Is Alcoholics Anonymous Religious, Spiritual, or Neither? Review Finds AA Effective, But Not In the Way You Think
Alcoholics Anonymous (AA) is a ubiquitous recovery mutual-help organization that continues to arouse controversy, in part because of the programs spiritual orientation.
WHAT PROBLEM DOES THIS STUDY ADDRESS?
Alcoholics Anonymous (AA) is a world-wide recovery mutual-help organization. While at one time high-quality research on AA was scant, the 1990s saw an explosion of AA research after the United States’ Institute of Medicine called for more studies on AA’s effectiveness and its mechanisms of behavior change. This paper reviews the religious/spiritual origins of AA and explores findings from the past 25 years of AA research on its effectiveness and mechanisms of behavior change.
HOW WAS THIS STUDY CONDUCTED?
The author conducted a literature review, summary and synthesis of studies examining the effectiveness of AA, and AA’s mechanisms of behavior change.
WHAT DID THIS STUDY FIND?
Does AA really confer causal benefits?
- Results from numerous studies (including randomized-controlled trials, quasi-experiments, instrumental variables and propensity score-matching studies, as well as numerous statistically controlled naturalistic longitudinal studies) provide consistent results pointing towards clinically meaningful benefit and cost-effectiveness resulting from AA participation.
- Even when compared to gold-standard treatments such as cognitive behavioral therapy (CBT), twelve-step facilitation — in which treatment providers guide patient participation in AA—tends to produce as good, or better, alcohol use outcomes, particularly if one looks at sustained abstinence and remission.
- Notably, though twelve-step facilitation is not ‘AA’, per se (rather it is a clinical approach that aims to stimulate AA participation), when studies have been conducted to determine why twelve-step facilitation often produces better outcomes than treatments like cognitive behavioral therapy, it is found that it is because of the greater AA participation among patients.
What are the mechanisms through which AA is thought to support recovery?
- As a program, AA suggests it supports recovery through helping members cultivate spirituality and related practices as a new way of living. A number of methodologically rigorous studies support this idea. It appears for many AA members AA’s ability to increase spiritual practices is indeed a mechanism through which AA benefits their recovery. Additionally, AA participation and, specifically, increased spirituality have been shown to explain lower depression among individuals with alcohol use disorder.
- AA members also cite reduced selfishness/self-centeredness and reduced anger/resentment as key benefits derived from AA participation, however, research has not supported these assertions.
- Rigorous studies simultaneously assessing multiple mechanisms of behavior change suggest AA confers benefit through multiple mechanisms simultaneously but, in particular, through facilitating helpful social network changes (e.g., by helping people drop heavy drinkers from their social networks and adopt abstainers and recovering people into their social network) and, by boosting people’s confidence in their ability to remain sober when faced with high risk social situations or when feeling down or angry. It also has been shown to reduce craving and impulsivity. In other words, for many individuals AA provides a number of pro-recovery benefits.
- Interestingly, the relative importance of these mechanisms was also found to differ depending upon whether one had higher or lower addiction severity, was a man or a woman, and young or old. Specifically, those with lower addiction severity, on average, tended to benefit from AA almost entirely through social mechanisms. This was also true to a large extent for the more severe participants, but these participants also benefitted by AA’s ability to mobilize changes in spirituality/religiosity and by helping participants to cope with negative emotions without drinking.
- Men tended to benefit much more from AA through its ability to help them cope with high-risk social drinking situations; this was also true for women, but to a much lesser degree. For women, AA appears to lower their risk of relapse to drinking by boosting their ability to cope with negative emotions.
- Young adults benefitted more by AA helping them to drop heavy drinkers from their social networks but, compared to older adults, they were less likely to benefit from AA’s ability to help them adopt abstainers/low-risk drinkers. This may because there are less young people in AA so they can’t adopt these new sober friends into their networks as older adults.
- Overall, findings from the studies reviewed by the author suggest that AA helps different people in different ways, and that people use AA differently to help them to cope with the different challenges they face in their particular life-contexts at particular phases of their recovery.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
The author notes that the quasi-religious overtones of AA continue to raise skepticism and concern in the popular media and scientific arena. Evidence now exists, however, demonstrating that AA is an effective clinical and public health ally that aids addiction recovery through its ability to mobilize therapeutic mechanisms similar to those mobilized in formal treatment, but is able to do this for free over the long term in the communities in which people live. To dismiss AA superficially as a potentially effective addiction recovery support option on the grounds that it is religious or spiritual and therefore unscientific is inconsistent with the body of rigorous research accumulated during the past 25 years.
- While many scientifically rigorous studies now exist helping to clarify the mechanisms through which AA confers recovery benefits, there is still much to learn about these mechanisms.
- Even the most sophisticated studies reviewed in this paper were only able to explain 50% of the direct effects of AA on alcohol outcomes, leaving the other half unexplained; even less was explained in young adult samples. This means there likely other mechanisms through which AA confers benefit which are not currently explained. Further research is needed to understand these other mechanisms as well as how the importance of these mechanisms may differ across different individuals.
- There is limited data on the dynamic nature of the mechanisms of behavior change in AA. That is, the ways in which individuals benefit from participation in AA over time are likely to shift in nature and magnitude as individuals progress in recovery and mature. This also needs further study.
- For individuals & families seeking recovery: Evidence for AA’s effectiveness is strong. Although AA is a spirituality-based program, it works through a number pathways. As such, individuals may benefit from AA participation regardless of their spiritual leanings.
- For scientists: The models explaining AA’s mechanisms of behavior change require further specification. Work is needed that more deeply explores the underlying mediators influencing AA’s effectiveness, as well as for whom, and under what conditions AA works best. Greater knowledge in this regard could inform the nature of recovery processes more broadly and enhance recovery management interventions.
- For policy makers: AA offers effective, free and widely available recovery support for individuals with alcohol and other substance use disorders. In the context of soaring healthcare costs, AA offers closest thing we have to a free lunch. Moreover, in spite of it being free and non-professional, AA appears to confer its benefits through similar mechanisms to clinical interventions. Supporting the dissemination of resources that link people to AA is likely to have public health benefit. Additionally, funding is needed for more research, particularly on the application of 12-step interventions for drugs other than alcohol.
- For treatment professionals and treatment systems: A large base of evidence now supports AA’s effectiveness. Evidence also suggests AA can complement and extend the benefits of clinical care while simultaneously reducing health care costs. Patients may benefit from AA participation even if they do not identify with the spiritual aspects of the program.
Kelly, J. F. (2017). Is Alcoholics Anonymous religious, spiritual, neither? Findings from 25 years of mechanisms of behavior change research. Addiction, 112(6), 929-936.
**Note: One or more authors of this study were Recovery Research Institute Staff, including the director and/or other research scientists. As with all summaries, staff made the greatest possible effort to recognize and account for any potential biases in the review of this article.