Talk:Alcoholics Anonymous/Archive 10

Including Dennis M. Gorman’s claims violates WP:UNDUE and WP:MEDDATE

I have twice had to remove versions of the the following content from the page:

Critics, including epidemiologist Dennis M. Gorman, have described Alcoholics Anonymous as a form of pseudoscience due to its reliance on anecdotal evidence and less rigorous studies (e.g. no randomized-controlled trials).

While referenced, the references are from 2003 and 2010. Because of WP:MEDDATE, the more recent 2020 Cochrane study (which, for the record, uses only randomized-controlled trials), this information is down right incorrect. Adding it again without discussion about exactly why we should add 2003/2010 research which directly contradicts more recent 2020 research will be considered a form of edit warring.

SkylabField (talk) 06:40, 16 February 2023 (UTC)

uses only randomized-controlled trials
Actually not true. It also uses quite a few quasi-experimental studies, which are different from RCTs. More than half of the included studies in that review are non-randomized. Many of the randomized trials did not compare directly to standardized treatment in the fashion expected from RCTs (see Figure 3). Selection bias was a concern in ~40% of the included patient data. Attrition bias in ~30% (See Figure 4).

We included 27 studies containing 10,565 participants (21 RCTs/quasi‐RCTs, 5 non‐randomized, and 1 purely economic study).

The 2020 review also, importantly, did not compare or standardize AA with respect to the medical standard therapy involving disulfiram and/or Naltrexone. AKA we have no idea how many or which of these patients were taking medical therapy. And it's possible, as a result, that a medical-use bias exists in more manualized studies or studies with greater or lesser adherence a la Berkson's bias.

In general, I think AA probably is effective based on all this evidence. But that's just my personal bias based on my understanding of the treatment. The evidence is good that it probably works, but also not good enough to forestall these criticisms. Gorman is also not the only one who has voiced this criticism. We have sources here and elsewhere from 2015 which describes similar concerns.

When we compare treatments in systematic reviews, it's also extremely important to think about non-manualized interventions (e.g. Intention-to-treat analysis, as it will actually happen in most cases in the real world). In such cases, there is only "low-certainty evidence" or "very-low-certainty evidence") of non-inferior efficacy in this 2020 Cochrane review. Overall, evidence for AA is trending towards efficacy, and it's clear that an academic consensus supports its efficacy in this review. But not enough to forestall even MENTIONING significant academic criticism published in trustworthy reliable academic sources per WP:FRINGE.

I would be in favor of making the mention more general and not specific to Gorman, however. And citing Lilienfeld.

Sources

— Shibbolethink ^{(♔ ♕)} 15:28, 16 February 2023 (UTC)

The restored edit says “no randomized-controlled trials” have been conducted. This is false and needs correction, or better yet, removal due to its expiration.— Preceding unsigned comment added by 5ive9teen (talk • contribs) 17:23, 16 February 2023 (UTC)

fixed — Shibbolethink ^{(♔ ♕)} 17:53, 16 February 2023

To say “Because of the anonymous and voluntary nature of AA meetings, it has been difficult to perform random trials with them” without adding that many RCTs have been conducted is incomplete and potentially misleading.

@Shibbolethink: please do not attempt to edit the Alcoholics Anonymous article until you get consensus to add the content. Right now, you are reverting the edits of two other editors in an attempt to add this content that, it would appear, no other editor here wants in the article. You do not have consensus to add this content. An attempt to add it again (unless we get consensus, which we do not have right now) will result in me escalating the issue to WP:AN/I. You have been warned. SkylabField (talk) 05:25, 17 February 2023 (UTC)

Right now, you are reverting the edits of two other editors in an attempt to add this content that, it would appear, no other editor here wants in the article

Actually @Bon courage added it on 27 January 2023. You are now disputing its inclusion, ~3 weeks later. It appears @5ive9teen would like to adjust how these things are mentioned, but has not actually explicitly said it should be excluded. I agree with them that we should adjust the mention.

But to say no other editor here wants [the content] in the article is blatantly false. You used to have the username Defending AA and have top 10 edited pages that include: Effectiveness of Alcoholics Anonymous/Talk (34% of your overall edits) (now a redirect to this page), Alcoholics Anonymous/Talk (25%), Lance Dodes (3%) (a noted critic of AA), and a number of other Alcoholism/AA-related pages.....

It certainly appears as though you may be a single-purpose account, whose goal on Wikipedia is to remove or reduce criticism of AA. I would give you the benefit of the doubt on that, but the appearance certainly isn't good.

