By Robynn Moraites
The lawyer assistance movement got its start in the mid-1970s when lawyers started getting sober in Alcoholics Anonymous (“AA”). As they got sober, they realized that their drinking buddies – typically other lawyers – could also benefit from getting sober. In its earliest days, the lawyer assistance movement (both nationally and in North Carolina) was basically AA meetings for lawyers. In the mid to late 1990s the movement expanded to include mental health issues. Following the national trend, North Carolina’s program evolved from a purely volunteer run organization of sober lawyers to an organization with clinical staff equipped to address a range of mental health issues, including substance use disorder, while incorporating and maintaining the organized energy and enthusiasm of those early pioneer volunteers. Our peer support groups, whether substance use disorder related or mental health related, are largely modeled on AA’s peer support structure. The strength of our volunteer network is squarely rooted in our AA origins. So LAP began out of AA and AA is the program of recovery that most of our participants recovering from substance use disorder use today to not only get sober, but to stay sober.
Every few years someone emails me an article critical of AA and other twelve-step fellowships as non-evidence-based. The authors inevitably promote their own book or treatment approach as a superior option (without evidence). Sometimes the authors go so far as to say that AA’s General Service Office (“GSO”) never responded to their requests for evidence proving that AA works. To begin, AA GSO does not collect this data. AA GSO does not even have a membership list. But there is another more important reason AA GSO does not respond to these requests.
The Twelve Traditions are the set of rules that govern how AA operates.[1] Tradition 10 states, “Alcoholics Anonymous has no opinion on outside issues; hence the AA name ought never be drawn into public controversy.” Every spinoff twelve-step fellowship[2] follows the same Twelve Traditions to govern themselves. These requests for evidence and proof of efficacy are considered outside issues that will draw the twelve-step fellowships into public controversy. It stands to reason that in following Tradition 10, no twelve-step fellowship will ever defend its existence. Moreover, they do not need to. If they did not work, they would vanish because people would stop going. Since AA’s beginning in 1935, the only “evidence” of AA’s (and eventually other twelve-step fellowships’) efficacy was their grassroots expansion around the world with increasing numbers of people getting clean and sober and carrying a message of hope and recovery to others.
Enter John Kelly, PhD,[3] a Harvard researcher and founder of Massachusetts General Hospital’s Recovery Research Institute. He came to Charlotte to speak in the fall of 2025, and I had the pleasure of attending his presentation. The audience was a veritable Who’s Who in the addiction/treatment/recovery world. Why? Dr. Kelly has spent the last 30 years conducting treatment and recovery research in the addiction field. As a part of his efforts, he has focused on collecting, analyzing, and documenting empirical evidence not only showing that twelve-step fellowships work, but also how they work. I hope to highlight some key takeaways from his presentation in this article. For those interested in the unabridged version, feel free to visit the published synopsis on the research page of our website.[4]
To begin, it was fascinating to see the recovery journey measured and quantified.[5] For example, we know from experience that it takes multiple serious conversations with concerned family members, friends, coworkers, and doctors (and often serious consequences like a DWI, divorce, unemployment, etc.) for a person with severe alcohol and other substance use disorder to finally acknowledge the problem and seek help. Alcohol and other substance use disorders are often progressive diseases, so over time, if left untreated, symptoms continue to worsen (as do the attendant consequences). We also know it takes several years of continued recovery before the risk of relapse drastically drops. The research bears this out. At five years of continuous remission/sobriety, the risk for meeting criteria for an alcohol or other drug use disorder in the following year drops to 15%, which mirrors the risk of the annual general population risk for developing one of these disorders.
The public health costs associated with addiction are high. Alcohol use disorder alone imposes an estimated economic and public health burden reaching hundreds of billions of dollars annually (latest inflation-adjusted figure of approximately $349 billion, a figure which continues to rise). The direct healthcare costs associated with treating alcohol-related illnesses and injuries are estimated at $28-$35 billion annually. This includes emergency room visits, hospitalizations, treatment of liver diseases, and other alcohol-related medical conditions. The largest portion of the total burden, however, comes from lost workplace productivity, accounting for more than 70% of the total economic cost. As reported in 2022 for years 2015-2019, alcohol use disorder is responsible for roughly 232 million missed workdays per year in the US. Additional indirect costs include law enforcement, criminal justice expenses, property damage, and losses due to premature mortality. About 15% of the United States’ entire national healthcare budget is spent on treating addiction in some form.
