The Effectiveness of the Twelve-Step Treatment
by A. Orange

'After all, facts are facts, and although we may quote one to another with a chuckle the words of the Wise Statesman, "Lies - damn lies - and statistics," still there are some easy figures the simplest must understand, and the astutest cannot wriggle out of.'
Leonard Henry Courtney, the British economist and politician (1832-1918), later Lord Courtney, speaking at New York, August 1895.






At the beginning of every Alcoholics Anonymous meeting, someone reads a plastic-laminated document that says, among other things, that this Twelve-Step program has rarely been known to fail, except for a few unfortunate people who are "constitutionally incapable of being honest with themselves":


RARELY HAVE we seen a person fail who has thoroughly followed our path. Those who do not recover are those who cannot or will not give themselves completely to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way.
A.A. Big Book, 3rd Edition, William G. Wilson, page 58.
Nothing could be further from the truth. Even the most ardent true believers who will be honest about it recognize that A.A. and N.A. have at least 90% failure rates. And the real numbers are more like 95% or 98% or 100% failure rates. It depends on who is doing the counting, how they are counting, and what they are counting or measuring.

A 5% success rate is nothing more than the rate of spontaneous remission in alcoholics and drug addicts. That is, out of any given group of alcoholics or drug addicts, approximately 5% per year will just wise up, and quit killing themselves.6 They just get sick and tired of being sick and tired, and of watching their friends die. (And something between 1% and 3% of their friends do die annually, so that is a big incentive.) They often quit with little or no official treatment or help. Some actually detox themselves on their own couches, or in their own beds, or locked in their own closets. Often, they don't go to a lot of meetings. They just quit, all on their own, or with the help of a couple of good friends who keep them locked up for a few days while they go through withdrawal. A.A. and N.A. true believers insist that addicts can't successfully quit that way, but they do, every day.

Every disease has a spontaneous remission rate. The rate for the common cold is basically 100 percent -- almost nobody ever dies just from a cold. On the other hand, diseases like cancer and Ebola have very low spontaneous remission rates -- left untreated, they are very deadly and few people recover from them. Alcoholism is in the middle. The Harvard Medical School reported that in the long run, the rate of spontaneous remission in alcoholics is slightly over 50 percent. That means that the annual rate of spontaneous remission is around 5 percent.

Thus, an alcoholism treatment program that seems to have a 5% success rate probably really has a zero percent success rate -- it is just taking credit for the spontaneous remission that is happening anyway. And a program that has less than a five percent success rate, like four or three, may really have a negative success rate -- it is actually keeping people from succeeding in getting clean and sober. Any success rate that is less than the usual rate of spontaneous remission indicates a program that is a real disaster and is hurting patients.


It's like this:
Imagine that there is a nasty disease that kills 50% of the people who get it. A pharmaceutical company has a new medicine that they want to test. So they give the drug to a bunch of the people who have the disease, and 50% of them get better.
The drug manufacturer cheers and brags, "Look at how great our new medicine is! We saved half of the patients!"

Wrong. The new drug saved nobody. The half who survived were the ones who were going to survive anyway. The drug had an effective zero percent cure rate, above and beyond normal spontaneous remission. The new medicine didn't make anybody recover.

And if fewer than half of the patients survived, then the experimental medicine was actually poisoning people, not helping them.


When one of those people who is going to quit drinking anyway, or who did just quit, walks into an A.A. meeting, A.A. is happy to take all of the credit for that success, while disavowing any responsibility for all of those other people who walk in, are disgusted by what they see, and walk right back out, and relapse. That is grossly dishonest.

A.A. is also more than happy to convince the person who just quit that it is all due to A.A. and the Twelve Steps. And many of them will believe it. At meetings, you will sometimes hear testimonials like "I tried everything, the V.A. program, the Christian Brotherhood, and finally, A.A. is what worked."

The speaker is forgetting one of the famous corollaries to Murphy's Law:
"The thing you seek always seems to be in the last place that you look."


Many people who are in recovery require one or more relapses to convince themselves that they really can't drink or dope any more, not even just a little bit. They will think that they can just nibble, or "just have one", and that it will be okay. They will go through a lot of programs while they experiment and fail. It's a learning process. In the end, when some of them finally quit, really totally quit and stay quit, rather than die, they often give the credit to whichever program they happen to be in when they finally quit. (All of them tend to overlook the fact that they stopped examining other programs after they successfully quit drinking. They just stuck with the program that they were in.)

