AA Efficacy

What’s the story on Alcoholics Anonymous and other 12-step recovery groups? This of course relates to the science behind it and outcomes regarding efficacy. This post will relate only to AA and alcohol misuse problems where the information is most complete. Since the others are so similar we might presume that they will also show similar data – or lack thereof since that is the major problem with all the so called faith-based programs.

First off, it’s important to say that Alcoholics Anonymous and the other twelve-step groups have been an established entity for many years, and although there is considerable conflict about their efficacy. There will be many, many people who will testify to the fact that it was of an inordinate amount of help to them and further was instrumental in their successful recovery. Furthermore, I agree with and strictly adhere to the concept that bashing or demeaning these programs is not to be tolerated in spite of the fact that my own personal view is that there are many things about it that I object to.

But that’s not the point here. Basically I would ask, what is the scientific support that would allow one with confidence to recommend a twelve-step program at all? Or especially, what is the science in favor of a science-based program such as ours – SMART recovery®? The bold and patent fact is, there is none!

There are numerous studies about this and if one is really interested in seeing a rather comprehensive review of this, I would recommend The Orange Papers (http://www.orange-papers.org/orange-secrets.html). A critical reading of the literature would lead one to realize that there are some studies which do show AA efficacy, some that do not, and actually, some which show that AA can cause harm. Hence the conclusion about this is basically… we don’t know!

Of the science behind this, is that which stems from a concept known as locus of control. This concept is not universally accepted in the psychology community. Although it’s actually based on some pretty sound sense and is helpful in understanding how we deal with ourselves and others.

Locus of Control

At a recent New England facilitators meeting, it was asked if a person’s locus of control was fixed by genetics. The idea was, if that is the case and the locus is external, then there is less likelihood that a program like SMART would be helpful to such an individual. This has the further implication that a facilitator might better focus attention on more receptive individuals.

This is an excellent question with no easy or single answer.

A response begs the question as to whether a facilitator ought to focus attention on those more likely to succeed. My own opinion is a vigorous no -- not in a SMART meeting. Choosing only to work with high internal locus participants is cherry picking and requires an assessment on the part of a facilitator that he/she is not equipped to make.  

So the question is rather whether the outlook for success is less with those in the external locus category, whether they might be better off with a higher power based group, etc.

Those questions I also cannot answer. The genetics one is hard enough and thanks DV for asking it. But I can summarize the available information and try to at least partially answer the question:

The best answer is yes… And no.

Let’s unravel that:

Locus of control is a theory used in social psychology and is based on the work of Julian Rotter, from the 1950s wherein he estimated that people’s outlook is either based internally or externally; that is, either we believe that we are in control of our own thoughts, feelings, and behavior thus destiny; or that outside forces are. Joe G. likes to refer to the famous Rafael painting here of Plato and Aristotle with one with finger pointing up and the other down. http://upload.wikimedia.org/wikipedia/commons/f/ff/Plato_and_Aristotle_in_The_School_of_Athens,_by_italian_Rafael.jpg

Wikipedia puts it this way: Those with a high internal locus of control have better control of their behavior, tend to exhibit more political behaviors, and are more likely to attempt to influence other people than those with a high external (or low internal respectively) locus of control. Those with a high internal locus of control are more likely to assume that their efforts will be successful. They are more active in seeking information and knowledge concerning their situation.

One's "locus" (Latin for "place" or "location") can either be internal (meaning the person believes that they control their life) or external (meaning they believe that their environment, some higher power, or other people control their decisions and their life).

Locus of control is basically a belief and is on a sliding scale from extreme internal to extreme external. Either extreme is not good. But there is a set point and that can be measured. For example I’m at a .8 on the internal side. For those who complain that I sometimes don’t listen, or I’m too self-assured, they mean I’d be better at a .7.

Even though there is no really good science behind this by the way, which is a separate issue; as a model it is still rather well-accepted and useful. Regarding the science, I feel I must explain this in spite of it not being directly on topic.

