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Alcoholics Anonymous

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AA meeting sign

Alcoholics Anonymous (AA) is an informal meeting society for recovering alcoholics whose primary purpose is to stay sober and help other alcoholics achieve sobriety.[1] AA suggests that alcoholics follow its program and abstain from alcohol in order to recover from alcoholism, and share their experience, strength, and hope with each other that they may solve their common problem.[2][3][4] AA was the first twelve-step program and has been the model for similar recovery groups like Narcotics Anonymous. Al-Anon/Alateen are programs designed to provide support for relatives and friends of alcoholics. The organization was named after its primary guidebook Alcoholics Anonymous, also known as The Big Book. Although AA is not for everyone, there is growing evidence supporting the effectiveness of AA as a treatment for alcoholism.[5]

History

Main article: History of Alcoholics Anonymous

By 1934 alcoholic Bill Wilson had ruined a promising Wall Street career with his constant drunkenness. He was introduced to the idea of a spiritual cure by old drinking buddy Ebby Thacher who had become a member of a Christian movement called the Oxford Group. Wilson was treated by Dr. William Silkworth who promoted a disease concept of alcoholism. While in the hospital, Wilson underwent a spiritual experience which convinced him of the existence of a healing higher power and he was able to stop drinking. On a 1935 business trip to Akron, Ohio, Wilson felt the urge to drink again and in an effort to stay sober, he sought another alcoholic to help. Wilson was introduced to Dr. Bob Smith, and Smith also found sobriety through spiritual means.

Wilson and Smith co-founded AA with a word of mouth program to help alcoholics. By 1937 they determined that they had helped 40 alcoholics get sober, and two years later, with the first 100 members, Wilson expanded the program by writing a book entitled Alcoholics Anonymous which the organization also adopted as its name. The book described a twelve-step program involving admission of powerlessness, moral inventory, and asking for help from a higher power. In 1941 book sales and membership increased after radio interviews and favourable articles in national magazines, particularly by Jack Alexander in The Saturday Evening Post. By 1946, as membership grew, confusion and disputes within groups over practices, finances, and publicity lead Wilson to write the guidelines for noncoercive group management that eventually became known as the Twelve Traditions. AA came of age at the 1955 St. Louis convention when Wilson turned over the stewardship of AA to the General Service Board.[6] In this era AA also began its international expansion, and by 2001 the number of members worldwide was estimated at two million.

Organization

See also: Twelve-step program: The Twelve Traditions

In 2006 there were a reported 1,867,212 AA members in 106,202 AA groups worldwide.[7] The Twelve Traditions informally guide how AA groups function, and the Twelve Concepts for World Service guide how AA is structured globally.[8]

A member who accepts a service position or an organizing role is a "trusted servant" with terms rotating and limited, typically lasting three months to one year and determined by group vote. Each group is a self-governing entity with AA World Services acting only in an advisory capacity. AA is served entirely by alcoholics, except for seven "nonalcoholic friends of the fellowship" out of twenty-one members of the AA Board of Trustees.[9]

AA groups are self-supporting and not charities, and they have no dues or membership fees. Groups rely on member donations, typically $1 collected per meeting in America, to pay for expenses like room rental, refreshments, and literature.[10] Visitors and new members are asked not to donate, and no one is turned away for lack of funds.[11]

AA receives proceeds from books and literature which constitute more than 50% of the income for the General Service Office (GSO),[12] which unlike individual groups is not self-supporting and maintains a small salaried staff. It also maintains service centers which coordinate activities like printing literature, responding to public inquiries, and organizing conferences. They are funded by local members and responsible to the AA groups they represent.

Program

See also: Twelve-step program: The Twelve Steps

The suggested AA recovery program for alcoholics includes not drinking alcohol one day at a time, following Twelve Steps,[13] helping with duties and service work in AA,[14] and regular AA meeting attendance[15] or contact with AA members.[13] Members are encouraged to ask their group for help in finding an experienced fellow alcoholic called a "sponsor" to help them follow the AA program, ideally one that has enjoyed sobriety for at least a year and is of the same sex as the sponsee, and who does not impose personal views on sponsees but only teaches the suggested AA program.[16]

Anyone is allowed to attend "open" AA meetings while "closed" meetings are for alcoholics, or those who feel they might be alcoholics, only.[17] There are groups for men only, groups for women only, groups angled at gay people, and groups for speakers of minority languages. Meeting formats vary between groups, and beginner meetings include a speech by the leader about how he or she came to AA and what was learned, then a group discussion on topics related to alcoholism and the AA program.[18]