The impact of alcohol use disorder on lawyers and their clients is also significant. There are some old broad-brush studies on file effectively demonstrating the correlation between impairment and harm to the public. In the late 1990s, a study of the Client Protection Fund cases in Louisiana examined the correlation between impairment and trust account violations. They found that 80% of trust account violation cases involved some form of substance use disorder or a compulsive gambling disorder (a so-called, “process addiction” or behavioral addiction). The Illinois bar conducted a study looking at discipline cases broader than just trust account violations over a several year time span. Depending on the year, they found that anywhere from 40% to 75% of lawyer discipline cases involved some form of substance use disorder or mental health issue (like depression). Another study in Oregon found that 80% of the Client Security Fund cases involved substance use disorder, gambling, or a mental health issue. A separate 1991 Oregon study found that ethical violations and malpractice claims each dropped by roughly 75% for lawyers with five years of continuous sobriety. That same Oregon study found that lawyers with five years of continuous sobriety had lower malpractice claims and discipline complaint rates than the general population of lawyers. It stands to reason that as a self-regulating profession charged with protecting the public, we have a vested interest in doing what works best and most effectively to curb the harm caused by alcohol and other substance use disorders, especially over the long-term.
Beginning in the 1980’s, Twelve-Step Facilitation (“TSF”) interventions and treatment approaches were incorporated into inpatient and outpatient treatment programs across the country. These TSF approaches are designed to educate patients about the role and nature of 12-step organizations like AA and recommend and facilitate active involvement in them as a means of gaining continuing recovery support over time. From “standalone tracks” to “add-on modules”, the method of incorporating TSF into treatment has been broad and varied – and now studied and tested for their efficacy in randomized controlled trials. Beginning around 1990, a flurry of studies began to measure TSF’s and AA’s efficacy – from federally funded clinical trials to studies of health care cost offsets and cost-benefits analyses, as well as investigations into AA’s mechanisms of behavior change.
The findings? In study after study, TSF interventions prove to be at least as effective as (sometimes more effective than) other treatment modalities, like cognitive behavioral therapy or motivational enhancement therapy. But TSF approaches actually perform better than all other treatment modalities to which they’ve been compared regarding helping patients achieve continuous abstinence and remission over time, and at a substantially reduced health care cost. We knew that. But now we have 35 years of randomized control trial evidence to back it up. The most fascinating findings, however, were centered around mechanisms for behavior change – that is, how twelve-step fellowships actually work. The following findings were analyzed from hundreds of studies over many decades.
Most of the existing body of research has revealed that AA confers relapse prevention and recovery benefit by mobilizing changes across multiple domains simultaneously. Mechanisms of behavior change that have been studied and measured include 1) change in social networks by: a) dropping drinking buddies, or b) making sober friends, 2) enhancing and maintaining recovery motivation (wanting to be sober), 3) abstinence self-efficacy (belief that one can stay sober, regardless of what situations one encounters down the road), 4) boosting cognitive-behavioral relapse prevention skills,[6] 5) reducing impulsivity, 6) reducing craving, and 7) enhancing spiritual practices.
To clarify, a spiritual awakening is defined broadly in AA as “a profound alteration in [our] reaction to life” that represents an internal change experienced by each member in their own way and in their own time (often characterized by a gradual change in outlook and functioning known as the “educational variety” of spiritual awakening). AA neither asks nor demands belief in any specific religion (or any religion). Instead, AA encourages an open-minded approach to spiritual and personal growth by suggesting that wisdom can be found in religious traditions, without advocating a particular religion, which probably explains why it has thrived worldwide.
It should be noted, however, that religious participation is neither needed nor required for AA to help someone get sober. Through the process of working through the 12 steps, “members find that they have tapped an unsuspected inner resource.” There are “spiritual” principles associated with each step, like honesty, hope, open-mindedness, courage, integrity, love, humility, and self-discipline. The AA group itself provides a sense of hope, connection, and a moral compass to guide on-going, long-term recovery.
