that “Instead of criticizing this ancient art with arguments culled from modern medicine and science, physicians and scientists should try to integrate current knowledge into this ancient, yet ever-evolving practice so it may be used to treat conditions for which pharmaceutical interventions are ineffective and/or potentially dangerous.”

This debate is also present within substance use treatment – when there is no accepted medication, and no specific psychosocial therapy for the particular problem presented by a client, one solution has been to offer complementary therapies, among which acupuncture (usually at sites in the ear) is by far the most widely used. A case in point is those dependent on cocaine, for whom acupuncture is a popular alternative, though in fact just about any psychosocial therapy helps some of these clients some of the time. It is also commonly used to ameliorate withdrawal symptoms from drugs including alcohol and heroin.

When sham treatment is as good as the ‘real’ thing

However, the faith placed in acupuncture by services and patients appears contradicted by research, which generally finds that whether the needles are placed where they are supposed to be or at ‘sham’ sites (see box describing how acupuncture works) makes little or no difference. For example, in patients withdrawing from alcohol, nicotine or drugs, acupuncture was found no better at reducing withdrawal-associated anxiety than acupuncture needles inserted at sham sites, or a relaxing experience in the same setting as acupuncture was provided. In other words, if acupuncture does work, it seems it may not be working in the way it is supposed to (again, see box).

The study above tested the National Acupuncture Detoxification Association protocol, developed in the 1970s to “help addicts with their recovery dealing with trauma, anxiety, depression, irritability and cravings”. The following extract from the UK version of the website describes the protocol:

acupuncture

An image depicting the National Acupuncture Detoxification Association acupuncture protocol and ‘sham’ points

“The process involves the gentle insertion of up to five fine, single use, [sterilised], stainless steel disposable needles into specific energetic points in the outer ear. No electrical stimulation is used.”

“The five ear points:
  1. Sympathetic – calms the nervous system and helps with overall relaxation.
  2. Shen Men / ‘Spirit Gate’ – reduces anxiety and nervousness.
  3. Kidney Point – for calming fears and healing internal organs.
  4. Liver Point – for detoxification, blood purification, and to quell aggression.
  5. Lung Point – promotes aeration and helps clients let go of grief.”
“The outer ear acts like a switchboard that sends impulses to the brain, which stimulate the release of endorphins, lowers stress and induces relaxation.”

Traditionally, studies comparing ‘real’ versus sham acupuncture points (see image above right) have kept the other conditions of treatment the same, including the type of needle used – the only difference being where the needles are placed. More recently, other types of needles have been used for the control group, for example using a needle that “has a blunt tip and achieves no skin penetration”.

Similar improvements in ‘real’ and sham acupuncture suggest that acupuncture may only be having a ‘placebo effect’. Of course, as the NHS website acknowledges on its page The placebo effect and complementary and alternative medicine, “improvement in a health condition due to the placebo effect is still improvement, and that is always welcome”. Nonetheless, “it is important to remember that for many health conditions, there are treatments that work better than placebos [… and by choosing] a treatment that only provides a placebo effect, [the patient] will miss out on the benefit that a better treatment would provide.”

When in 2011 the evidence for acupuncture in relation to alcohol treatment and withdrawal was reviewed for the UK’s National Institute for Health and Care Excellence, the verdict reached for this official advisory body was that conflicting evidence meant no recommendation could be made, except for more research. Currently, acupuncture is only a recommended treatment option for chronic tension-type headaches and migraines, though it is also used for treating other types of pain. More research too was called for in 2006 when the respected Cochrane collaboration published an assessment of whether acupuncture at sites on the ear has helped in the treatment of cocaine dependence. The unusually definite conclusion was, “There is currently no evidence that auricular acupuncture is effective for the treatment of cocaine dependence.” However, evidence was limited and from methodologically poor studies, so neither could it be said for sure that acupuncture was ineffective.