In the United States of America, Courts have ruled since 1996 that inmates or parolees cannot be ordered to attend AA or other recovery programs that have a substantial religious component since such coercion is in violation of the Establishment Clause of the First Amendment of the Constitution.[19][20] AA receives 11% of its membership from court ordered attendance.[21]

Influences on the Treatment Industry

Since 1949 when Hazelden treatment center was founded by members of alcoholics anonymous, some alcoholic rehabilitation clinics have frequently incorporated precepts of the AA program into their own treatment programs.[22] A reverse influence has also occurred with AA receiving 31% of its membership from treatment center referrals.[23]

Effectiveness

Limitations on research

The study of AA, like politics, tends to polarize observers into believers and non-believers,[24] and discussion of AA often creates argument rather than objective reflection.[25] Many researchers take a skeptical view of AA because some of AA's methods are spiritual, not scientific.[26] Membership is voluntary and determined by the individual, not by the group, with no requirements, dues or fees, or membership lists.[27] A randomized trial of AA is very difficult because members are self-selected, not randomly selected.[28] Two opposing types of self-selection bias are that drinkers may be motivated to stop drinking before they attend AA, and AA may attract the more severe and difficult cases.[29] Control groups with AA versus non-AA subjects are also difficult because AA is so easily accessible.[29] AA can work, but how well and for whom has not yet been adequately researched.[30]


Health Canada's Assessment on Alcoholics Anonymous Research and Treatment: Alcoholics Anonymous is not really a treatment for alcoholism but a community resource for those wishing to stop drinking. Uncontrolled studies of AA have shown that people who affiliate with AA tend to stop drinking and find that their lives improve in many respects (Emrick et al. 1993). However, evaluating AA alongside professionally delivered interventions presents problems and perhaps should not be done.

Because AA is not a fixed form of "treatment" and people are free to participate in different ways...only a minority of those ever exposed to AA seem to become full, active members over a long period and consistently "work" all the steps. There is evidence that certain types of people may be more likely to fully affiliate with AA than others (Ogborne and Glaser, 1981; Emrick et al., 1993)but more research is needed [31]

AA surveys

AA's own 2004 survey of over 7500 members in Canada and the United States concluded that AA is composed of 89.1% white, 65% male, and 35% female members. Average member sobriety is eight years with 36% sober more than ten years, 14% sober from five to ten years, 24% sober from one to five years, and 26% sober less than one year. Factors that may influence AA success rates involve 64% of members receiving medical, counseling, or spiritual help before attending AA, and 65% receiving help after attending AA, with such help playing an important role in recovery for 84% of them.[32]

Other data on attrition and retention is given in a 1989 internal AA report based on an average of five surveys. It estimated that of those who attended AA for the first time, 19% remained in AA after one month and 5% remained after twelve months. As length of sobriety increased, chances of remaining in AA for at least another year increased, from 41% with less than a year of sobriety to 91% with five years or more. There is no accurate way to determine why people leave, but the high attrition rate was significant in revealing that more needed to be done to help newcomers remain in AA.[33]

Project MATCH

Project MATCH began in 1989 and was sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The project was an 8-year, multi site, $27-million investigation that studied which types of alcoholics respond best to which forms of treatment. MATCH studied whether treatment should be uniform or assigned to patients based on specific needs and characteristics. The programs were administered by psychotherapists and studied twelve-step methods, not necessarily AA.[34][35]

Three types of treatment were investigated:

  • Cognitive Behavioral Coping Skills Therapy, focusing on correcting poor self-esteem and distorted, negative, and self-defeating thinking.[36][37]
  • Motivational Enhancement Therapy, which helps clients to become aware of and build on personal strengths that can help improve readiness to quit.[38]
  • Twelve-Step Facilitation Therapy administered as an independent treatment designed to familiarize patients with the AA philosophy and to encourage participation.[34]

The study concluded that patient-treatment matching is not necessary in alcoholism treatment because the three techniques are equal in effectiveness. NIAAA Director Enoch Gordis, M.D. said that treatment providers and patients can have confidence that, if well-delivered, they represent state of the art in behavioral treatments.[34]

Dr. Stanton Peele criticized MATCH on the basis that there was no untreated study group to determine whether the treatments were more effective than the natural recovery process. Therapists in MATCH were more highly trained and monitored than addiction counselors usually available to the public. Effectiveness for all treatments was measured by reduction in frequency and intensity of drinking, whereas twelve-step and abstention-based programs, he argued, should claim no improvement without full abstention.[39] Other researchers stated that "AA has rarely been investigated with the kind of rigorous methological attention it received in Project MATCH." [40]

Health Canada's Assessment of Project Match: "The Project MATCH Research Group (1997) reported that only one hypothetical "match" was clearly supported by the data. This proposed that clients with low psychiatric severity would do best in the 12-step facilitation condition. The results showed that these clients had more abstinent days during six and twelve months of follow-up than those treated with cognitive behavioural therapy. However, the extent to which clients in either condition became involved in AA during the follow-up period has not been reported.