Research has also discovered that participation in AA reduces something called “negative affect.” Negative affect is a social science term describing the tendency to experience negative emotions and thoughts, such as anger, anxiety, sadness, guilt, fear, and poor self-concept. It reflects a person’s general disposition toward negative mood states and negative emotional (over) reactions to life events and to oneself. Let’s use an example to illustrate. A long-awaited lunch appointment is canceled at the last minute. A person low in negative affect might feel disappointed but understand the situation without internalizing it and would react by saying something to that effect and suggesting some alternate dates. A person high in negative affect, however, might internalize the situation and at first feel rejected, then quickly turn to anger, and react by lashing out with a snarky remark like, “I guess I’m not someone you want to associate with,” (and vowing to never meet with them again). Or, he or she might show no direct reaction to the person who cancelled lunch but be a total jerk to everyone in the office and/or at home later that day. It is not surprising that folks with high negative affectivity are at far greater risk for substance use disorders.
AA has a similar efficacy rate in terms of relapse prevention across different group characteristics (i.e., addiction severity; gender; age), but for different reasons. For example, for more severely addicted people, AA was shown to help mostly by facilitating changes in their social networks, but also by boosting spirituality. However, boosting spiritualty was not found to influence relapse risk for less severely addicted people. Instead, AA helped this second group mostly by facilitating changes in their social networks and by boosting confidence in their ability to cope with high-risk social situations without drinking (i.e., by enhancing what is known as “abstinence social self-efficacy”).
When analyzing whether men and women differ in the ways that AA aids their recovery, studies demonstrated that both groups derived equal overall relapse prevention benefits, but the ways in which they benefitted differed. For both groups, enhanced self-efficacy (albeit different subtypes of self-efficacy) played a key role. Among women, AA helped by boosting their confidence in their ability to cope with negative affect without drinking (known as “negative affect self-efficacy”) and by reducing depression symptoms. That same measure was negligible among men. Rather, among men, AA helped by changing men’s social networks and by boosting their confidence in their ability to cope with high-risk social situations where alcohol was present without drinking (abstinence social self-efficacy) – a negligible measure among women.
The magnitude of these differences by gender was stark and highlights the different types of relapse risk factors: for men, the biggest risk for relapse seems to involve direct and indirect alcohol cue exposure in social contexts; for women, it is the experience of negative affect.
Slicing the data yet another way, a further analysis compared young adults (18–29 years old) to older adults (30+ years old). As we saw with the addiction-severity and gender cohorts, young adults derived the same degree of relapse prevention benefit as older adults, but once again, the ways that this occurred differed in nature and magnitude across the two groups. The most striking way that AA helped young adults recover was by helping them drop drinking/using buddies. The data shows this singular mechanism is twice as impactful for young adults as it is for their older adult counterparts. On the other hand, AA helped older adults by helping them adopt sober friends (as opposed to dropping drinking buddies). Whereas AA was not found to work through this mechanism for young adults. The exact reason for this difference remains unclear and warrants further study. One plausible explanation is the relative dearth of young adults in AA, making it harder for this cohort to make sober friends.
One thing you may have noticed is that whichever way the data is sliced (addiction severity, gender, age), studies consistently show that a change in social networks is a key mechanism for behavior change across groups. Whether by dropping drinking and using buddies, or making new clean and sober friends, a change in social networks is key for long-term relapse prevention. Why? Because we are social creatures, and we tend to model our behavior on those around us.
Take this example. A social experiment featured on the National Geographic show Brain Games investigated peer pressure and human conformity by staging a waiting room scenario where actors were instructed to stand up every time a beep sounded, without any apparent reason.[7] The real patient, unaware of the experiment, initially hesitates but begins mimicking the group behavior after just a few beeps. This conformity persists even after the actors leave, with the woman continuing to stand at each beep while alone in the waiting room. When new (also unaware) patients enter, they also begin to conform to this behavior, even after being offered no viable reason for doing so when one patient asks about it. This experiment demonstrates the powerful influence of social conformity, where individuals adopt group behaviors (even without understanding the reason), driven by a desire to fit in and avoid social exclusion. This phenomenon is linked to social learning, as a way of becoming socially integrated. It is a major reason why ongoing peer support is crucial for sustained long-term recovery, because we learn from the lived experience of sober role models.
