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Alcoholics Anonymous vs. the Benefits of Integrative Treatment in the Biopsychosocial Framework

Columbia University School of Social Work
SOCWT7302 Z41 Social Work Practice in Alcohol and Substance Abuse
Professor Jacques Nir
May 6th, 2022


Twelve-step programs such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) are widely considered to be the most effective treatment for substance use in the United States. Even within our judicial and medical systems, their programs are recommended in the legal setting and by medical practitioners based on their purported efficacy. What is not widely known is that research has shown that there are other forms of treatment that may be more effective either independently or concurrently with twelve step programs to provide more long-term success. These other modalities provide advantages which could equate to higher rates of success and lower rates of attrition/relapse by taking a more well-rounded approach to individuals struggling with alcohol abuse. By combining these modalities to form an integrated approach an individual can experience greater recovery outcomes through a biopsychosocial lens.

Alcoholics Anonymous vs. the Benefits of Integrative Treatment
in the Biopsychosocial Framework

Alcoholics Anonymous (AA)

The road to recovery can be incredibly isolating. Twelve-step programs can help provide a safety net for an individual in recovery and allow them to be vulnerable in a safe and non-judgmental environment. In this environment they can engage with peers that are also experiencing the struggles of recovery and the aspect of anonymity and relatability work together to dissolve shame. Many individuals in recovery struggle with deteriorated relationships with their families and social networks and the group dynamic that AA provides can fill this relational gap. Studies have shown the effectiveness of peer recovery support or mutual-help programs and it can be attributed to the emphasis on community and fellowship. One major factor for potential to relapse is an individual’s social environment and potential aspects of the environment to activate urges. In the twelve-step group setting, one can build positive, sober relationships with other members of the group through sharing and allowing oneself to become vulnerable. This model expedites this bond building process whereas in organic relationships, the progression wouldn’t be so immediate.

Another positive aspect of twelve step programs that helps continue the recovery process outside of the group meetings, is the relationship between sponsor and sponsee. The sponsor can provide insight and accountability while modeling a sober lifestyle. Additionally, this peer based; dyadic relationship helps the individual by providing additional, real-time support when an individual is actively feeling urges to relapse. It is generally recommended that a sponsor have at least one year of sobriety and is active member of the twelve-step community. The nature of becoming a sponsor in these programs coincides with the twelve-step mission of “Service”; to serve others to further their own recovery thus making a mutually beneficial dyadic relationship that sustains the community.

Problems with AA

One of the major controversies with AA/NA are its religious origins and the integration of religion in its overall framework. For example, the twelve steps are analogous to Christianity’s twelve commandments and its ideology is built around the belief that an individual acknowledges the existence of and should surrender their will to a higher power. Although individuals are advised that it is not necessary to have any particular religious affiliation, the ‘Big Book’, the emphasis placed on powerlessness, and even language can be off-putting to people with backgrounds in other religions or who have no religious background at all. Even in mutual recovery programs that are secular, the overall nature of the group environment and shared intimacy can feel cult-like.

An AA sponsor engages with an individual on a more intimate and personal level due to their shared experiences and a mutual peer-based relationship. Sponsors provide invaluable support that can help target specific behaviors and/or urges in real time with the lived experience and empathy necessary to support the client. Though this situation may seem ideal, there are many factors that could affect this relationship due to incompatibility, inconsistency in the commitment, the risk of the sponsor to relapse, and abuse of power in the dynamic. It is generally recommended that sponsor/sponsee relationships are same gender relationship (in heterosexual dyads) to avoid the potential for romantic situations, and potentially lead to abusive situations. This is not to say that all abusive situations are romantic in nature but there are situations when those in a vulnerable state are preyed upon.

Lastly, AA overlooks comorbid mental disorders. Alcohol abuse rarely functions alone and beside comorbidity of other substances, there is also the potential presence of underlying psychological factors. Depression, anxiety, bipolar disorder, and more are some common disorders that occur comorbidly with alcohol use disorder. The use of substances can exacerbate symptoms and complicate an individual’s ability to function and live normally. AA doesn’t address how this could affect the recovery process.

Recent Data

A recent report (2006) released by Cochrane Library concluded that “42% of participants participating in AA would remain completely abstinent one year later, compared to 35% of participants receiving other treatments including CBT.” (Kelly J.F. et al 2020). After many years of speculation at the efficacy of AA this report seemingly confirms AA to be the definitive treatment for alcohol use disorder. Despite this claim, the review has significant flaws that cannot be overlooked.

The review found that overall, participants had similar days abstinence as other treatment modalities however, had more abstinent days in the early part of recovery but not continuously. Also, AA was not able to moderate levels of drinking at relapse, and the report states that participants would actually drink more heavily when relapsing vs. other modalities.

