NCSB Journal Summer 2026

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 Pro tection Fund cases in Louisiana examined the correlation between impairment and trust ac count 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 ad diction” 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 Se curity Fund cases involved substance use dis order, 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 mal practice claims and discipline complaint rates than the general population of lawyers. It stands to reason that as a self-regulating pro fession 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 1980s, Twelve-Step Fa cilitation (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 recom mend and facilitate active involvement in them as a means of gaining continuing recovery sup port over time. From “standalone tracks” to “add-on modules,” the method of incorporat ing TSF into treatment has been broad and varied—and now studied and tested for their

efficacy in randomized controlled trials. Be ginning around 1990, a flurry of studies began to measure TSF’s and AA’s efficacy—from fed erally 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 in terventions prove to be at least as effective as (sometimes more effective than) other treat ment modalities, like cognitive behavioral ther apy 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, how ever, were centered around mechanisms for behavior change—that is, how 12-step fellow ships 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. Mech anisms of behavior change that have been stud ied 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 cravings, 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 charac terized 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 un suspected inner resource.” There are “spiritual” principles associated with each step, like hon esty, hope, open-mindedness, courage, in tegrity, love, humility, and self-discipline. The AA group itself provides a sense of hope, con nection, and a moral compass to guide on-go ing, long-term recovery. Research has also discovered that participa tion 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 re lapse prevention across different group char acteristics (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 spiritual ity. 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 situa tions 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

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THE NORTH CAROLINA STATE BAR JOURNAL