Twelve Step Programs – Conclusions From Research

Alcoholics ?anonymous (A.A.) is a science-based intervention with proven effectiveness. A.A. is more effective than non-treated control groups and equally effective to Cognitive Behavioral Therapy (CBT) and Motivational Interviewing. This issue is settled in the scientific literature. I have a bibliography of over 200 published articles that support the effectiveness of 12-Step Programs.

Nothing works for everyone. 12-step programs are no exception. People who had a bad experience with 12-Step programs are not reliable reporters. Neither are A.A. advocates who see 12-Step Programs doing all things for all people.

Twelve Step Programs are well-known and utilized in the United States. Of the US adult population:

  • 9% have been to an AA meeting at some time,
  • 3.6% in the prior year, only about one-third of these for problems of their own.
  • About one-half these percentages, mostly women, have attended Al-Anon.
  • Of the same population, 13.3% indicate ever attending a 12-step meeting (including non-alcohol-oriented groups), 5.3% in the last year.
  • During the prior year a further 2.1% used other support/therapy groups and 5.5% sought individual counseling/therapy for personal problems other than alcohol. In contrast to this high reported utilization, only 4.9% (ever) and 2.3% (12-months) reported going to anyone including AA for a problem (of their own) related to drinking. (Room and Greenfield 1993)

Research into 12-Step effectiveness shows clearly that Twelve Step Programs are effective in helping many people recover from alcoholism and drug dependence. Twelve-step programs get many of their members as a result of referrals from professional counselors, therapist, and doctors.

Many people who achieve long-term recovery use other forms of counseling and therapy at various points in their recovery. They use what I call a “12-Step Plus” Approach. Most people use professional counseling and therapy in addiction to working the 12-Step Program. Some people, however, have found recovery through professional therapy and support groups, like SMART Recovery, that are not based on the 12-Steps.

Many people in long-term recovery use 12-Step Programs very heavily in the first one to three years although the frequency of meetings goes down after that. Many people who start in 12-Step programs and achieve a stable recovery significantly reduce or stop attending meetings and do well. Most in this category start attending meetings again or increase the frequency of meeting during highly stressful periods of life.

Twelve Step programs are the single most effective, least expensive, and most readily available recovery program world-wide. As such, it is being supported by managed care companies in order to reduce the price of healthcare. The tendency to refer to A.A. is expected to increase as the Affordable Health Act (ACA) imposed greater demands for cost containment.

Twelve step programs work better when used in conjunction with other forms of counseling, therapy, and treatment.

Relapse rates in 12-Step Programs, and all forms of addiction treatment, are highest in the first 90 days. This is the period of recovery where people are most toxic from the effects of long-term alcohol and drug poisoning to the brain. It is a time of change and crisis. It is the period of time when recovery supports have not yet been firmly established. Detoxification and residential or day treatment are valuable to get people stabilized in this critical first 12 weeks of recovery.

After five years of continuous sobriety relapse in a group of alcoholics is less likely than having addiction develop in a similar group who has never had an addiction.

The comparative effectiveness of 12-step and cognitive-behavioral (C-B) models of substance abuse treatment was examined among 3,018 patients from 15 programs at the US Department of Veterans Affairs Medical Centers. Across program types, participants showed significant improvements in functioning from treatment admission to a 1-year follow-up. Although 12-step patients were somewhat more likely to be abstinent at the 1-year follow-up, 12-step, C-B, and combined 12-Step–C-B treatment programs were equally effective in reducing substance use and improving most other areas of functioning. The finding of equal effectiveness was consistency over several treatment subgroups: Patients attending the “purest” 12-step and C-B treatment programs, and patients who had received the “full dose” of treatment. Also, patients with only substance abuse diagnoses, those with concomitant psychiatric diagnoses, and patients who were mandated to treatment showed similar improvement at the 1-year follow-up, regardless of type of treatment received. These data provide important new evidence supporting the effectiveness of 12-step treatment. (Ouimette 1997)


Ouimette, Paige Crosby; Finney, John W.; Moos, Rudolf H., Twelve-step and cognitive-behavioral treatment for substance abuse: A comparison of treatment effectiveness. Journal of Consulting and Clinical Psychology, Vol 65(2), Apr 1997, 230-240.

ROOM, R. and GREENFIELD, T. (1993), Alcoholics anonymous, other 12-step movements and psychotherapy in the US population, 1990. Addiction, 88: 555–562.

You can find other studies with a simple search on Google scholar searching on Twelve Steps Outcomes and Twelve Step Facilitation (TSF).





4 Responses to Twelve Step Programs – Conclusions From Research

  1. Linda R says:

    Terry, I wanted to comment on your reference to Twelve-Step Facilitation (TSF) and cost containment. You said:

    ”Twelve Step programs are the single most effective, least expensive, and most readily available recovery program world-wide. As such, it is being supported by managed care companies in order to reduce the price of healthcare. The tendency to refer to A.A. is expected to increase as the Affordable Health Act (ACA) imposed greater demands for cost containment.”

    It does seem like the optimum model for cost containment is for patients / clients to go through TSF, and start attending AA meetings during treatment. Ideally, the patients / clients would continue with AA meetings after treatment, in the expectation of obtaining long term non-professional peer-to-peer support from the recovery community.

