If You Work it, It Works

By Joseph Nowinski, Ph.D.

A Look at "Naturalistic" Studies

The first research method we will examine is used in studies that follow men and women who do (or don’t) choose to participate in AA. Rudolf and Bernice Moos conducted one such study. Rudolf Moos is a professor in the Department of Psychiatry and Behavioral Sciences at Stanford University and the recipient of the Hofheimer Prize Award from the Journal of Psychiatric Research. He and his wife and co-researcher, Bernice, are both affiliated with the Center for Health Care Evaluation, also in Palo Alto, California.

This study began by identifying a sample of 362 men and women who had experienced enough problems related to drinking that they were motivated to call an information and referral center to find help. They were diagnosed based on what they reported about themselves and their drinking via a questionnaire. The researchers then followed these volunteers for sixteen years—a remarkable length of time for any study—assessing them periodically.

The Moos sample was divided into three categories, depending on what individuals chose to do. No one was assigned to any of these groups; rather, they simply represent the different path-ways that the participants voluntarily chose in the first year of the study. That is what makes this a naturalistic study. Here are the pathways:

• Group 1: People who decided to start going to AA but not to seek professional treatment of any kind
• Group 2: People who decided to start going to AA and seek professional treatment at the same time
• Group 3: People who decided to seek professional treatment but did not start going to AA

When examined “at the starting gate”—when they first entered this long-term study—the three groups did not differ demographically or in terms of their drinking patterns. For example, those with the worst drinking problems did not systematically choose one path over the others. This is important because it means that initially the three groups were essentially alike other than for the different pathways they chose.

All three groups were followed for sixteen years and assessed after years one, three, eight, and finally again at year sixteen. This is indeed a long time to follow a group of people and is a good example of what researchers call a longitudinal study. Another example of a naturalistic study would be to identify two comparable groups of people, one that then decided to diet and
exercise carefully, and a second that did not. Assuming that the two groups were equivalent at the outset, a longitudinal study could be used to compare the status of their health one year, three years, eight years, and sixteen years later.

Obviously, naturalistic longitudinal studies have the potential to tell us a lot about the consequences of pursuing different pathways. In the case of the Moos study, here is what they found:

• People in group 2, who opted for treatment and AA at the same time, participated in AA longer and more frequently.
• Moreover, people in this group were the most likely to stay sober throughout the course of the study.
• People who began attending AA but then dropped out were more likely to start drinking again.

The longer people remained active in AA, the more likely they were to stay sober at all four follow-ups: one year, three years, eight years, and sixteen years.

One additional finding of interest in this study concerned those in group 3, who opted at the outset for treatment but decided against going to AA. Some of the men and women in this group later decided to try AA, but this delayed move did not seem to improve their chances of staying sober. We do know, however, that when they finally decided to attend AA meetings, they did so less often than those in the other groups. The authors conjecture the men and women in group 3 may have held more negative or skeptical attitudes about AA; for example, that it encourages dependency. Alternatively, they may not have believed (rightly or wrongly) that their alcohol use disorder was severe enough to warrant attending AA. Either way, these late-starters did not fare as well as their counterparts who opted either for AA alone or AA plus treatment from the beginning of their recovery efforts.

A companion naturalistic longitudinal study, also conducted by researchers at the Center for Health Care Evaluation, followed 135 individuals (half men, half women) who also reached out to an information and referral service in Northern California. Prior to initiating these contacts, none of the men and women had ever received treatment for an alcohol use disorder.

The researchers followed this group for three years, gathering information at different points in time. Here are some of the questions they sought to answer:

• How severe was each individual’s drinking problem?
• Had they sought treatment after making contact?
• Had they tried AA?
• Were they drinking heavily, moderately, or not at all at each point in time?
• How much support did they feel they had for staying sober from a spouse, friends, or family?
• What was their socioeconomic status?

One thing I found of interest in this particular study, which was published in a 1995 edition of the journal Addictive Behaviors, was a footnote that appeared on the first page. The footnote addresses whether recovery that is associated with attending AA should be considered “natural” or a “treatment.” I believe the authors correctly asserted that AA is not a treatment, for two reasons. First, they suggest that fellowships like AA are better viewed as natural community resources and ways of life, rather than treatments.

Second, self-help, peer recovery fellowships like AA require no professional guidance or intervention, but are run by their members. This is important, because critics of AA often refer to it as an “unproven treatment,” when in fact AA has always considered itself to be a recovery fellowship, not a treatment program. That’s not to say, however, that AA and the Twelve Step program is “unproven” as a way to stop drinking. That is the very issue we are examining here.

Out of this starting group of 135 men and women with alcohol use disorders, 28 eventually became abstinent—they did not drink at all, showed no objective signs of dependency, and had no drinking-related problems. Another 29 people in the study ended up being “moderate” drinkers—they drank significantly less, showed a few (but not a lot) objective signs of dependency, and reported few drinking-related problems. This finding, that some people became moderate drinkers, will be addressed in more detail in the next chapter. For now, let’s explore what the researchers discovered when they took a closer look at the people who abstained:

• This group had more severe drinking problems at the outset.
• They believed their drinking was a very serious problem.
• They had little social support; instead they relied heavily on AA to maintain their recovery.

The second bullet may be the most significant. These individuals had decided on their own that they had a severe drinking problem that needed attention. In other words, they agreed with the diagnosis they received. Findings from this second naturalistic study echo those from the one previously discussed, but they also amplify them. These additional data point in a specific
direction: the men and women in this study who had more severe drinking problems, who believed their problem was severe, and who reported having little social support were inclined to choose AA as their solution. It became their path to recovery, and they became abstinent. Moreover, they did so without any outside intervention.

In contrast to the above, the group whose problems were less severe, and who reported having the added benefit of supportive relationships, eventually became moderate drinkers. Again, this does not mean that they experienced no drinking-related problems, but rather that they experienced relatively few of them.

These results raise the question of whether abstinence or moderate drinking should be the goal of treatment, and this will be addressed in chapter 4. As it stands, the two naturalistic studies we’ve looked at so far support the idea that AA works for those who choose to work it. In addition, and perhaps because AA has become so ubiquitous and accessible in society, it is often chosen as a solution, especially for those with more severe drinking problems who do not have other sources of social support.

Since the publication of Alcoholics Anonymous in 1939, the Twelve Steps have been central to staying sober for millions of people around the world. AA (Alcoholics Anonymous), NA (Narcotics Anonymous), Al-Anon, and countless other recovery organizations and treatment programs have adopted the Steps as their program for abstaining from substance use and compulsive behaviors. However, recently a growing chorus of critics of the Twelve Step model is claiming that the science behind this model is questionable.

In If You Work It, It Works!, Joseph Nowinski, Ph.D. calls upon the most up-to-date research, teamed with the critical work he did on Project Match, an eight-year multi-site research study proving the efficacy of Twelve Step Facilitation, to build a compelling case as to why working the Steps provides predictable and successful outcomes with:

• Experienced, knowledgeable sponsors
• Consistent attendance at peer support groups
• Systematic application of the Steps
• Treatment professionals effectively incorporating the Steps and peer support in their recovery management programs

Joseph Nowinski, Ph.D. is a clinical psychologist who has taught at the University of California San Francisco and the University of Connecticut, as well as serving as Supervising Psychologist, University of Connecticut Health Center. He is the author of Twelve Step Facilitation Therapy (TSF), listed in the National Registry of Evidence-based Programs and Practices and Almost Alcoholic: Is My (or My Loved One's) Drinking a Problem? with co-author Robert Doyle, and blogs regularly for the Huffington Post and Psychology Today.