One explanation for the failure of Project MATCH to find more interactions is that there were "ceiling" effects due to client selection and the use of three quite powerful interventions. The overall results of the study were quite impressive and the majority of clients in each condition showed significant and sustained reductions in alcohol use over the follow-up period. The selection of socially stable and research-compliant clients, together with the high quality of the three types of treatment, certainly contributed to these results and may have left little room for matching effects to show up."[41]

George Vaillant

In The Natural History of Alcoholism Revisited[42] Harvard professor of psychiatry George E. Vaillant, a member of the Board of Trustees of Alcoholics Anonymous World Services, described his investigations into the effectiveness of AA.[43] In the sample of 100 severe alcoholics from his clinic, 48% of the 29 alcoholics who eventually achieved sobriety attended 300 or more AA meetings,[44] and AA attendance was associated with good outcomes in patients who otherwise would have been predicted not to remit.[45] In the sample of 465 men who grew up in Boston's inner city, the more severe alcoholics attended AA, possibly because all other avenues had failed[46] Vaillant's research and literature surveys revealed growing indirect evidence that AA is an effective treatment for alcohol abuse,[26] partly because it is a cheap, community-based fellowship with easy access.[47] Although AA is not a magic bullet for every alcoholic, in that there were a few men who attended AA for scores of meetings without improvement, good clinical outcomes correlated with frequency of AA attendance, having a sponsor, engaging in a Twelve-Step work, and leading meetings. Vaillant concluded that AA appears equal or superior to conventional treatments for alcoholism and that skepticism of some professionals regarding AA as an effective treatment for alcoholism is unwarranted.[47]

Other studies

  • Clients who had 27 weeks or more of treatment in the first year had better outcomes 16 years later. After the first year, continued clinical treatment had little effect on the 16-year outcomes, whereas continued involvement in AA did help. Associations between treatment and long-term alcohol-related outcomes appeared to be due to participation in AA.[48][49][50]
  • In a study of 1,774 low-income, substance-dependent men who had been enrolled in inpatient substance abuse treatment programs at ten Department of Veteran Affairs medical centers around the United States, five of the programs were twelve-step based and five used cognitive-behavioral therapy. Over 45% of the men in twelve-step programs were abstinent one year after discharge, compared to 36% of those treated by cognitive-behavioral therapy.[51]
  • A 1997 study assessed subjects during treatment, and at one and six-month follow-ups. Increased affiliation with AA produced better outcomes, greater motivation, and improved coping skills.[52]
  • The largest benefit associated with AA attendance was increased abstinence, followed by reductions in alcohol-related consequences. A slight positive association was also found between AA attendance and increased purpose in life – the study found that AA attendance was associated with psychosocial improvement.[53]
  • For a 1967 study a court judge randomly assigned offenders to either clinical treatment, AA treatment, or no treatment, and after one year 68% in the clinic group were rearrested, 69% in the AA group were rearrested, and 56% were rearrested in the group receiving no treatment. No statistically significant differences between the three groups were discovered in recidivism rate, in number of subsequent rearrests or in time elapsed prior to rearrest.[54]
  • Belief in the disease theory of alcoholism and high commitment to total abstinence were found to be factors correlated with increased likelihood that an alcoholic would have a full-blown relapse (substantial continued use) following an initial lapse (single use).[55]
  • "Holder et al. identify two studies in which alcoholics were referred to AA by the courts (Ditman et al., 1967 and Brandsma, Maultsby and Walsh, 1980). One study in which subjects in an employee assistance program (EAP) were required to attend AA under threat of job loss has also been reported (Walsh et al., 1991). In no case did the results favour AA and this should discourage courts and employers from mandating AA attendance.[56]

Criticism and controversy

See also: Twelve-step program: Criticism

Moderation vs. abstinence

The debate about moderation versus total abstinence is one of the most hotly contested issues in alcohol treatment.[57] AA acknowledges that not all drinkers are alcoholics, but advocates total abstinence for those who are.[58] Critics believe more options should be available to problem drinkers who can manage their drinking with the right treatment.[57]

