2.1 WHAT IS AA?
2.2 DOES AA WORK?
A comprehensive literature review was undertaken that was compared to the author's own AA-experience in various cultures. The search was neither restricted to a specific time period nor were language restrictions employed. Studies published in peer-reviewed, academic journals as well as books and websites were selected on the basis of "usefulness" in regards to the research question. After establishing what AA is, the essay examined whether AA works. It found that AA differs substantially in regards to other treatment approaches by it's "acting into thinking"-philosophy. The efficacy of AA could not be proven by employing a cause-and-effect methodology. Moreover, the complexity of human behaviour as well as the fact that AA is not practised uniformly raises many seemingly unanswerable methodological problems and it remains questionable whether AA treatment and outcomes can be measured by a cause-and-effect method. Testimonies of personal experience as well as for centuries practised human wisdom seem however to suggest that AA does work – for the ones who work the programme, that is.
This study of whether AA works consists of a comprehensive literature review that was compared to the author's own AA-experience in various cultures. The search was neither restricted to a specific time period nor were language restrictions employed. The following search terms were used (both individually and in various combinations – the list is not exhaustive) in Google and Yahoo: alcohol treatment, treatment outcomes, alcohol treatment efficacy, addiction treatment effectiveness, AA success, alcohol treatment outcomes, measuring treatment, addiction therapy success, alcohol therapy success, twelve step effectiveness, twelve step efficacy, AA programme, AA promises, cause and effect proof, recovery, definition recovery, AA cult, AA religion, AA testimonials, AA statistics, personal AA experiences, addiction treatment scientific evidence.
The following databases were searched: Alcohol Concern Online Library, Drugscope database, NIDA database, Robin Room Archive, SAMHSA's National Clearinghouse for Alcohol and Drug Information, Scottish Addiction Studies Online Library, Social Science Information Gateway, Stirling University Library E-Journal Gateway, World Health Organization database.
Blogs and websites searched: Addiction Search, Alcoholic Anonymous, Alcohol Reports, Dirk Hanson's Chemical Carousel Website, Drink and Drugs News Website, Spiritual River Website, The Orange Papers, The Stanton Peele Addiction Website, Wired in to Recovery Website, Websites of Recovery Centers.
The following journals were searched: Addiction, Addiction Research & Theory, Addiction Treatment Forum, Alcohol, Alcohol and Alcoholism, Alcohol Research & Health, BMC Health Services Research, Drug and Alcohol Dependence, Drug and Alcohol Findings, Journal of Substance Abuse Treatment, The Journal of Studies on Alcohol and Drugs.
Selection criteria for studies retained: blogs and websites were mainly used in order to "get a feel" for the various ideological positions held. Otherwise there were no particular restrictions: studies published in peer-reviewed, academic journals as well as books were exclusively selected on the basis whether they were able to meaningfully contribute to the research question.
The study proceeds in the following way: In a first step, it attempts to outline what AA is before, in a second step, examining whether AA works. A third step finally discusses the findings before, in a final step, a conclusion is presented.
2.1 WHAT IS AA?
The book "Alcoholics Anonymous" (1994), also known as the "Big Book", is considered the "basic text for our Society" (Alcoholics Anonymous 1994: i) and names as the essentials of the AA-approach "the need for moral inventory, confession of personality defects, restitution to those harmed, helpfulness to others, and the necessity of belief in and dependence upon God" (Ibid, vi).
The following statement is read out load at the start of AA meetings and is aimed at reminding the participants what these meetings should be all about:
Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism. The only requirement for membership is a desire to stop drinking. There are no dues or fees for AA membership; we are self-supporting through our own contributions. AA is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy, neither endorses nor opposes any causes. Our primary purpose is to stay sober and help other alcoholics to achieve sobriety" (This is A.A. 1984).
The AA programme is based on the twelve steps and the twelve traditions (see appendix). It is a spiritual programme – "spiritus contra spiritum", as C.G. Jung penned in a letter to Bill Wilson (Alcoholics Anonymous 1984: 384) - and explicitly states that only a Higher Power can relieve sufferers from their alcoholism.
Our description of the alcoholic, the chapter to the agnostic, and our personal adventures before and after make clear three pertinent ideas: (a) That we were alcoholic and could not manage our own lives. (b) That probably no human power could have relieved our alcoholism. (c) That God could and would if He were sought (Alcoholics Anonymous 1994: 60).
This seems to sugget that AA is a religious movement. In fact, Jacques T. (1991: 50) affirms that the twelve steps, when practised, do not differ from the dramatic conversion that Saint Paul experienced on the road to Damascus. A conversion is central to the AA programme. As William James in The Varieties of Religious Experience, by which Bill Wilson, one of the founders of AA, was deeply influenced, states:
... the salvation through self-despair, the dying to be truly born, of Lutheran theology, the passage into nothing of which Jakob Behmen writes. To get to it, a critical point must usually be passed, a corner turned within one. Something must give way, a native hardness must break down and liquefy; and this event (as well shall abundantly see hereafter) is frequently sudden and automatic, and leaves on the Subject an impression that he has been wrought on by an external power (James 1994: 125).