One very small but profound study stands out in my mind from Dr. Kelly’s talk because it ties into this concept of social network/peer support and goes to the heart of what we do at the LAP. Twenty clients were selected from an outpatient alcoholism treatment program and randomly assigned to one of two groups. Half were assigned to a control group that received a standard referral procedure which involved giving the client information about AA; encouraging the client to attend meetings; and providing information with the time, date, and location of weekly meetings. The other half were assigned to an experimental group that received a “warm handoff,” which involved a phone call to a local AA member in which the member briefly talked to the client about the AA meeting, offered to meet the client before the meeting, offered to give the client a ride to the meeting, and called the client the night of the meeting to remind them of it and encourage them to come. The results of the study showed that 100% of the experimental group attended AA within 1 week of referral and continued to attend, whereas none of the control group ever attended. Researchers concluded that a warm handoff is significantly more effective than a standard referral.
As Dr. Kelly relayed this study, it reinforced for me our best practice of having our LAP counselors visit lawyers in detox or inpatient treatment, offering a warm handoff to them upon discharge – serving not only as a warm handoff to the Lawyer Assistance Program itself, but also eventually to facilitate a warm handoff to a sober LAP volunteer. In healthcare it is called “continuity of care,” which is the consistent and coordinated management of a patient’s health over time achieved by ensuring seamless communication and collaboration between healthcare providers, settings, and the patient themselves. This approach means patients are supported by the same core healthcare team as much as possible, with a unified strategy for ongoing care across various transitions in the healthcare system. We have plenty of evidence that lawyers are at less risk of relapse if they are involved with the Lawyer Assistance Program in the early years of sobriety as they work towards sustained remission of 5+ years.
I was also reminded of one of our active LAP volunteers who penned the story Being a Lawyer Saved My Life. In it, he shares that he went to a few AA meetings but felt out of place. He stopped going and drank again despite a growing list of serious consequences. It was only when he was paired with a sober LAP volunteer, who took him to an AA meeting, that he suddenly felt comfortable there. He observes, “Like so many active alcoholics, I would not allow myself to open up to and become part of a recovery fellowship of which I (incorrectly) believed I had nothing of significance in common. It was only when I finally asked for help from my fellow lawyers that I was able to see that I was not so terminally unique.”
The evidence is in. Substance use disorders are chronic conditions conferring a remarkable burden of disease, disability, and cost to our country and more specifically, our profession. Twelve-step programs, like AA, are free, community-based peer support resources and are the most commonly sought source of help for alcohol and other drug problems. Most inpatient and outpatient substance use disorder treatment programs utilize some form of twelve-step facilitation (TSF) in their treatment programs. Rigorous randomized controlled trials and studies examining the efficacy of AA and TSF interventions began around 1990. Study after study indicates that AA and TSF interventions are at least as good as other clinical modalities and therapeutic approaches. However, when it comes to long-term remission and stable sobriety, AA and TSF interventions outperform everything else (for different reasons for different groups).
As part of a self-regulating profession, the LAP is concerned with long-term recovery and the ongoing stability and sobriety of lawyers and judges. Mark Twain once said stopping smoking was the easiest thing he ever did – that he’d done it hundreds of times. The LAP is interested in helping folks stay stopped if they have a substance use disorder. Moreover, the LAP is interested in maintaining and fostering the general well-being of the profession, because happy, healthy, balanced lawyers make better lawyers.
The LAP’s “evidence” that AA and TSF approaches work, particularly the peer support aspect, can be found in our long-standing volunteer network. We have volunteers who have been with our program for 20, 30, even 40 years, and most of them are former LAP clients. While not “scientific,” our experience with LAP clients and volunteers exemplifies what the scientific data now says.
[1] https://www.aa.org/the-twelve-traditions
[2] The list is long. There are 128 additional anonymous twelve-step fellowships: i.e., Narcotics Anonymous, Gamblers Anonymous, Codependents Anonymous, etc.
[3] John Kelly’s full title is Chief, Division of Addiction Treatment and Prevention, Mass General Brigham AMC, Dept of Psychiatry
Elizabeth R. Spallin Professor of Psychiatry, Harvard Medical School
Founder and Director, MGH Recovery Research Institute
Founder and Director, National Center on Youth Prevention, Treatment, and Recovery
President, American Board of Addiction Psychology
Board Certified Addiction Psychologist
[4] Protective Wall of Human Community.
[5] I am omitting research citations for brevity. All research citations can be found in Dr. Kelly’s article on our website.
[6] Topics of discussion in AA meetings regularly include strategies for how to avoid triggers or how to navigate social events where there will be a lot of drinking. Suggestions like “take a different route home (to avoid passing a favorite bar)”, “take your own car (to an event so that you can leave at any time)”, and “take a sober friend” are examples of cognitive behavioral techniques.