Thus the Christian sects have a bunch of totally convinced true believers who say that Jesus saved them, and the Veteran's Administration has some veterans who believe that the V.A. program is the best, and Alcoholics Anonymous has a bunch of people who insist that A.A. and the Twelve Steps are the only answer.


In 1964, Dr. Milton A. Maxwell (who eventually became a member of the Board of Trustees of Alcoholics Anonymous World Services, Inc.) did a study of the relations between doctors and other treatment professionals and Alcoholics Anonymous. He wrote:

Another root of Professional-AA strains consists of the very human tendency to be loyal to the therapy which has been successful in one's own case -- and rather uncritically to adopt the ideological framework within which the help has come. We see this phenomenon in other areas. For example, the benefits of religious faith and personal integration can come through many different theological frames of reference -- Roman Catholic, Pentacostal, Christian Science, Theosophy, Zen Buddhism, you name it. And, so often, the help found is taken as absolute proof of the truth of the accompanying theological framework. Or, witness what happens when a patient has shopped around from doctor to doctor, and finally finds one that helps: he becomes very loyal to the successful therapist -- and to the successful therapeutic program. Why should the behavior of alcoholics be so different? I've been in alcoholism clinic and hospital settings where I've heard: "I tried the 'cure' over there. I tried AA. None of it worked. But this place has got the answers." And I've heard alcoholics talk who had boxed the professional compass and finally made it in AA. In either case, the reason for the success of the particular treatment may have been due more to the patient's by-now greater pain and desperation than to the nature of the treatment or the context of beliefs. But few patients can see this at the time and they become loyal to the "successful therapy" -- and, unfortunately, sometimes antagonistic or unfavorable in their attitude toward other therapeutic programs. Now, I submit that this is quite standard human behavior. But it is one of the roots of misunderstanding, distrust, and strain in AA-professional relations.
PROFESSIONAL and ALCOHOLICS ANONYMOUS RELATIONS IN OREGON; An Exploratory Study Report, Milton A. Maxwell, Ph.D., 1965, page 10.



The Harvard Medical School says that the vast majority of the people who successfully quit drinking for a year or more -- eighty percent of them -- do it alone, all by themselves, without any treatment program or "support group". Naturally, those do-it-yourselfers will also insist that they have the sure-fire solution that really works:
"Just don't drink any more alcohol, not ever, no matter what."

When you are at an A.A. meeting, you are in a self-selecting group. You won't hear from the Jesus-freak Christians, or the gung-ho V.A. guys, or the do-it-yourself guys, because they aren't there. You will only hear from the A.A. true believers, who will be happily reassuring each other that they are doing the only thing that really works.


A bunch of people went to a Baptist church for years.
During those years, many of the women got pregnant and had babies.
That proves it: Going to Baptist churches causes women to get pregnant and have babies.
Not!
That goofy logic is the same logic as A.A. uses to insist that it's a proven fact that going to A.A. meetings and doing the Twelve Steps causes people to quit drinking.

Many A.A. members are confusing causation with correlation, or causation with coincidence. They fail to see that they go to A.A. meetings because they want to quit drinking, not that they want to quit drinking because they go to A.A. meetings. And the reason that they finally quit drinking is because they really want to quit -- want it so strongly that they finally really do it. And the commonest reason for quitting is because people just get sick and tired of being sick and tired, and wish to avoid death.








The Harvard Mental Health Letter, from The Harvard Medical School, stated quite plainly:


On their own
There is a high rate of recovery among alcoholics and addicts, treated and untreated. According to one estimate, heroin addicts break the habit in an average of 11 years. Another estimate is that at least 50% of alcoholics eventually free themselves although only 10% are ever treated. One recent study found that 80% of all alcoholics who recover for a year or more do so on their own, some after being unsuccessfully treated. When a group of these self-treated alcoholics was interviewed, 57% said they simply decided that alcohol was bad for them. Twenty-nine percent said health problems, frightening experiences, accidents, or blackouts persuaded them to quit. Others used such phrases as "Things were building up" or "I was sick and tired of it." Support from a husband or wife was important in sustaining the resolution.
Treatment of Drug Abuse and Addiction -- Part III, The Harvard Mental Health Letter, Volume 12, Number 4, October 1995, page 3.
(See Aug. (Part I), Sept. (Part II), Oct. 1995 (Part III).)
So much for the sayings that "Everybody needs a support group" and "Nobody can do it alone". Most successful people do.


And note that the Harvard Medical School says that the support of a good spouse is more important than that of a 12-step group. But A.A. says just the opposite: "Dump your spouse and marry the A.A. group, because A.A. is The Only Way."