In other words, "a new human being has to be created", as Enquist (2008: 494) noted, and added that this might meet with resistence.
There are statements by Bill Wilson that suggest that AA is a religion. For instance: "I must turn in all things to the Father of Light who presides over us all" (Alcoholics Anonymous 1994: 12). Moreover, five of the twelve steps mention God (and/or Him) explicitly and quite some meetings that I attended closed with the Lord's Prayer. In spite of that the "Big Book" clearly states: "Alcoholics Anonymous is not a religious organization" (Alcoholics Anonymous 1994: x).
Yet "... federal courts have asserted, 'AA is unequivocally religious.' They only looked at AA’s doctrinal literature, and unhesitatingly declared what is obvious to anyone" (Trimpey 1997). And Rudy and Greil (1988: 41) opine: "A.A. is properly classified as a quasi-religion in so far as a tension between sacred and secular is crucial to its functioning."
There are dangers of distorting a treatment ideology with quasi-religious overtones, as Goethals, Broekaert and Yates (forthcoming) point out, and AA has indeed quasi-religious overtones and also cult-like elements: members who revere Bill Wilson as if he were a saint, for example, or the ones who read the Big Book as if it were written by God. As the writer Wilfrid Sheed (1995: 89) notes: "In the new world I was about to enter, the assumption was that it was always the truth you were flinching from like a vampire at high noon, and never just from cliché or, in this case, a shower of clichés, the bane of my profession". Yet AA is clearly not a cult: it has no leader, makes no financial demands, does not coerce people into the programme (with the exception of US courts) and everybody is free to leave (Bufe 1998). As the "Big Book" states: "We are not allied with any particular faith, sect or denomination, nor do we oppose anyone" (Alcoholics Anonymous 1994: iv).
To look at the AA literature is one way to approach AA, to look at the fellowship in action another. While the format of AA meetings is the same all over the world (there are all sorts of meetings, from step-meetings to discussion-meetings, open and closed ones etc.), it is the ones attending who decide how these meetings are conducted and who create the vibes (and it is often these vibes that make people stay or leave). I've heard of meetings in the Philippines, and in Italy, where, allegedly, alcohol was consumed, have participated in meetings that I've found difficult to bear in the sense that David Foster Wallace (1995) described: "So then at forty-six years of age I came here to learn to live by clichés ... To turn my will and life over to the care of clichés. One day at a time. Easy does it. First things first. Ask for help. Thy will not mine be done. It works if you work it. Grow or go. Keep coming back", and I've been to meetings where I felt profoundly helped by the stories shared. In other words, what AA do we refer to when asking whether it works?
Miller and Rollnick (2009) hold that, in the late 20th century, the 12-step model was quite at variance with original descriptions of the AA programme. "At some point, such a reinvention no longer contains and may even violate the spirit and elements that defined the original approach" (Miller and Rollnick 2009: 130). In addition, as a 36 year member of AA in 1976 penned: "There are three ways to work the program of Alcoholics Anonymous. (1) The strong, original way, proved powerfully and reliably effective over forty years. (2) A medium way – not so strong, not so safe, not so sure, not so good, but still effective. And (3) a weak way, which turns out to be really no way at all but literally a heresy, a false teaching, a twisting corruption of what the founders of Alcoholics Anonymous clearly stated the program to be" (24 Magazine 1976).
In sum: On the one hand, there seem to be as many interpretations of AA as there are AA members. On the other hand, there are the ones who appear to regard not only the „Big Book“ as a sacred text but also advice like "90 meetings in 90 days" and "Get a sponsor" that cannot be found in the „Big Book“. And then there are the ones like me who take from the programme what they like and leave the rest. In other words, it is questionable whether the voluntary and informal nature of AA allows for an assessment that meets scientific criteria.
2.2 DOES AA WORK?
"To share your experience, strength and hope in order to stay sober - that is basically the AA-secret formula" writes Zocker (1989: 19). The "Big Book" states:
Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average. There are those, too, who suffer from grave emotional and mental disorders, but many of them do recover if they have the capacity to be honest (Alcoholics Anonymous 1994: 58).
In other words, rigorous honesty is key for getting, and staying, sober: if you're honest you will recover. And if you do not recover, you simply haven't been honest. Ludwig (1989: 4) comments: "Along with other addictions, alcoholism is unique in the extent to which the individual is blamed if the treatment fails. If the alcoholic does not remain abstinent, therapists and staff presume that he is unmotivated for or unreceptive to help."
