Book review: the science behind 12 Step recovery

Nowinski’s excellent popular science book If You Work It, It Works! The Science Behind 12 Step Recovery (2015) makes it pretty clear: AA only works if you participate.

Dr Joseph Nowinski’s name came up a bunch of times when I was doing research into international best practice in treatment and support for alcoholics and risky drinkers.  I was completing this work at the same time my drinking was at its white-spirit-worst and, because of that, I nearly lost the job for good.

In fact I’m pretty sure Nowinski’s Twelve Step Facilitation Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence(1999) was even on the shelf when I was poking around in the literature cupboard at my last rehab. By that stage I had decided AA was definitely some kind of cult. Why else would people willingly go out of their way to help perfect strangers? Surely they had some other motive?

It turns out they did have an alterior motive. But they weren’t trying to sell me salvation proportionate to my income. No, helping others made them feel better.

Nowinski

Project MATCH :/

Dr Nowinski contributed to Project MATCH (1989-97), the largest alcohol treatment trial ever conducted involving 1726 alcohol dependent volunteers over several treatment sites in the US. The aim of Project MATCH was to find out if different types of ‘alcohol abusing or dependent patients’ respond differently to the most widely used treatments for alcohol dependency: Cognitive Behavioral Therapy (CBT), Motivation Enhancement Therapy (MET) or Twelve-Step Facilitation (therapists introduce patients to AA, explain some of the concepts and get them to attend meetings. The focus is on AA’s steps one to five).

Project Match’s data dissapointed a lot of people in the addiction and recovery field. It reinforced what many suspected: that matching the right treatment to individual alcoholics is difficult, and that treatment outcomes are similarly dissapointing across the board. In other words, Project Match didn’t offer a silver bullet for treating alcoholism.

Yet, the fact that a treatment protocol based on AA’s 12-steps – an unscientific, quasi-religious oddity – could achieve similar results as CBT and MET was notable, given that AA costs nothing to taxpayers and provides critical post-intervention (e.g. hospital E.R., detox, rehab) support in the community.

AA only works for those who take action

The title of If You Work It, It Works! is intentional because, as Nowinski points out, only half of us who attend AA stay active in the fellowship after three months.

I recently lost 20kg because I changed my diet and started running. Thinking about it didn’t get me healthy.

Nowinski analysed AA member surveys to find out what actions people take in AA to stay sober and found attending at least two and preferably three meetings a week, joining a home group, and getting a sponsor were the top three responses. These same three actions kept me sober in my early days of sobriety.

Nowinski examined a range of research on AA attendance and involvement, and treatments that encourage AA attendance. The results show that:

  • Getting into some form of counseling and starting AA at the same time is a winning combination if you want to stay sober.
  • Getting involved in the AA Twelve Step fellowship leads to superior results than simply attending meetings.
  • Identifying yourself as an AA member makes a positive difference.
  • Therapy that actively facilitates AA involvement is superior to treatment that does not include this focus.

He also notes that there is a spectrum of alcoholism and problem drinking and that, for some, controlled drinking may have its place after a period of conditional abstinence.  For those like me, who have tried and failed at controlled drinking and have ridden the ‘just one’, drink-drank-drunk *crash*, remorse cycle so many times the very idea of controlled drinking is laughable, Nowinski says that abstinence should be ‘the most appropriate goal’.

How it works

1. Social networks

Like me, Nowinski attributes much of AA’s value to the relationship between social networks and recovery. He uses a number of published studies to show how both involvement in AA, and the people in an alkie’s regular social network, are critical to long-term recovery. AA involvement seems to act as a buffer, particularly where a person’s regular social network includes frequent or heavy drinkers. Some people use AA as an alternative social network, particularly when there is always drink at home. I’m lucky that my immediate family are not huge drinkers and my best mates, while still capable of epic feats of party mayhem, are generally pretty sensible and respectful of my non-drinker status.

Interestingly, problem drinkers in a person’s social network exert a more powerful and negative influence on recovery than non-drinkers. In other words, surround yourself with drunks and you’ll probably end up just that – drunk. Surround yourself (at least some of the time) with AA members and you’ll probably stay sober. Dead simple.

2. Spirituality and sponsorship

As a scientist, Nowinski doesn’t engage in spiritual or theological argument. Instead, he presents published studies that have examined the role of spirituality in recovery. Obviously there are limitations in this data because concepts like spirituality are open to interpretation – particularly by sick people responding to surveys. The studies show that greater involvement in AA leads people to become ‘more spiritual’ over time, which is, in turn, positively associated with sobriety. This is not suprising, since AA is a program that emphasises the benefits of spirituality, particularly prayer and meditation.

The other aspect of AA’s spirituality Nowinski finds beneficial is the focus on personal values and self-reflection. He concludes that ‘spirituality, as it is reflected in AA’s emphasis on honesty, humility, and personal renewal, as opposed to formal religious observance, may be the key dynamic responsible for this change’ (p.148).

Nowinski’s message is clear: AA spirituality is not about joining a cult or a church. It’s about ‘pursuing a life of meaning and values. These include honesty, the courage to admit to shortcomings, humility, and altruism. Within the AA culture these values are demonstrated through action’ (p. 160).

Studies on sponsorship are pretty unequivocal: getting a sponsor early greatly increases your chance of not drinking again. However, this effect seems to decrease with time. Nowinski says that the adage ‘better late than never’ probably applies here, and I have to agree with him.

3. Neurological factors

Alcohol kills brain cells. That bit we knew already. But, if you drink like I did, it also greatly increases your chance of suffering from depression and/or anxiety, as well as PTSD and schizophrenia. The point is that most alkies seem to have some sort of psychiatric comorbidity or dual-diagnosis to party with their alcoholism and other addictions.

Nowinski reviews the evidence on recovery for alcoholics with dual-diagnosis and finds that, as long as people work their AA program, these illnesses ‘do not appear to consitute a major barrier to recovery’ (p. 181).  He concludes that recovery (and particularly Twelve Step recovery) has healing powers of its own.

Is it worth reading?

In a word, yes. Nowinski’s book is:

  • a much needed kick in the pants for alcoholics like me who forget to put in the action each day. Treatments for diabetes and heart disease are never effective 100 percent of the time, because they are dependent on whether or not a patient follows the treatment recommended by their doctor. As Nowinski puts it: ‘the best we can say, then, is that these treatements are likely to work if the individual works them’; and,
  • an excellent introduction to the medical literature on alcoholism and recovery, which shows that AA has some good, recent scientific studies supporting its approach to recovery.

One thought on “Book review: the science behind 12 Step recovery

  1. Pingback: AA member survey | Social drinking

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