"I decided I must place this program above everything else, even my family, because if I did not maintain my sobriety I would lose my family anyway."
The Big Book, 3rd Edition -- Chapter B10, He Sold Himself Short, page 293.
And a rehash of the Big Book that is targeted at youths tells this story of an allegedly-successful recovery:


Even after she remarries, she doesn't lose sight of her priorities. She places God first and A.A. second. Her husband is never more than the third most important aspect of her life.
Big Book Unplugged; A Young Person's Guide to Alcoholics Anonymous, John R., page 107.


Likewise, American Health Magazine reported:


...people are about ten times as likely to change on their own as with the help of doctors, therapists, or self-help groups.
J. Gurion, American Health Magazine, March 1990.



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In his book on the treatment of alcoholism, Dr. Sheldon Zimberg surveyed the literature for reports of spontaneous remission of alcoholism:


Spontaneous Remission in Alcoholism
A number of studies have found that a small percentage of alcoholics improve to the point of remission of problems associated with alcohol consumption. Bailey and Stewart (235) interviewed alcoholics after three years without treatment and found that about 27 percent of the former patients denied alcoholism. Cahalan (268) in a national drinking practices study noted that drinking problems decrease in men after age 50 and the amount of alcohol consumed also decreases. Cahalan, Cisin, and Crossley (11) in another national survey of drinking practices found that about one-third more individuals had problem drinking in a period before their three-year study period than during the study period itself, suggesting a tendency toward spontaneous remission of drinking problems. Goodwin, Crane, and Guze (269) found that on an eight-year follow-up with no treatment about 18 percent of the alcoholic felons had been abstinent for at least two years. Lemere (238) reported long-term abstinence in 11 percent of untreated alcoholics over an unspecified interval. Kendall and Staton (236) reported 15 percent abstinence in untreated alcoholics after a seven-year follow-up. Kissin, Platz, and Su (203) reported a 4 percent one-year improvement rate in untreated lower class alcoholics. Imber et al. (10) described a follow-up of 58 alcoholics who received no treatment for their alcoholism. It was noted that the rate of abstinence was 15 percent at one year and 11 percent after three years.
In sum, the preponderance of these studies suggests that a spontaneous remission rate for alcoholism of at least one-year duration is about 4-18 percent. Successful treatment would, therefore, have to produce rates of improvement significantly above this probable range of spontaneous remission.



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10. Imber, S., Schultz, E., Funderburk, F., Allen, R. and Flamer, R. The Fate of the Untreated Alcoholic. J. Nerv and Ment. Dis., 1976, 162:238-247.
11. Cahalan, D., Cisin, I. H. and Crossley, H. M. American Drinking Practices: A National Survey of Drinking Behavior and Attitudes. New Brunswick, Rutgers Center for Alcohol Studies, 1974.
203. Kissin, B., Platz, A. and Su, W. H. Social and Psychological Factors in the Treatment of Chronic Alcoholics. J. Psychiat. Res., 1970, 8:13-27.
235. Bailey, M. B. and Stewart, S. Normal Drinking by Persons Reporting Previous Problem Drinking. quart. J. Stud. Alc., 1967, 28:305-315.
236. Kendall, R. E. and Staton, M. C. The Fate of Untreated Alcoholics. quart. J. Stud. Alc., 1966, 27:30-41.
238. Lemere, F. What Happens to Alcoholics. Amer. J. Psychiat., 1953, 109:674-675.
268. Cahalan, D. Problem Drinkers: A National Survey, San Francisco, Jossey-Bass, 1970.
269. Goodwin, W. W., Crane, J. B., and Guze, S. B. Felons Who Drink: An Eight-Year Follow-up. quart. J. Stud. Alc., 1971, 32:136-147.

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The Clinical Management of Alcoholism, Sheldon Zimberg, M.D., page 179, footnotes on pages 223 to 234.
The key sentence is the last one -- for a treatment program to claim success, it would have to produce recovery rates greater than the usual rate of spontaneous remission. Alcoholics Anonymous comes nowhere near exceeding a 4 to 18 percent per year recovery rate.

Personally, I find the 18 percent number to be far too high to believe. (At that rate, 85% of all of the alcoholics in the country should have recovered in just the last 10 years. Obviously, that has not happened.) I agree with R. G. Smart, who calculated a spontaneous remission rate for alcoholism of between 3.7 and 7.4 percent per year. As a simple rule of thumb, the middle value of 5 or 5.5 percent per year is quite believable. Still, the claimed success rate of Alcoholics Anonymous does not even exceed that much lower rate of spontaneous remission