More up-to-date reviews have yielded positive results, but the small number of studies on which they were based fundamentally limits the strength of the conclusions that can be drawn. This was the case with a meta-analysis combining the results of studies published up to August 2016. It found a significant difference in reductions of clinical symptoms such as craving and withdrawal between the acupuncture and control group in patients with alcohol use disorder, where the control groups were variously given placebo needles or sham acupuncture via needles inserted into nonspecific points, or a different type of intervention altogether (eg, relaxation or transdermal stimulation). Another review reported the potential for acupuncture to reduce alcohol craving and withdrawal symptoms (to a statistically significant degree), but this was based on only two studies (of the 15 randomised controlled trials assessed). Similarly, a 2018 review of non-human studies (involving rats) found evidence that acupuncture may effectively reduce alcohol consumption, reduce alcohol withdrawal syndrome, and rebalance neurotransmitters and hormones associated with cravings and consumption. However, the key consideration of this review was the application of acupuncture to alcohol use disorder, and it is questionable whether the conclusions could be extrapolated from rats to humans as rats cannot have what we understand as ‘alcohol use disorder’. Finally, a systematic review reported that results in favour of acupuncture for withdrawal/craving and anxiety symptoms are limited by low-quality bodies of evidence, and that overall, available evidence suggests no consistent differences between acupuncture and comparators for substance use.

Placebo effect can provide a platform for active ingredients

In the broader context of trying to support people experiencing problem drinking and drug use through their recovery, offering something concrete like acupuncture – even if in reality this is ‘only’ a placebo – may attract people to services, and, as some studies have suggested, help retain patients in treatment by engaging clients and staff in something they believe is worthwhile. If this is the case, acupuncture could indirectly improve outcomes by increasing the patient’s exposure to treatment’s active ingredients. These considerations may explain why despite no convincing evidence of efficacy (ie, how well something works under highly controlled conditions), acupuncture has featured in many of the treatment plans developed by local partnerships responsible for commissioning treatment services in England. It will take more and different kinds of studies to determine whether even if all they are buying is a possible placebo effect, it remains a worthwhile investment.

Is there something valuable here which simply has not yet been proven to work due to few and sometimes methodologically weak studies, or is trying to find proof a dead end because the technique is simply ineffective? For the evidence to date run this hot topic search.

Last revised 16 April 2018. First uploaded 01 November 2010

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Can 12-step mutual aid bridge recovery resources deficit?

The profile of abstinence-based recovery has been heightened in recent UK national strategies (1 2 3), with renewed attention falling on one of the best-known and most widely implemented programmes for achieving this goal – 12-step ‘anonymous’ mutual aid fellowships such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). This hot topic keys into what qualities have preserved 12-step as the dominant model, despite its reliance on a ‘higher power’ and abstinence clearly not suited to everyone, what conclusions can be drawn about its effectiveness given the tensions inherent when ‘faith meets science’, and the extent to which confidence in the 12 steps comes from “consistency with established mechanisms of behavior change” as opposed to some of its more distinct components.

The 12 steps as described by Alcoholics Anonymous

  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.
  4. Made a searching and fearless moral inventory of ourselves.
  5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
  6. Were entirely ready to have God remove all these defects of character.
  7. Humbly asked Him to remove our shortcomings.
  8. Made a list of all persons we had harmed, and became willing to make amends to them all.
  9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
  10. Continued to take personal inventory and when we were wrong promptly admitted it.
  11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
  12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

Faith in one’s recovery

The 12 steps at the heart of Alcoholics Anonymous ( described here) have an overtly religious tone, with seven of the steps “refer[ring] either to a deity – ‘God,’ ‘Him’ or ‘a Power greater than ourselves’ – or to religious practices such as prayer.”

While the umbrella group for Alcoholics Anonymous in the UK acknowledges the programme has its origins in a Christian group, it says there is “only one requirement for membership and that is the desire to stop drinking. There is room in AA for people of all shades of belief and non-belief.” And, it does seem that there is some appetite for this application of the principles across the spectrum.

