Does AA Work?

Alcoholics Anonymous helped change the public view of alcoholism from a sin to a disease. This was progress. Unfortunately, once alcoholism came to be seen as a result of genetic vulnerabilities rather than a failure of will power or a flawed personality, Alcoholics Anonymous and its 12 steps to sobriety emerged as the one and only way to overcome it.

Every few years, someone valiantly tries to debunk the widespread belief, held by many physicians as well as the general public, that complete abstinence from alcohol is the only successful way to handle problem drinking and that most people will need AA to help them maintain that abstinence. Every time a critic comes forth, defenders of AA bring out the tragic story of Audrey Kishline, the founder of an alternative treatment called Moderation Management, who was involved in a head-on collision with another car because she had been driving drunk. A man and his young daughter died. Proponents of AA felt vindicated. 

Gabrielle Glaser, author of a book on women and alcohol, has been one of AA’s critics. Earlier this year she wrote an op-ed for the New York Times, describing the merits of Moderation Management and other programs based on cognitive-behavioral principles. M.M. isn’t for “severely dependent drinkers, for whom abstinence might be best,” she wrote. “But it’s been empirically shown to work for those on the more moderate end of the spectrum who outnumber dependent drinkers by about four to one—including the majority of women who drink too much…. We need to get away from the one-size-fits-all approach to drinking problems.” 

One-third to one-half of all people who join AA drop out because they find its philosophy unappealing or because they cannot adhere to full abstinence.

Indeed we do, yet those loyal to the AA model don’t want to let even this reasonable argument through the door. For them, the idea that many people can learn to drink moderately is too appealing an excuse for the people who cannot learn to drink moderately. Sure enough, a letter to the Editor invoked the story of Audrey Kishline to argue that MM doesn’t work. “Why bother with a moderation approach?” asked the letter-writer. “Alcohol is not that important. Just don’t drink.” 

But “just don’t drink” doesn’t appeal to the people who would like to drink on occasion, or who might benefit from moderate drinking. That is the reason that AA is neither as effective as its advocates believe, nor the only possible intervention for problem drinkers. One-third to one-half of all people who join AA drop out because they find its philosophy unappealing or because they cannot adhere to full abstinence. When they “relapse,” they then define themselves as hopeless failures, and don’t return. 

In 2006 the Cochrane Collaboration, the internationally recognized gold standard of impartial assessment and evidence-based practice, issued a report on the effectiveness of AA and other 12-step programs in achieving and maintaining abstinence, improving quality of life, and reducing alcohol-associated problems. The committee pored over every major database they could find, medical and psychological, involving men and women who were attending voluntary or coerced programs. They ended up with eight trials that involved 3,417 people and concluded: “No experimental studies unequivocally demonstrated the effectiveness of AA or [other 12-step] approaches for reducing alcohol dependence or problems.” One small study suggested that AA may “help patients to accept treatment and keep patients in treatment more than alternative treatments,” but that program combined AA with other interventions and “should not be regarded as conclusive.” 

The debate over the causes of and best treatments for alcoholism has been waged for more than a century. In their 1991 book The Diseasing of America, Stanton Peele and Archie Brodsky laid out the issues on each side. For people who are believers in the power of AA, key beliefs are: 

• Once an addict, always an addict: A person must accept this lifelong identity. 
• An addict must abstain from alcohol forever. 
• A person is either addicted or not. 
• Young people should not be permitted to drink, even at home with their parents, until they are 21. 
• An addict needs to continue the same treatment and group support forever. 

In contrast, Peele and Brodsky wrote, for researchers who emphasize the role of the environment, learning, and culture in addiction, opposite beliefs follow: Alcohol abuse is a way of coping, and individuals can learn to make better choices. 

• A person often can and does grow beyond the need for alcohol. 
• Most problem drinkers can learn to drink in moderation, by learning new habits, ways of coping, and getting out of environments and peer groups that reward heavy drinking. (In other words, graduate from college—or avoid fraternity parties.) 
• Young people should learn to drink safely and moderately at home, with meals and in social settings. 
• Treatment only needs to last until the person stops drinking heavily and having any alcohol-related work or relationship problems. 
• The person does not have to adopt a lifetime identity of being an “alcoholic.” 