Why don't we get some outside input on this question instead of relying on a consensus built from users with a bias? such as a WP:RFC. — Shibbolethink ^{(♔ ♕)} 14:19, 17 February 2023 (UTC)

I find it a little creepy and obsessive that you have looked in to my edit history at that level of detail, and you are making me feel uncomfortable. SkylabField (talk) 21:45, 17 February 2023 (UTC)

Yes, gatekeeper tendencies can go into play quickly and we then get lost in what Wiki policies are in effect. To say I don’t like that edit and to announce an edit war, but to then offer no suggested edit of the section itself suggests that policing, so far, is the only goal. Could we stop the pissing match and get the section itself? Here’s my 2 cents. The critique by Gorman is out of date and superced by the Cochrane review. But the section, presumably, is concerned with valid critiques, not ones well out of date.

Those who have no interest in contributing to the dialogue are not helping should take their hall monitor vests and themselves elsewhere. 5ive9teen (talk) 17:59, 17 February 2023 (UTC)

The critique by Gorman is out of date and superced by the Cochrane review. But the section, presumably, is concerned with valid critiques, not ones well out of date.
Yes I would agree with this. There are other valid critiques, e.g. this article from Nicole Lee, Professor at the National Drug Research Institute at Curtin University:

The 12 steps have a strong religious element including commitments to prayer, making a moral inventory of yourself, making amends to people you’ve harmed, and, once you’ve achieved your “spiritual awakening,” promoting the program to other people in need of help....There are now newer models, based on decades of research, that are better at explaining the development of alcohol and other drug problems. So this has put the theoretical basis of the 12-step model into question. The movement has a lot of dedicated fans but there has also been a lot of criticism...It has been difficult to work out how effective AA and NA are because there has not been a lot of good quality research into them. Many of the results are published by the “fellowship”, as the 12-step movement refers to itself. And because the 12-step fellowship is by definition anonymous, some members don’t want to participate in studies that might breach the anonymity of the group. The fellowship itself has been, until recently, cautious about allowing interviews or data to be collected by researchers.... It’s also difficult to compare 12-step groups to mainstream treatments, such as cognitive behaviour therapy and motivational interviewing because it is now rare for contemporary treatment to be longer than two to three months at a time.

or this view expressed in the 2015 academic book by Lilienfeld et al.:

...these findings suggest that AA is indeed a pseudoscientific treatment, persisting by virtue of intuitive appeal and strident adherents despite weak empirical support...To conclude, the role of AA in the science-based AUD treatment enterprise has been highly controversial....from a scientific standpoint, there are reasons to be critical of AA’s outmoded etiological model and to question the strong identification of formal treatment programs with AA principles (Kelly, 2013). Participation in community mutual-help groups like AA will not be for all patients, but, for some, AA may very well enhance formal treatment efforts."

A lot of criticism centers on the fact that AA is sometimes used or recommended as a replacement for medical therapy (e.g. disulfiram or naltrexone) rather than as an adjunct to it. or that AA groups sometimes stigmatize use of these medications. e.g. this 2012 report from the National Center on Addiction and Substance Abuse at Columbia University:

The overwhelming salience and considerable evidence--although largely anecdotal--of the benefits of mutual support programs like Alcoholics Anonymous (AA), for example, have led many people to conflate such support services with actual addiction treatment rather than to recognize them as highly useful systems of support that should accompany or follow evidence-based clinical treatment. Mutual support programs are facilitated by members whose main credential is that they themselves have experienced an addictive disorder and have learned to manage it. Such support, however, is quite different than treatment for a medical condition. Few would argue that any other disease be treated solely via support groups composed of those who themselves have had the condition.

Or this 2023 "state of the art" narrative review published in the International Journal of Environmental Research and Public Health:

Despite the fact that alcohol has been around and consumed for centuries, there is still no single effective tool to combat addiction. The main tools are group therapies in Alcoholics Anonymous, which focus on the 12-step program and non-pharmacological interventions, while medications that can reduce the craving for alcohol and the addict’s desire for alcohol are still under-prescribed

Or this 2022 review published in Occupational Health Science:

Research shows that MAT may improve treatment outcomes by reducing cravings for and the euphoria experienced from a misused psychoactive substance (Connery, 2015; National Institute for Occupational Safety and Health, 2019; Office of the Surgeon General, 2016). However, despite MAT’s effectiveness, the recovery literature points out that individuals using MAT may experience stigma from some therapists and peer support groups (e.g., Alcoholics Anonymous, Narcotics Anonymous) because they are not considered to be abstinent and in recovery (Krawczyk et al., 2018; Office of the Surgeon General, 2016; Robinson & Adinoff, 2018; White, 2007a, 2011). These circumstances have resulted in peer support groups that allow full participation for individuals using MAT, such as Methadone Anonymous and Medication-Assisted Recovery Anonymous.

