Not so long ago Alcoholics Anonymous was regarded with condescension by many professionals working in the addiction field. A common view was that science-based techniques, like Cognitive Behaviour Therapy (CBT) had made the Anonymous Fellowships seem like a quaint and outmoded quasi-religious cult.
At the same time, there were encouraging signs of scientific method being employed in the evaluation of both AA’s effectiveness, and of the value of the 12-step based Minnesota Method as practised in many treatment centres (Cook, 1988; McCrady & Miller, 1993). But the critical event leading to greater respect from the scientific establishment for the practices of AA was the publication of the results of Project Match in the 1990’s. This large-scale definitive study found that teaching alcoholics the basic tenets of AA philosophy and practice and encouraging participation in AA was at least as effective in facilitating recovery as was CBT. Subsequently, research into how AA works has continued unabated, and I wish now to highlight in particular a recent study from the USA that has examined the role of 12-step attendance with respect to current concern with the problem of “co-morbidity” – that is, the presence in an individual of a psychiatric condition like major depression alongside that of drug/alcohol addiction.
It’s now generally recognised that addicts with a “co-morbid” diagnosis of major depression present a particular challenge in treatment. Participation in AA/NA was shown in 2003 to have a beneficial effect on abstinence, whether or nor co-morbid depression was evident (Kelly et al 2003). A very recently published study shows just how important attendance can be for clients with both diagnoses (Worley et al 2012). 12-step treatment of co-morbid substance use and major depression was investigated,
in comparison with use of CBT. This study shows that 12-step attendance in itself, regardless of strength of affiliation, mediated a significant reduction in depression. In turn, the lower depression mediated an improvement in substance use. The improvement in depression in those treated by 12-step facilitation (TSF) actually exceeded that in a CBT group. Moreover, the beneficial effects of 12-step attendance on depression were also evident in those clients in the CBT treatment group who chose to attend the 12-step meetings. In summary, major depressive disorder is not an exceptional problem for those attending 12-step groups because AA attendance itself has a beneficial effect on depression, and lower depression leads to successful recovery from addiction.
There is an apparent problem in regard to clients with dual diagnosis or “co-morbidity”, as to which condition – the addiction or the accompanying psychiatric condition, in this case major depression – should have priority in treatment. If the findings in this study can reliably be confirmed then I think two conclusions emerge that illustrate the essential interdependence of the two tasks. First, in this particular group of clients, it is important to reduce depression as a prelude to effective therapy for substance use. Second, AA attendance in itself helps bring that about reduction. What in particular is it about attendance at AA that is important in this process? It would appear that it is not all to do with enthusiastically following the programme, important though that might be. I would suggest that the most important factor is the sense of hope that comes from social identification (or fellowship) with those who have found a meaningful route to personal wellbeing in recovery.
Professor Geoffrey Stephenson