In the United States, where the programme is a more established feature of addiction treatment, the New York Times covered the growing phenomenon of “Alcoholics Anonymous, Without the Religion”. At the time of publication, there were around 150 groups nationally which appealed to agnostics, atheists, and humanists alike. People were reportedly creating their own secular versions of the 12 steps, for example, instead of needing divine assistance for recovery, needing “strengths beyond our awareness and resources to restore us to sanity”, as well as creating secular traditions within the groups themselves – for instance, instead of clasping hands and reciting the Lord’s Prayer (or the Serenity Prayer) at the end of the session, reciting together, “Live and let live”.

Religion is one of several “controversial” aspects of 12-step programmes which research has identified as a “point of resistance” among some people with drug and alcohol problems, while recognising that for some belief in an external higher power may be just what is needed to propel them towards change (for which see the story of Bill Wilson who went on to co-found Alcoholics Anonymous). However, religion being a potential point of resistance is not necessarily the same as it being a major obstacle to participation.

A US survey of outpatient treatment services between 2001 and 2002 found that barriers to 12-step participation were more often perceived to be motivation, readiness for change, and feeling the need for help, than religion or accepting powerlessness over addiction – though around half of both still agreed that “the religious aspect of 12-step groups is an obstacle for many” and that “the emphasis on powerlessness can be dangerous”.

Whether similar findings would emerge in the UK is unclear. Certainly in one study, references to a ‘higher power’ and God seemed the least appreciated and most off-putting of the 12 steps, and more so among drinkers in treatment than drug users. In this study almost half the drinkers said the 12 steps would deter them from attending AA/NA meetings.

Comparing the importance of religion in the US and UK in 2003, a Gallup public opinion poll found that 60% in the US felt religion was very important (and 23% fairly important), but only 17% (and 30%) in Great Britain. More recently the proportion of the UK population identified as having no religion in the British Social Attitudes survey reached 53% (up from 49% in 2014 and 46% in 2011), outnumbering the 43% who defined themselves as Christian.

What (else) defines the 12-step experience?

The key tenets of Alcoholics Anonymous are sometimes referred to as the ‘AA six pack’: don’t drink, go to meetings, ask for help, get a sponsor, join a group, and get active.

As well as these, which give the gist of of how the 12 steps are implemented at the individual level, are the ‘12 traditions’, describing the operating principles of AA as an institution (reproduced in full below; unfold supplementary text Unfold supplementary text). Endorsed at an international convention in 1950, the 12 traditions begin with a statement that exemplifies the importance of maintaining an identity of group ‘fellowship’ within AA:

“Our common welfare should come first; personal recovery depends upon AA unity.”

This focus on the ‘social’, the ‘collective’, and ‘mutual aid’ is one of the defining features of 12-step programmes, not just because there is evidence to suggest that it may be one of the key “mechanisms of action” in deriving positive outcomes from 12-step programmes, but because it characterises the process or experience of recovery from the perspective of members.

Speaking to members in the US to mark the 75th anniversary of AA in 2010, the BBC addressed “What happens in an Alcoholics Anonymous meeting?” Dismissing the belief in a higher power as being just about religion, one member said: “The higher power is not just the god of your understanding, it is the people in the room,” another that “It works because everything I attempted to do about drinking by myself never worked … By coming into AA I was able to get support to not drink – people who think exactly like me, that common bond.”

In the UK, an academic case study documented the experience of a young adult participating in 12-step programmes, and what recovery looked like for him two, six, and 10 months down the line. Throughout this time, AA and NA were a strong feature of his social life; even when his frequent attendance at meetings started to decline, the programme still provided a key social network, with all of his friends members of the programme at the 10-month mark:

“I’ve got a lot of things you know like people in the Fellowship helped me to move so you know, I go out for a meal after the meeting every Tuesday with people from the Fellowship from AA, and I go out for coffee after the meeting tonight [at NA] … I do sort of participate in the social aspect of it.”