You can see how these opposite camps have ended up so far from each other: For one, complete abstinence is the only solution; for the other, it is a problem, because most people do not want to abstain completely, don’t need to, or are unable to. Obviously the issue cannot be resolved by anecdotes such as the drunk-driving death of Audrey Kishline. Because alcoholism and problem drinking occur for many reasons, neither total abstinence nor moderate drinking will be the best solution for every individual. 

Many people become addicted not because their brains have led them to abuse drugs, but because the abuse of drugs has changed their brains.

Genes are involved in some kinds of alcoholism but not all, and genes affect alcohol “sensitivity”—how quickly people respond to alcohol, whether they tolerate it, and how much they need to drink before feeling high. However, the assumption that biological factors cause alcoholism has overlooked the reverse causal path: Alcoholism can result from heavy drinking. Many people become addicted not because their brains have led them to abuse drugs, but because the abuse of drugs has changed their brains. Over time, the repeated jolts of pleasure-producing dopamine modify brain structures in ways that maximize the appeal of the drug, minimize the appeal of other rewards, and disrupt cognitive functions such as working memory, self-control, and decision making, which is why addictive behavior comes to feel automatic. Heavy drinking also reduces the level of painkilling endorphins, produces nerve damage, and shrinks the cerebral cortex. These changes can then create a craving for more liquor, so the person stays intoxicated for longer and longer times, drinking not for pleasure at all but simply to appease the craving. In this way drug abuse, which begins as a voluntary action, can turn into drug addiction, a compulsive behavior that addicts find exceedingly difficult to control. 

But that’s not the whole story. Rates of alcoholism vary according to cultural practices: Alcoholism is more likely to occur in societies that forbid children to drink but condone drunkenness in adults (as in Ireland) than in societies that teach children how to drink moderately but condemn adult drunkenness (as in Italy, Greece, and France). (During Prohibition in America, rates of overall drinking declined, but rates of alcoholism increased among those who did drink—when they got the chance, they drank to excess.) In cultures with low rates of alcoholism, adults demonstrate correct drinking habits to their children, gradually introducing them to alcohol in safe family settings. Drunkenness is not considered charming, comical, or manly; it is considered stupid and obnoxious. 

When norms within a culture change, so do drinking habits and abuse rates. The cultural norm for American college women was once low to moderate drinking; today, they are more likely to abuse alcohol because the culture of many college campuses encourages drinking games, binge drinking (having at least four to five drinks in a two-hour session), and getting drunk. A European student of mine once asked me in great puzzlement why so many American students drank so much they became sick or unconscious. “We drink for fun,” he said, “with meals. To feel good. They drink to feel bad.” 

His observation is right: alcohol abuse does not depend on properties of the drink alone, as the disease model predicts, but also on the reasons for drinking. People who drink to be sociable or to relax when they have had a rough day are unlikely to become addicted. Problem drinking occurs when people drink to disguise or suppress their anxiety or depression, when they drink alone to drown their sorrows and worries, or when they want an excuse to abandon inhibitions. College students who feel alienated and uninvolved with their studies are more likely than their happier peers to go out drinking with the conscious intention of getting drunk. 

So instead of asking, “Does AA work?” or “Can problem drinkers learn to drink moderately?” we would be better off asking, “What are the factors that make it more or less likely that an individual can learn to control problem drinking?” Many people who have been abusing alcohol for years probably cannot learn to drink moderately, because physiological changes in their brains may have turned them from heavy drinkers into alcoholics. But it is undeniably the case that many heavy drinkers—including most of the college students who now spend years in an environment that encourages binge drinking—can learn to reduce and manage their drinking. For them, programs like AA—which require them to identify themselves as alcoholics for life, and which admonish them that they have no mastery over their drinking—are likely to add to their problems rather than solving them.