struggled with the question of cause and effect:
[I]ndividuals self-selected into treatment and AA and, based on their experiences, decided on the duration of participation. Thus, in part, the benefits we identified are due to the influence of self-selection and motivation to obtain help as well as that of longer participation per se. Although our findings probably reflect the real-world effectiveness of participation in treatment and AA for alcohol use disorders, the naturalistic design precludes firm inferences about the causal role of treatment or AA.
A BIG QUESTION
Why do large observational studies such as that of Fiorentine and Moos seem to suggest that AA is effective, while smaller controlled studies like those of the Brandsma, Walsh, and others included in the
Cochrane Review
do not? The likely explanation is simple: people stay in AA if they’re getting better and leave if they aren’t. This is understandable. If you are able to stop drinking, then continuing to attend AA is a comfortable and affirming choice. If you struggle with drinking and can’t make use of the AA approach, then you are less likely to keep attending. Over the long term, the people who remain in AA are, by definition, the success stories. But they represent a very small slice of the people who start there; as we will see shortly, the dropout rate from AA is extremely high.
These facts—that AA works for the diehards and fails for the dropouts—are perennially misunderstood by the press and even by some researchers. Proponents of the program proudly point to the fact that people who stay in AA tend to be sober, ignoring the tautological nature of this claim. Reviewing this logic, Harvard biostatistics professor Richard Gelber said, “The main problem is the self-fulfilling prophesy: the longer people stick with AA the better they are, hence AA must be working. It is like saying the longer you live, the older you will be when you die.” As we will soon see, this fundamental error in logic undergirds nearly every claim of AA’s efficacy.
Despite the known limitations with the Moos data set, a number of researchers have used it to publish pro-AA papers of their own. For instance, in 2008, J. McKellar (writing as lead author, with Ilgen, Moos, and Moos as coauthors) concluded that “clinicians should focus on keeping patients engaged in AA.” 22 This recommendation is even more dogmatic than Moos and Moos suggested in their original paper. In fact, this paper itself notes that pressuring people to attend AA is usually unhelpful: “a significant number of substance abuse patients never attend self-help groups after discharge,” that is, when no longer mandated to attend.
In 2011, again, using the original Moos data, Stanford’s Christine Timko published as lead author on another paper with Moos and Moos, drawing a similar conclusion:
Among initially untreated individuals, sustained mutual help may be associated with a reduced number of occurrences of DWI [Driving While Intoxicated arrests] via fewer drinking consequences and improved psychological functioning and coping. Treatment providers should attend to these concomitants of DWI and consider actively referring individuals to AA to ensure ongoing AA affiliation. 23
Another observational AA study was conducted by John-Kåre Vederhus in 2006, once again without randomization or any interventions. This one looked at a small group—just 114 patients—with drug and alcohol problems, and found the same broad correlation as Moos and Moos: Intention-to-treat-analysis showed that 38 percent still participated in self-help programs two years after treatment. Among the regular participants, 81 percent had been abstinent over the previous 6 months, compared with only 26 percent of the non-participants. 24
Once again, after two years, over 60 percent of the people remaining in the study had dropped out of AA. The people who stayed were admirably sober, on the order of 81 percent. But the
[I]ndividuals self-selected into treatment and AA and, based on their experiences, decided on the duration of participation. Thus, in part, the benefits we identified are due to the influence of self-selection and motivation to obtain help as well as that of longer participation per se. Although our findings probably reflect the real-world effectiveness of participation in treatment and AA for alcohol use disorders, the naturalistic design precludes firm inferences about the causal role of treatment or AA.
A BIG QUESTION
Why do large observational studies such as that of Fiorentine and Moos seem to suggest that AA is effective, while smaller controlled studies like those of the Brandsma, Walsh, and others included in the
Cochrane Review
do not? The likely explanation is simple: people stay in AA if they’re getting better and leave if they aren’t. This is understandable. If you are able to stop drinking, then continuing to attend AA is a comfortable and affirming choice. If you struggle with drinking and can’t make use of the AA approach, then you are less likely to keep attending. Over the long term, the people who remain in AA are, by definition, the success stories. But they represent a very small slice of the people who start there; as we will see shortly, the dropout rate from AA is extremely high.
These facts—that AA works for the diehards and fails for the dropouts—are perennially misunderstood by the press and even by some researchers. Proponents of the program proudly point to the fact that people who stay in AA tend to be sober, ignoring the tautological nature of this claim. Reviewing this logic, Harvard biostatistics professor Richard Gelber said, “The main problem is the self-fulfilling prophesy: the longer people stick with AA the better they are, hence AA must be working. It is like saying the longer you live, the older you will be when you die.” As we will soon see, this fundamental error in logic undergirds nearly every claim of AA’s efficacy.
Despite the known limitations with the Moos data set, a number of researchers have used it to publish pro-AA papers of their own. For instance, in 2008, J. McKellar (writing as lead author, with Ilgen, Moos, and Moos as coauthors) concluded that “clinicians should focus on keeping patients engaged in AA.” 22 This recommendation is even more dogmatic than Moos and Moos suggested in their original paper. In fact, this paper itself notes that pressuring people to attend AA is usually unhelpful: “a significant number of substance abuse patients never attend self-help groups after discharge,” that is, when no longer mandated to attend.
In 2011, again, using the original Moos data, Stanford’s Christine Timko published as lead author on another paper with Moos and Moos, drawing a similar conclusion:
Among initially untreated individuals, sustained mutual help may be associated with a reduced number of occurrences of DWI [Driving While Intoxicated arrests] via fewer drinking consequences and improved psychological functioning and coping. Treatment providers should attend to these concomitants of DWI and consider actively referring individuals to AA to ensure ongoing AA affiliation. 23
Another observational AA study was conducted by John-Kåre Vederhus in 2006, once again without randomization or any interventions. This one looked at a small group—just 114 patients—with drug and alcohol problems, and found the same broad correlation as Moos and Moos: Intention-to-treat-analysis showed that 38 percent still participated in self-help programs two years after treatment. Among the regular participants, 81 percent had been abstinent over the previous 6 months, compared with only 26 percent of the non-participants. 24
Once again, after two years, over 60 percent of the people remaining in the study had dropped out of AA. The people who stayed were admirably sober, on the order of 81 percent. But the
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