Does Alcoholics Anonymous actually work?

Much of what we know about the effectiveness of AA has been generated by the fellowship itself, and this creates some obvious problems of bias, writes Ian Hamilton

There is also a darker side to AA that is rarely mentioned, namely how members can be exploited (Getty/iStockphoto)

There is an organisation that has been around longer than the Queen and is almost as popular, with millions of members worldwide. It is Alcoholics Anonymous (AA).

The first UK meeting of AA can be traced back to March 1947 when it was held in a room of the Dorchester in London. Despite its place in our collective consciousness and the millions of people who have participated in AA, what do we actually know about how effective it is in supporting people from addiction to sobriety?

To answer that question, it’s worth summarising how AA works. Rather than being led by professionals, AA works on the basis of peer support. Those who have already been through the process help new members. Compared to specialist professional services, AA is very accessible, with meetings in most areas. Added to this is the “buddy” system, where new members are paired with an experienced peer to guide and support them on their journey to abstinence.

The AA philosophy is based on the 12 steps, in which members acknowledge a “higher power”. This religious theme to the steps can be off-putting for some.

All these elements appear to provide timely and important components to help individuals who have problems with alcohol. Unlike other interventions used to treat this group, AA hasn’t received the same level of research scrutiny, something that needs to be rectified given its scale and the fact that it might be the only help some people access.

AA has been slow to evolve over its lifetime. There is still a belief that the only goal people should aim for is complete abstinence from alcohol, and while this may work for some, it won’t be achievable or necessary for many. We know that controlled drinking may be a better and more realistic option for some people, but this isn’t catered for in the way AA currently operates.

Research knowledge has advanced in recent years to the point that we now know that problems with alcohol are a blend of genetics and environmental factors, such as poverty, mental health and relationship difficulties. This contrasts with the AA view that individuals are helpless and must rely on a “higher power” to overcome their addiction.

Much of what we know about the effectiveness of AA has been generated by the fellowship itself, and this creates some obvious problems of bias. Added to this, and perhaps presenting a more significant problem, is that members are anonymous and may decline to be involved in any evaluation of outcomes from participating in AA. Those who struggle with AA are the least likely to be captured in any evaluation, meaning findings are skewed towards those that successfully navigate the 12-step process. This is problematic for everyone, as it fails to capture important factors that impede some members, and this intelligence has the potential to shape the future direction of AA that could improve success.

As with all interventions in addiction, the way success is defined varies, particularly the time parameters used as measurement points. For example, it is easy to imagine that measuring abstinence at three months is likely to yield more favourable outcomes than those measured in years.

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Even AA’s own evaluation suggests this, with 27 per cent of participants in AA being alcohol free at a year, but this fell to just 13 per cent at five years. Independent analysis found more modest rates of success of between 5-10 per cent. Contrast this relapse rate of 90 per cent to more conventional treatment, which has a relapse rate of 40 per cent.

What both types of research share is a lack of knowledge about those who drop out of treatment, whether it’s AA or professional programmes. This is arguably the most important group to understand.

There is also a darker side to AA that is rarely mentioned, namely how members can be exploited. The buddy system sounds good on the surface, but we have to remember that people are vulnerable when they join AA. There are several reports of how established AA peers known as “sponsors” have exploited their new charges, sexually or otherwise.

While there is an obvious benefit to members’ anonymity, this doesn’t absolve AA from its responsibility to objectively scrutinise not only its effectiveness, but serious reports of exploitation. Unless it is willing to acknowledge that this happens and be transparent in its approach to investigating, it will be complicit in adding to the trauma that many of its new members are seeking refuge and support only to be met with yet more abuse.

Ian Hamilton is a senior lecturer in addiction and mental health at the University of York