Another interesting aspect is the idea that twelve-step programs are effective only insofar as attendees remain adherent, thus creating an issue of "real-world generalizability" or "intention-to-treat" analyses. Meaning, sure these things work really well in theory and in abstract in large clinical trials, but there are significant issues when we bring this idea to the real world of low adherence etc. E.g. John Kelly's opener to this 2013 issue of Substance Abuse:

Further analyses indicated that the greater relative increases in alcohol use for the TSF patients were mediated by their greater relative decreases in 12-step participation. These findings provide valuable information on potentially important moderators of the benefits derived from both TSF interventions and community 12-step meeting participation.

And this part of the 2020 Cochrane Review (also first authored by Kelly) which describes much lower certainty regarding evidence of "non-manualized" AA, aka treatments which are not forcibly adherent to a specific modus operandi:

For the proportion of participants completely abstinent, non‐manualized AA/TSF may perform as well as other clinical interventions at three to nine months follow‐up (RR 1.71, 95% CI 0.70 to 4.18; 1 study, 93 participants; low‐certainty evidence). Non‐manualized AA/TSF may also perform slightly better than other clinical interventions for PDA (MD 3.00, 95% CI 0.31 to 5.69; 1 study, 93 participants; low‐certainty evidence). For drinking intensity, AA/TSF may perform as well as other clinical interventions at nine months, as measured by DDD (MD ‐1.76, 95% CI ‐2.23 to ‐1.29; 1 study, 93 participants; very low‐certainty evidence) and PDHD (MD 2.09, 95% CI ‐1.24 to 5.42; 1 study, 286 participants; low‐certainty evidence).

Sources

These represent more recent, academic minority views critical of AA that should be represented here per WP:RSUW. — Shibbolethink ^{(♔ ♕)} 19:08, 17 February 2023 (UTC)

RFC draft

Should we include any mention of AA's critics and their arguments?

Arguments in favor of inclusion describe such criticisms as a notable but minority academic view per WP:FRINGE, given that AA's critics are experts in addiction psychiatry or epidemiology though their views are not necessarily embraced as academic consensus (per WP:MEDSCI) given more recent studies (systematic meta-analyses) demonstrating efficacy (e.g. Cochrane 2020).

Arguments against inclusion say that such critical views are now FRINGE nonsense since the publication of the 2020 Cochrane Systematic Review shows efficacy of AA compared to other treatments.

(edit these drafts as much as you want, I will only revert/edit to WP:STEELMAN each argument/proposal)

Draft #1 - Short mention without names

Some critical researchers/psychiatrists have described AA as a form of pseudoscience due to its quasi-religious culture. Others have described that participation in AA may stigmatize use of medical therapies (e.g. disulfiram, naltrexone), which are considered the standard of care in addiction psychiatry as part of a harm reduction approach. Some in the 12-step community have expressed skepticism about harm reduction approaches, given the common belief in the program that no amount of alcohol is safe for an alcoholic.

Draft #2 - more elaborate mention with names of critics

Critics, including addiction researcher Nicole Lee, have expressed concerns about the religious element of many Alcoholics Anonymous groups, including commitments to prayer, moral inventories, making amends, and "spiritual awakening". Concerns have also been expressed about the nature of Alcoholics Anonymous research, given that many of the published studies are conducted by the "fellowship" itself and many are non-randomized or "quasi-experimental" in nature. Others, including the National Center on Addiction and Substance Abuse at Columbia University, have described that participation in AA may stigmatize use of medical therapies (e.g. disulfiram, naltrexone), which are considered the standard of care in addiction psychiatry as part of a harm reduction approach. Members of the 12-step community have expressed skepticism about harm reduction approaches, given the common belief in the program that no amount of alcohol is safe for an alcoholic.