Disease of alcoholism

Main article: Disease theory of alcoholism

The concept of alcoholism and addiction as a disease is controversial.[59] Dr. William Silkworth introduced to Wilson and AA the idea that alcoholism is a disease consisting of an obsession to drink alcohol, and an allergy, which was the compulsion to continue drinking once the first drink had been taken.[60] Alcoholics, he argued, can never safely use alcohol in any form at all, since once forming the habit, they cannot break it.[61]

AA regards alcoholism as a disease[62][63] (though Bill Wilson once stated that it was not and more comparable to an illness or malady)[64] and uses the concept to challenge the belief of chronic, compulsive drinkers that they can stay sober by willpower alone.[65] AA has been criticized by opponents of the disease model, especially those who argue that AA groups apply the disease model to all problem drinkers, whether or not they are full-blown alcoholics.[66]

Thirteenth-stepping

Mutual support and abuse have both been observed in AA groups.[47] AA undertakes no external restriction, screening, or vetting of its members, and the long-form version of Tradition Three states that any two or three alcoholics gathered together for sobriety may call themselves an AA group.[67]

"Thirteenth-stepping" is a euphemistic term describing the practice of targeting new and vulnerable AA members for dates or sex. Fifty-five female AA members, selected through convenience and snowball sampling, were surveyed on the thirteenth-stepping behavior they witnessed or experienced in AA, such as: feeling seduced, or feeling intimidated and uncomfortable with sexual comments; receiving unwanted hugs and flirting; observing men flirting with, pressuring, and seducing of other women; and observing men who seemed more interested in sex than in recovery. At least 50% of the survey participants experienced seven or more of these behaviors, two volunteered that they were raped by men they met in AA. Chemical dependency treatment providers should be aware of this trend, and vulnerable women like those with histories of sexual abuse should be referred to female-only groups or be trained to avoid sexual exploitation in coed meetings.[68]

A leaked internal AA memorandum stated that the UK AA service board was considering how to deal with a small minority of members being investigated by police for taking advantage of vulnerable new AA members.[69] Former members of a Washington DC Midtown AA group alleged that females were manipulated into sexual relationships with older male group members, older male sponsors were assigned to young women, members were told to cut off ties with family and friends, and others told to stop taking their medications. Several churches banned the group from meeting in their facilities and members complaining to AA New York office, found that AA has no firm hierarchy and exercises no oversight of individual groups.[70][71][72]

Cult-like behavior

The rhetoric and emotional language of AA leads some journalists and social scientists to fear AA is a religion or cult: that the term "sobriety" has taken on a religious flavor and AA members over-rely on dogmatic slogans and are slaves to the group;[73] that AA's need for submission to a higher power leaves potential for abuse, and submission can become the basis for cult-like cohesion.[74] Individual alcoholics attending incompatible AA groups or allying themselves with unfortunate sponsors sometimes tell horror stories about AA. Common to cults, AA members are not encouraged to take a dispassionate or scientific view of their organization, and as with any partisan group, members can be extremely and erroneously opinionated, convinced for example, that AA is the only way to recover from alcoholism.[75]

AA is unlike cults in that its program is based on suggestion only, religious conviction does not prevent AA membership since it has no doctrine of any one specific type of God or obedience to charismatic leaders, and it operates on the principle of leadership rotation. AA's encouragement of dependence is healthy in the way that dependence on exercise is healthy,[47][76] and it does not try to isolate its members from society and take over their lives by creating an unusual and total dependence on the organization for basic human needs like friends, food, and shelter, as is typical with other cult practices.[77]

Confidentiality

Twelve-step program members are not legally bound to keep confidentiality agreements like therapists or clergy so care should be taken before revealing sensitive information to a meeting or sponsor.[78]

Literature

  • Alcoholics Anonymous (1976-06-01). Alcoholics Anonymous. Alcoholics Anonymous World Services. ISBN 0916856593. OCLC 32014950.
  • Alcoholics Anonymous (2002-02-10). Twelve Steps and Twelve Traditions. Alcoholics Anonymous World Services. ISBN 0916856011. OCLC 13572433.
  • Alcoholics Anonymous (1984). Pass It On. Alcoholics Anonymous World Services. ISBN 0916856011.

See also

References

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  78. ^ Coleman, Phyllis (2005). "Privilege and Confidentiality in 12-Step Self-Help Programs: Believing The Promises Could Be Hazardous to an Addict's Freedom". The Journal of Legal Medicine. 26 (4): 435–474. doi:10.1080/01947640500364713. ISSN 0194-7648. OCLC 4997813. {{cite journal}}: Unknown parameter |month= ignored (help)
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