Another problem with the studies in this review is the high selection bias. As all the studies reviewed were in highly controlled environments with participants selected from voluntary rehabilitation centers and it is highly likely that these participants would outperform randomized participants or participants who are court mandated to be in AA. They were all privileged, cooperative, “socially stable, no involvement in the criminal justice system.” (Peele, 2020)

Therapeutic alliance

In the therapeutic relationship between clinician and client, there is always the potential for ambivalence on the side of the client due to dissimilar backgrounds. The client may also feel that because the therapist perhaps has not had the same struggles with substance that they’re not able to fully understand their experience. Although the clinician could be well versed in most treatments for substance use disorder, there exists a barrier in that dyadic relationship. Alternatively, with the sponsor/sponsee relationship in AA, where there are two individuals of shared experience and struggle, it could potentially be easier to have an intimate level of engagement. Additionally, twelve step programs have been heavily promoted for efficacy and because it is free, are accessible to every population whereas finding a compatible clinician can be quite tedious. There are numerous meetings available in virtually every city daily so there is no shortage of participants to meet with and find potential sponsors, so it is understandable that and individual would find support in AA alone rather than go through the process of finding a clinician and dealing with the complications of health insurance coverage.

Despite the ease with twelve step groups, there isn’t this potential for independent learning and thinking or individualized treatment. Again, they do not account for any co-occurring disorders and although they have narcotics anonymous (NA) to support additional substance use, it can be time consuming to attend two different sets of meetings. There are complex nuances in the relationship between alcoholism and other mental health disorders and without the support of a professionally trained clinician, it can be difficult and overwhelming to navigate.

MAT treatment and advantages

The use of psychopharmaceuticals to treat alcohol use is not new. Although there is some stigma in AA groups regarding MAT treatment (Rychtarik, et al. 2000) because it can be looked at as replacing one substance with the use of another, studies have shown that certain drugs can help reduce the frequency of relapse.

Naltrexone (Brand name ReVia, Vivitrol and Depade), is a non-addictive opioid antagonist that was developed in the 1960s for treatment of opioid dependency and it was approved over thirty years ago in the 1990’s by the FDA to be used in the treatment of alcohol use. Naltrexone works by blocking the endorphin effects of alcohol and over time can minimize the desire to drink overall or can help an individual manage their drinking. In past research developed by Dr. John David Sinclair it was suggested to use naltrexone while still drinking by the process of pharmacological extinction. (Sinclair, et al. 2001) In operant conditioning, extinction works against the reward response that the brain has conditioned to have in response to alcohol. It is recommended to take one dose one hour prior to having a drink and this would block the subsequent feelings of euphoria. Although these feelings are blocked, naltrexone does not block the physical functions such as motor impairment and does not prevent or stop withdrawal symptoms. Over time, the urge and cravings to drink would diminish. Due to the recommended use of taking this drug while still drinking, it was generally not supported for those participating in AA. Recent research has shown however, that naltrexone can actually be used in recovery after a period of abstinence. (Maisel, et al. 2013). Although it does not work in the same way as we see in the Sinclair method, taking the drug daily has been shown to reduce heavy drinking and cravings.

Another common drug prescribed for the alcohol dependency is acamprosate (Brand name Campral). This drug also works as an antagonist, but it works as a GABA regulator to stabilize the brain and over time, homeostasis. As acamprosate is not an opioid blocker, it is not generally recommended for individuals who have comorbid opioid-based substance use as it is only effective for alcohol.

Neither drug has psychoactive properties and they both require periods of withdrawal prior to treatment but Naltrexone is a bit easier to take; once a day, or one hour before drinking vs. three times daily for acamprosate. Naltrexone has been shown to be more effective targeting heavy drinking and cravings, while acamprosate may be better for overall abstinence. Perhaps taken together, it could be beneficial for recovery, however more research needs to be established to confirm this. (Maisel, et al. 2013), (Keifer, et al. 2003). Studies have also shown that the use of naltrexone could also help encourage individuals to be more active in therapy after experiencing less intense relapse. (Rubio, G. 2001). There are other drugs available for alcohol treatment such as Disulfiram, which incurs feelings of nausea in the body at the presence of alcohol, however the efficacy of these other drugs is not as confirmed.

Barriers to MAT

Although studies have shown MAT treatment to be highly effective, lack of awareness and studies regarding how to use them has led to ambivalence among practitioners. Many clinicians have the concern that patients may not be consistent in taking the medications as prescribed, which may be more of an issue with acamprosate because the dosage is three times a day, vs. naltrexone which is only as needed or once daily. (Depending on if it is being used for abstinence or moderation.)

Additionally, there is debate on the use of these drugs interfering with the development of “willpower”, however this is related to the ideology that alcoholics choose to continue in their addiction and need to build the strength to abstain. In AA, MAT treatment is often looked at as replacing one substance with another or creating dependency on another substance in favor of another, however, as naltrexone, and acamprosate are both non-addictive and have no psychoactive properties, it is not necessarily comparative.

There is also the argument that MAT treatment doesn’t address the causality for alcohol use disorder, however, mutual support groups alone don’t address this either. Working with a mental health practitioner, paired with MAT treatment, through skills training or psychodynamic therapy, depending on the clinician, can resolve the questions of causality with the individual. Then, based on the individual’s reasons for drinking, and after identifying specific environmental, situational, or tangible triggers, coping and mindfulness exercises can be implemented to strengthen their intervention.

