Commentary on Kelly et al. (2010): Alcoholics Anonymous, alcoholism recovery, global health and quality of life


Scientific studies to evaluate the effectiveness of Alcoholics Anonymous (AA) have increased significantly in number and methodological sophistication [1]. Early AA studies focused narrowly on drinking outcomes, but more recent studies reflect growing interest in the effects of AA participation on the larger arenas of emotional/behavioral health and quality of life [2–4]. Current efforts to define recovery for research and clinical purposes similarly include the elements of global health and citizenship in addition to the resolution of alcohol and other drug problems [5]. These trends are congruent with AA's view of itself. A central tenet of AA is that recovery from alcoholism involves far more than the removal of alcohol from an otherwise unchanged life. AA's 12 Steps and core concepts within the culture of AA (e.g. dry drunk, emotional sobriety, spiritual awakening) convey a vision of recovery as a radical transformation in character, identity and interpersonal relationships. AA's ‘promises’ speak not of an escape from drunkenness but from fear, selfishness, self-pity and regret and the acquisition of freedom, happiness, serenity, peace, confidence and authentic connection to others [6].

Kelly et al.[7] have added to the literature of the effects of AA on global health through their study of changes in depression as a mediator of the influence of AA participation on drinking outcomes. The authors begin with two foundational points: (1) depression can predate the onset of alcohol use disorders (AUD), be exacerbated by AUD or emerge as a consequence of AUD; and (2) depression constitutes an obstacle to recovery and a risk factor for relapse following recovery initiation. Kelly and colleagues' finding that AA participation alters drinking patterns (via increased abstinence and lowered intensity and duration of relapse episodes), in part, by decreasing negative affect and depression adds an important new contribution to the existing literature on mechanisms of change in AA. They also add nuance to the question of whether factors such as decreased depression are peripheral outcomes of changes in drinking behavior or the driving force behind changes in drinking behavior. The lagged design of this study allows a clearer suggestion of causation related to the latter influence. Hopefully, future studies of mechanisms of change in AA will similarly distinguish mediators of change from outcomes of change.

If the study by Kelly and colleagues were to stand as a historical artifact of early 21st-century research on AA and recovery from AUD, that artifact would suggest several important findings. It would tell us that AA has survived and thrived as it approaches its 75th birthday—an important finding, given that few of its predecessors outlived their founding generation [8]. The finding that AA's 12 Step program can alter a targeted behavior and enhance global health and quality of life simultaneously or sequentially offers an important clue to AA's growth to more than 2 million members, its world-wide dispersion and the seemingly endless adaptation of AA's program to other problems of living. The Kelly et al. study also stands as a testament to our deepening understanding of the recovery process and a symbol of the coming of age of methodological rigor in the scientific study of mutual aid groups.

Research on the resolution of alcohol and other drug problems has focused traditionally on a process of subtraction—the problems that are diminished or eliminated through the recovery process. The Kelly et al. study is indicative of a new focus: the measurement of what recovery adds to the lives of individuals, families and communities. That shift in focus is long overdue, and its fruits could help to alter the social and professional stigma that continues to be attached to alcohol and other drug use disorders.

Scientific knowledge and experiential knowledge represent two radically different traditions of knowing [9], yet scientists and AA members are finding common ground as both groups try to understand more deeply how AA works and seek to widen the doorway of entry into long-term recovery from severe alcohol-related problems. Science can pose both threats and opportunities to recovery mutual aid societies, but there seems little question that we are entering an era of confluence between key elements of AA folklore and the findings of rigorous scientific studies.

Declaration of interest