Initially, ‘James’ attended NA and AA meetings four to five days a week, dropping down to three to four times a week at six months, and then hovering around four times a week at ten months (though mostly NA attendance at this point). Although in general there can be considerable variability in AA meeting attendance during early recovery, research finds that attendance tends to be higher during the early days of recovery, then decreasing in the following months to an estimated average of three meetings per week.

Long-term engagement with 12-step programmes is critical to AA philosophy that “addiction [is] a disease that can be arrested but never eliminated”. With regard to AA, this is embedded in the accepted language for talking about alcoholism and accepting the identity of alcoholic (ie, ‘Once an alcoholic, always an alcoholic’), and eventually – if someone is willing to “face the problem honestly and try to do something about it” – the qualified identity of ‘recovering alcoholic’.

“We understand now, that once a person has crossed the invisible line from heavy drinking to compulsive alcoholic drinking, they will always remain alcoholic. So far as we know, there can never be any turning back to ‘normal’ social drinking. ‘Once an alcoholic – always an alcoholic’ is a simple fact we have to live with.”

In the above case study, James’ understanding of recovery changed over time. To begin with he offered a description aligned with the AA story of recovery, but then went on to create his own story – one that was more positive and complemented his evolving worldview. From the authors perspective this illustrated that, although official AA literature can be quite prescriptive about what addiction and recovery mean, it is possible for people to construct their own interpretations and way of making sense creatively and meaningfully.

Facilitating attendance

In respect to 12-step 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.

However, given the constraints faced by providers in non-speciality settings, including a lack of training on substance use disorders and few resources available for referring patients, many professionals in medical, mental health, and social service settings feel ill-equipped to adequately or fully address the issue, and resort to recommending readily available and free services such as 12-step self-help groups even when they are not convinced these programmes would be effective or that the client would go.

Potentially filtering down into client perceptions of the validity of the 12-step approach, interviews conducted with patients who had a diagnosis of alcohol dependence one year after entering community alcohol treatment services in three London boroughs revealed that more than half had experienced 12-step groups such as AA, but some described being ‘pushed’ into them, and overall there was an impression that AA was “second class to ‘treatment’ or not part of the legitimate treatment services available”.

Relevant to 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.

This is not the only study 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.

These findings were broadly replicated in a UK inpatient addiction unit, 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 ‘artificially’ 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”.

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.

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, these therapies unexpectedly 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 may also be 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 by random allocation 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.

Reviewing literature on AA’s effectiveness in its totality, and organising the studies according to six key criteria for establishing cause and effect, one paper aimed to help readers judge for themselves whether the Cochrane Review was, on balance, correct in concluding that there is no experimental evidence of AA’s effectiveness:

  1. Strength of association: rates of abstinence were approximately twice as high among those who attended AA.
  2. ‘Dose–response’ relationship: higher levels of attendance were related to higher rates of abstinence.
  3. Consistency of association: found across different samples and follow-up periods.
  4. Demonstrating the effect followed the influence: prior AA attendance was predictive of subsequent abstinence.
  5. Specific effects: evidence weakest when held to the standard of ruling out other explanations for abstinence.
  6. Plausibility: the ‘active ingredients’ predicted by theories of behavioural change were evident at AA meetings and through the AA steps and fellowship.

Only two studies provided strong proof of a specific effect from AA or ‘12-step facilitation’ (which introduces clients to the 12-step philosophy and support system), but this may have been due not to AA, but to the treatment programme which promoted attendance at AA groups: the outpatient arm of Project MATCH (with effects at one and three years) (1 2); and the intensive-referral condition in another trial (with effects for abstinence at six months and one year).