Opportunities to change treatment

Although there is no doubt that AA is an effective treatment for those struggling with alcohol use disorder, it is more beneficial to follow an evidence-based treatment model and use an integrated form of treatment that has been tested empirically. Biologically, the use of MAT treatment with either naltrexone, or acamprosate, or both, could facilitate the initial stages of recovery. Whether an individual is choosing to proceed with an abstinence based or moderate management-based route with recovery, there are psychopharmological treatments that are specialized for either method. Psychologically, working with a clinician specializing in behavioral therapy (and medications if seeing a psychiatrist) can support the individual throughout the treatment process and provide psychoeducation and skill building. These skills working synchronously with the MAT can provide additional support when dealing with cravings and the effects of withdrawal. Lastly, a mutual help support group to provide the individual with the fellowship and peer support that programs like AA provide, would complete the integrated treatment. History and numbers play a huge role in the endurance of twelve step programs, however, there needs to be more of an emphasis on individualized treatments that could have better outcomes for individuals struggling with addiction.

For MAT treatment to be more widely used concurrently with therapy and a mutual support group, there needs to be more research and education for physicians to feel more comfortable prescribing this. As of now, naltrexone is rarely prescribed for alcohol use disorder despite the studies indicating its effectiveness and overall low cost. (Heinrich, et al 2008). Additionally, making these drugs available over the counter would make this style of treatment more accessible to those who are ineligible for insurance.

This dependence on the social structure and community of the AA program alone, although fulfilling to some, can inhibit the potential for independent growth, development, and recovery. Filling the gaps that AA doesn’t fill with therapy and MAT treatment would create successful, integrated treatment that would follow the biopsychosocial model and take a well-rounded approach to the individual while being easily modifiable to their specific needs.


1. 2019. Evidence for Peer Support. Technical Report. Mental Health America. 9 pages. https://mhanational.org/sites/default/files/Evidence20for%20Peer%20Support%20May%202018.pdf

2. Flanagin, J. (March 2014) The Surprising Failures of 12 Steps. The Atlantic. https://www.theatlantic.com/health/archive/2014/03/the-surprising-failures-of-12-steps/284616/

3. Kelly, J.F., Humphreys K., Ferri, M. (2020) Alcoholics Anonymous and other 12‐step programs for alcohol use disorder. Cochrane Database of Systematic Reviews 2020, Issue 3. Art. No.: CD012880. DOI: 10.1002/14651858.CD012880.pub2. Accessed 06 May 2022.

4. Peele, Stanton (2020) So Alcoholics Anonymous Is “Proven” to Work After All? Not So Fast. Filter. https://filtermag.org/alcoholics-anonymous-cochrane/

5. Donoghue, K., Elzerbi, C., Saunders, R., Whittington, C., Pilling, S., and Drummond, C. (2015), The efficacy of acamprosate and naltrexone in the treatment of alcohol dependence, Europe versus the rest of the world: a meta -analysis. Addiction, 110, 920– 930. doi: 10.1111/add.12875.

6. Rubio, G., Jiménez-Arriero, M. A., Ponce, G., Palomo, T. (September 2001) NALTREXONE VERSUS ACAMPROSATE: ONE YEAR FOLLOW-UP OF ALCOHOL DEPENDENCE TREATMENT, Alcohol and Alcoholism, Volume 36, Issue 5, Pages 419–425, https://doi.org/10.1093/alcalc/36.5.419

7. Kiefer, F., Jahn, H., Tarnaske, T., Helwig, H., Briken, P., Holzbach, R., Kämpf, P., Stracke, R., Baehr, M., Naber, D., & Wiedemann, K. (2003). Comparing and combining naltrexone and acamprosate in relapse prevention of alcoholism: a double-blind, placebo-controlled study. Archives of general psychiatry, 60(1), 92–99. https://doi.org/10.1001/archpsyc.60.1.92

8. Heinrich, C. J., & Hill, C. J. (2008). Role of state policies in the adoption of naltrexone for substance abuse treatment. Health services research, 43(3), 951–970. https://doi.org/10.1111/j.1475-6773.2007.00812.x

9. Maisel, N. C., Blodgett, J. C., Wilbourne, P. L., Humphreys, K., & Finney, J. W. (2013). Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction (Abingdon, England), 108(2), 275–293. https://doi.org/10.1111/j.1360-0443.2012.04054.x

10. Sinclair, J.D. (January 2001). Evidence about the use of naltrexone and for different ways of using it in the treatment of alcoholism, Alcohol and Alcoholism, Volume 36, Issue 1, January 2001, Pages 2–10, https://doi.org/10.1093/alcalc/36.1.2

11. Rychtarik, R. G., Connors, G. J., Derman, K. H., & Stasiewicz, P. R. (2000). Alcoholics Anonymous and the use of medications to prevent relapse: An anonymous survey of member attitudes. Journal of Studies on Alcohol, 61(1), 134–138. https://doi.org/10.15288/jsa.2000.61.134