    I’m not an expert on TSF treatment, but it seems like group treatment sessions would be based on well recognized principles of group therapy, under the guidance and direction of a professional facilitator / counselor. The principles, or “mechanisms of change” might likely include those described by Irwin Yalom in his well known textbook “The Theory and Practice of Group Psychotherapy” as follows:

    • Universality – realization through group interaction that one’s problems are not unique
    • Instillation of hope – seeing that others have overcome the same problems
    • Imparting information – increased understanding of the problem and reduced uncertainty
    • Catharsis – expression or experience of emotion that is liberating
    • Imitative behavior – learning by observing and listening to others
    • Interpersonal learning – coming to know oneself without distortions, how one is perceived by others
    • Development of socializing techniques – social learning and modifying interaction with others
    • Group cohesion – esprit de corps, resulting in solidarity and belonging
    • Altruism – a sense of value and self-worth by helping others
    • Existential factors – awareness and acceptance of the limitations and inevitabilities inherent in life

    The patient / client may likely obtain these benefits from a professionally facilitated group, during treatment group sessions. However, when referred to an AA group, these principles are not the focus of the group’s meeting, and the person who joins an AA group may receive few, if any, of these benefits from peer group interaction. Instead, AA groups are focused on teaching the original 12 Steps. The pamphlet “The AA Group” published by AA World Services, states that the primary purpose of an AA group is: “to help alcoholics recover through A.A.’s suggested Twelve Steps of recovery.” AA groups may not modify, alter or extend the original 12 Steps. Furthermore, AA World Services tells AA groups that the US / Canadian General Service Conference expects groups to focus the AA meeting on the 12 Steps, as expressed in AA literature rather than outside material.

    I noticed that the studies done on AA group effectiveness were dated 1993 and 1997. These are approximately 15-20 years old, and AA groups may be significantly different now than they were when these studies were done. Perhaps these studies included AA groups that focused on sharing experience, strength and hope between peers, rather than teaching the 12 Steps using the Big Book and 12 & 12 textbooks. Perhaps when these studies were done, there were fewer 12 Step Study meetings, Big Book Study meetings or 12 & 12 Study meetings.

    A private organization such as AA can change a lot in 15-20 years. Public policy makers need to be aware that AA is a private organization, and AA groups are now primarily focused on teaching the original 12 Steps, using the Big Book and 12 &12 textbooks. In the U.S. the original 12 Steps are religious, as well as these AA textbooks, per the rulings of the U.S. courts. AA groups are absolutely free to exercise their religious rights to teach the original 12 Steps from these textbooks. However, public policy makers should be made aware that they are forming public policy based on and dependent on private religious groups.

  2. Linda R says:

    Terry, I’ve mentioned in my comments to your other blogs that AA as an organization is not well understood. In light of the likely increase in involvement of public health policy makers with AA groups, these AA groups should be better understood.

    First, AA groups are not allied with any other religious denomination, and are themselves non-denominational. In the pamphlet “Members of the Clergy Ask about Alcoholics Anonymous,” published by AA World Services, the non-denominational aspect of an AA group is clarified. Page 9 of the pamphlet says:

    “Many members of the clergy are familiar with A.A. as a nonsectarian, nondenominational ally in their efforts to help alcoholics to stop drinking and lead healthy, productive lives.”

    A religious denomination is a sub-group within a religion that operates under a common name, tradition, and identity. The term describes various Christian denominations (for example, the many varieties of Protestantism, as well as Anglicanism, and Eastern Orthodox). The term also describes the four branches of Judaism (Orthodox, Conservative, Reform and Reconstructionist), and describes the two main branches of Islam (Sunni and Shia).

    In contrast, non-denominational religious organizations are not formally aligned with an established religion. Non-denominational groups explicitly reject the idea of a formalized denominational structure as a matter of principle, holding that each congregation is better off being autonomous.

    The AA World Services pamphlet goes on to say:

    “Although many A.A. meetings are held in facilities owned and operated by religious organizations, no affiliation or alliance with specific religious doctrines or movements is implied.”

    To help the clergy understand the AA organization, the pamphlet has a section entitled: “How is A.A. Organized? Who Runs it?” This section, on pages 14-15, says:

     A.A. has no central authority. There is minimal structural organization and a handful of Traditions instead of bylaws.

     The Traditions are suggested principles that ensure the survival and growth of the thousands of groups comprising A.A. The Traditions are not formally binding on A.A. groups.

     Traditionally, two or more alcoholics meeting together for purposes of sobriety may consider themselves an A.A. group, provided that, as a group, they are self-supporting and have no outside affiliations.

     Overall responsibility for A.A.’s worldwide service agencies has been entrusted by the groups to the General Service Conference, composed of area delegates from the United States and Canada who meet annually.

     Serving in a custodial role is the board of trustees — 14 A.A. members and seven nonalcoholic friends of the Fellowship who serve on a rotating basis.

    The pamphlet explains the role of the Twelve Steps:

    “At the core of the A.A. program are the Twelve Steps of Recovery, a group of principles based on the trial-and-error experience of A.A.’s early members. Practiced as a way of life, the Twelve Steps include elements found in the spiritual teachings of many faiths.”

    Although these spiritual teachings are expected to be taught by AA groups, the pamphlet recognizes that some individuals who attend AA group meetings may not adopt these spiritual teachings:

    “It would be unrealistic to assume that all A.A. members are spiritually inspired. Many, too, are not committed to a formal body of religious doctrine.”

    The pamphlet explains that individuals who do not want to adopt these spiritual teachings may still participate in an AA group’s meeting, without having to adopt the expressions and practices of the Twelve Steps:

    “The A.A. program of recovery is based on certain spiritual values. Individual members are free to interpret these values as they think best, or not to think about them at all.”

    AA groups are intended to be non-sectarian, as well as non-denominational. Sectarianism is bigotry or discrimination from attaching importance to perceived differences in beliefs. When it is non-sectarian, an AA group does not practice bigotry or discrimination towards individuals who do not agree with nor adopt the spiritual principles of the Twelve Steps — “a group of principles based on the trial-and-error experience of A.A.’s early members.”

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