Reviews inconclusive

A review published in 1999 synthesised the results of trials comparing AA groups against other approaches or no treatment at all. Finding just three randomised trials – in general the ‘gold standard’ research method, but in this case all involving coerced attendees – among its collection of studies, the results 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) alcohol clients 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, and recommended that people considering attending 12-step groups should be made aware of the lack of rigorous evidence on their effectiveness. But with just eight trials to go on, often trialling very different approaches with different comparators, evidence was lacking rather than conclusive. Due to “a flurry of additional empirical investigations” since the 2006 review, the need for an update was identified and expounded upon in a 2017 protocol.

If AA does work, it is likely that 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 strengthening 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.

The social “mechanisms of action” work by contributing to a shift in one’s social network, with a reduction in the number of individuals who support drinking and an increase in those who support abstinence. This is accompanied by a decrease in exposure to drinking-related activities (and cues that induce craving), as well as an increase in non-drinking activities, belief that abstinence is achievable, and rewarding social relationships.

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 meetings are more or less available to them or for other extraneous reasons unrelated to drinking, not because they are more or less motivated and able to overcome their drinking problems. Three US studies have used statistical techniques called an ‘instrumental variable’ analysis to simulate this situation.

The first capitalised on the relative availability of AA meetings to patients encouraged to attend following 12-step based inpatient treatment. Standard analysis found a significant positive effect of attending the meetings. Even after adjusting for other factors, patients who went on to attend AA in the three months after leaving the detoxification centre were almost four more likely to have remained abstinent. Though it remained, at 1.7 times more likely to be abstinent the effect was halved and became statistically insignificant when adjusted for self-selection. The adjustment relied on the fact that most of the sample were not in a position to drive themselves to meetings and a minority did not live in a town with an AA group. Both factors affected whether patients attended the groups but were presumed to have no direct impact on abstinence – the only effect they could have, it was thought, was via influencing attendance. Unfortunately this assumption was not tested by examining the data, and it is not hard to think of ways both factors could be related to drinking – for example, via car owners having greater economic resources and more to lose from not sustaining abstinence, and via towns with AA groups having a different drinking culture to those without. The study also found no extra abstinence due to attending more meetings, bolstering the impression that attending AA groups had little effect.

A second study, which also used the instrumental variable methodology, instead recruited previously untreated alcohol clients who had contacted the alcoholism treatment system via an information and referral centre or detoxification centre. Instead of abstinence as an outcome, it averaged the severity of drinking in each of the last six months of a one-year follow-up period, and related this to AA attendance in the previous six months. Drinkers selected for the analysis were those who (apart from detoxification) did not go on to start professional treatment, many of whom nevertheless attended AA groups. In this study the factors relied on to sift AA’s impacts from those of self-selection were how serious a problem the participant considered their drinking, a tendency to cope with problems by seeking information/advice, and the participant’s sex. As hoped, all three were related to whether the participant attended AA meetings, but not to the severity of their drinking as assessed at the one-year follow-up. In other words, they only affected drinking in so far as they promoted AA attendance. In contrast to the study described above, it found that using these factors to eliminate bias due to self-selection into AA doubled the strength of its association with reduced 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 this second study investigated an untreated sample, the reverse was the case. Perhaps appreciating their difficulties, patients least likely to be able to avoid drinking chose AA rather than attempting to go it alone without treatment and without the support of a mutual aid group.

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.

The policy backdrop in the UK

For UK commissioners, mutual aid offers a way to reconcile diminished resources with the desire to get more patients out of treatment without triggering a relapse and consequently threatening lives, health, and communities. The 2017 Drug Strategy described peer support as an “essential component of effective recovery”, referencing “well-documented” evidence for the efficacy of mutual aid. Outlining the nation’s steps going forward, the strategy said that Public Health England will continue to develop, promote and support the implementation of its mutual aid toolkit (work up to 2015 is documented here), and explore the potential of online mutual aid groups (particularly useful in sparsely populated rural areas).

The interest at a national level can be judged from staff engagement and staff 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.

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 a previous version of 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 11 April 2018. First uploaded 01 March 2011

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