Draft #3 - describe the criticism as in the past and then the current evidence

In the past, some medical professionals have criticized 12-step programs as pseudoscientific and "a cult that relies on God as the mechanism of action". Ethical and operational issues had, until recently, prevented robust randomized controlled trials from being conducted comparing 12-step programs directly to other approaches. Others, including addiction researcher Nicole Lee, have expressed concerns about the nature of many published AA studies, given that many are conducted by the "fellowship" itself. More recent studies employing randomized and blinded trials have shown 12-step programs provide similar benefit compared to motivational enhancement therapy (MET) and cognitive behavioral therapy (CBT), and were more effective in producing continuous abstinence and remission compared to these approaches.

Sources

• Option A - Include Draft #1 (Shorter mention of criticism without names)
• Option B - Include Draft #2 (Longer mention of criticism with names)
• Option C - Include Draft #3 (Medium-length mention of prior criticisms, then describe current state of research)
• Option D - Remove all mention of criticisms in the Effectiveness section

— Shibbolethink ^{(♔ ♕)} 14:39, 17 February 2023 (UTC)

I vote for draft 3.— Preceding unsigned comment added by 5ive9teen (talk • contribs) 19:47, 17 February 2023 (UTC)

@5ive9teen, I just made some edits to draft 3, let me know if you still like it or what you would want to change.— Shibbolethink ^{(♔ ♕)} 20:54, 17 February 2023 (UTC)

Thanks for asking. I do have one quibble: yes AA has been called a cult, but structurally it resemble no cult since it is an intentional anarchy without a hierarchy. The link for this, unfortunately is not available to me in full, so whether it addresses this or not. Also and unfortunately is I don’t know how to address it except perhaps to note that Bill Wilson called it a benign anarchy. Otherwise I like the suggested edit. 5ive9teen (talk) 06:24, 18 February 2023 (UTC)

Here’s the link for benign anarchy ref>Bill W. (1957). "benign+anarchy" Alcoholics Anonymous Comes of Age: A Brief History of A.A. Harper, and Brothers. p. 224.</ref> 5ive9teen (talk) 22:04, 18 February 2023 (UTC)

Well, how the founder describes it is of very little usefulness, especially here on Wikipedia. When independent sources say one thing and a party with a COI says something else, we take the independent sources. In any case, I don't think a hierarchical organization is a requirement for something to be described as a cult CodeTalker (talk) 22:28, 18 February 2023 (UTC)

Its also not really our place as an encyclopedia to decide which descriptions are "accurate" when we're attributing them to other people. Our only role here is to decide whether or not the criticism is WP:DUE, i.e. do other reliable sources consider this person or the opinion notable in some way. And in this case, the answer is yes. Many other sources cite Kaskutas on this, even if they do not agree, they point it out as an opinion that exists. And so should we. — Shibbolethink ^{(♔ ♕)} 23:04, 18 February 2023 (UTC)

Wilson wrote the traditions that shape AA and no one has disputed that he was in drafting the traditions influenced by the anarchist theory of Kropotkin. No need to argue whether an actual non-hierarchical cult exists (doubt it tho, I’ll believe in Big Foot before that), and a source besides Wilson will be found. 5ive9teen (talk) 05:22, 19 February 2023 (UTC)

yes AA has been called a cult, but structurally it resemble no cult since it is an intentional anarchy without a hierarchy. The link for this, unfortunately is not available to me in full, so whether it addresses this or not. Also and unfortunately is I don’t know how to address it except perhaps to note that Bill Wilson called it a benign anarchy.
This appears to be original research on your part, interpreting the "benign anarchy" and founder's intention as a direct rebuttal to whether or not someone else in 2009/2010 called AA a "cult". That's not how Wikipedia works. We do not interpret our sources like that, we rely on secondary sources to do that interpretation for us. I don't see how this 1957 source could possibly be responding to a 2009 criticism. — Shibbolethink ^{(♔ ♕)} 18:56, 19 February 2023 (UTC)

I vote for draft 3 too. AA can and does help get people sober, and it does have a small but significant increase in abstinence compared to other therapies. While the program itself has been criticized as being “pseudoscience”, the bottom line is that the science shows that the program works for many alcoholics. SkylabField (talk) 21:34, 17 February 2023 (UTC)

Okay, so then why don't we just implement Draft 3 since we can all agree on it? No RFC necessary. I think it's a very fair representation of the existing minority view criticism, while also providing the mainstream view per WP:FRINGE. — Shibbolethink ^{(♔ ♕)} 22:02, 17 February 2023 (UTC)

I bow to consensus, and have added Draft #3 to the article. SkylabField (talk) 03:50, 19 February 2023 (UTC)