Psychology is often not based on good science as a more basic scientist knows it. One huge problem is psychologists have is the lack of crisp objective and quantifiable endpoints they can use to measure things. Although some progress is being made they have a very long way to go.

Another problem is more workable. Psychologists frequently ignore Occam’s razor – the idea that the simplest explanation with the fewest variables is the best one. They try to resolve confusion by adding new variables or theories. For example, there are about 140 “validated” cognitive “therapies”. How can one really ever tell which is effective? Many psychologists don’t seem to understand very well the ideas of rules of evidence, proper hypothesis generation, hypothesis based and driven research, falsifiable hypotheses, weight of evidence concepts, etc. There are good ways to go about this in spite of the lack of good objective endpoints to measure in psychology. And to psychologists’ credit their studies are getting better.

So is poor science better or worse than no science? I prefer no science. But we can at least reason from hypotheses and that’s what I’m doing here.

The other thing that needs clarification is what we mean by genetics. That too has become a less well-defined term. To say something is genetic today is very vague and imprecise; similar to saying someone is an “alcoholic”. What does that mean? One thing it means is poor science. So what we are talking about is heritability and that is a fraction of the total trait. For example, just a part of what comes from the parents vs. what comes from the environment.

Further scientific clarification includes whether a trait is gene-based inheritance or not, and if gene-based whether it’s DNA-based. OMG this is out of control. Anyway…

DNA-based means that a trait is fixed, like eye color. This is Mendelian genetics.

Non DNA-based but gene-based is not fixed… This ability of a trait to adapt is known as epigenetics and resides in the non-nucleotide portion of a gene. This is Epigenetic Inheritance. This is an exciting new field which implies a kind of human evolution more rapid than that of natural selection originally described by Charles Darwin.

Without getting deeper into inheritance and heritability (there are at least one and maybe two other kinds), we can say the following based on a reasonable weight of evidence:

Locus of control, like most personality traits, has a heritability of between .4 and .5.  That means that at least part of one’s locus of control is environmental; that is, it is learned behavior. 

A personality trait is more likely epigenetic rather than genetic (DNA based). That means that its set point will change over the lifespan of an individual. For example, at age 16 your locus of control was more external and at 60 it is likely to be more internal. Now the good part; if you had a kid at age 16 the kid would likely have a more external locus than the one you had at 60.

It also means that locus of control is somewhat plastic i.e. malleable to other forces.

That’s epigenetics at work and what is so exciting about the field.

There is one more thing to take into consideration -- the “depth” of the belief in the personality spectrum. For example, sexual identity is very deep and therefore very unlikely to change with any form of therapy. Phobias are the most superficial and thus mutable. Martin Seligman, proponent of positive psychology, explains this particularly well.  

“Depth” of the trait has three components. One is “genetic” and not under our control. The other two components are “affirmable” and “power”. If a trait is easy to affirm then the depth is greater. (However, in SMART we can often illustrate that a given belief, something they might believe is a personality trait, is not working for the person.)

Power refers to how general a trait is. 1 + 1 = 2 is generally believed to be true and hence has great power... and thus is not plastic.

Locus of control on a depth scale l is somewhere in the middle—therefore somewhat mutable.

So what does this all mean?

First: locus of control is plastic – the set point will change on its own and to some extent can be changed willfully.

Second: the learned behavior part can be modified as well. Again, willfully.

And both can be changed with help. Cognitive psychology is the tool to help this along.

So the answer is yes and no…

SMART Recovery CAN be helpful to those with an external locus of control.

Okay, “How do we do it?” is the more important question

Motivation is one part. Showing with a reward/punishment model how the results improve with a more internal locus. I personally strive to help people take “ownership” of their problem. This involves a locus shift. If you have diabetes, you manage it by measuring blood sugar and administering insulin... all with help and support of others but you do it... Same goes for addiction.

There are test instruments to gauge where a person is on the continuum but I’ve no experience with them.

REBT is of use with some people using the ABC tool... especially with absolute negative thoughts, such as “I can’t do this.” 

Awareness training, what I call Mindful Awareness, is also helpful.