This insistence on honesty is by no means limited to Christianity – to ask whether AA is a religion means whether it is a Christian religion – but an ancient wisdom that is shared by Buddha, Socrates, Spinoza, Hegel and Marx (Fromm 1979: 7). The same applies to the hero-myth that, according to Joseph Campbell (Maher and Briggs 1989), exists in all cultures and shows "obvious parallels between the processes of addiction and recovery and the structure of the hero's tale. There are hundreds of thousands of people whose recovery stories share striking similarities to Campbell's myth of the hero" (White 2007a).
In 1955, AA claimed that of the ones who "really tried, 50% got sober at once and remained that way; 25% sobered up after some relapses, and among the remainder, those who stayed on with A.A. showed improvement" (Alcoholics Anonymous 1994: x). Yet how does one measure "really tried"?
In 1972, an anonymous writer argued in 24 Magazine (1976) "that as AA has gotten bigger and older, its effectiveness has dropped from about three in four to about two in three." In the same article it says: "two in three was in 1976 – our data shows numbers much LESS in 1997 – 1 in 15".
In 1989, Robertson (1989: 108) claimed that 60 percent of all newcomers to AA who stay for about a year will generally stay sober forever.
Such claims are however disputed. According to Peele (1998), "AA succeeds with relatively few (5% at most) of the massive numbers of alcoholics who wander through its meetings." And, as Ludwig states, only about 10 percent of all those who recover do so through AA (Ludwig 1988: 67).
Since AA "does not publish data on its participants’ success rate" (Carey 2008: D1), one wonders where these figures come from. Besides, difficulties in measuring treatment success are manifold. For instance: "The resort-and-spa private clinics generally do not allow outside researchers to verify their published success rates. The publicly supported programs spend their scarce resources on patient care, not costly studies" (Carey 2008: D1). Moreover, there are no standard guidelines in the field. "Each program has its own philosophy; so, for that matter, do individual counselors. No one knows which approach is best for which patient, because these programs rarely if ever track clients closely after they graduate" (Carey 2008: D1).
However, outcome studies have investigated the relationship between AA attendance and length of abstinence and found that AA members report greater abstinence than nonmembers and that the longer the membership in AA the greater the length of sobriety is (Le, Ingvarson and Page 1995).
Project MATCH was a study that aimed to establish what works for whom in regards to alcohol abuse and drug dependency. The hypothesis was that treatment that would adress the individual patient's needs and characteristics would surely yield better results than one which would treat all patients (with the same diagnosis) in the same manner (Project MATCH Research Group 1993). It found that treatments (Cognitive Behavioral Coping Skills, Motivational Enhancement Therapy, Twelve-Step Facilitation) didn't differ in effectiveness when applied to a heterogeneous group. Culter and Fishbain re-examined the study and pointed out that "a median of only 3% of the drinking outcome at follow-up could be attributed to treatment. However this effect appeared to be present at week one before most of the treatment had been delivered. The zero treatment dropout group showed great improvement, achieving a mean of 72 percent days abstinent at follow-up" (Culter and Fishbain 2005). Peele criticised the lack of a control group and that the effectiveness was measured by reduction in frequency and intensity of drinking while the 12-step approach is based on total abstinence (Peele 1998a).
In sum, there is little empirical evidence to support the notion of patient matching. Moreover, questions in regards to the typicality of the client sample have persisted (Velasquez, DiClemente and Addy 2000: 179).
In 1994, a treatment outcome evaluation of 65,000 patients by CATOR found that "people who complete treatment but who don't follow through with either self-help support group attendance or regular continuing professional contacts have a less than 50 percent chance of staying sober; those who follow through with both have a greater than 80 percent probability of greater sobriety" (West 1997: 146).
The most recent study on treatment effictiveness is DATOS, carried out in a decade of widespread cocaine (especially crack) use in the US and seems to prove that treatment (12-step philosophies dominated) works. "A year after teatment, drug use, illegal activities and psychological stress had fallen by about 50%" (Franey and Ashton 2002: 5). In regards to treatment modalities, the study found that: "Delivered with sufficient quality, they are all effective" (Franey and Ashton 2002: 18).
Yet, how can one know whether people who attend AA meetings are really alcoholics (I know of people who, admittedly, did not have alcohol problems but simply liked the vibes at meetings) or, if they were, would have not become sober naturally due to life stages and/or environmental factors? (Vaillant 1983; Peele 1995). As Yates (1997: 30) points out:
What limits outcome monitoring is that even the most loyal client will probably only spend a tiny part of their life visiting drug or alcohol services. A lot of other things will be going on in their lives which will almost certainly have a much bigger effect on their health and behaviour. These outside forces may be stronger at some times than at others ... Put simply, there is no way of proving whether changes identified in service users use of drugs/drink etc. have to do with their contact with an agency or can be accounted for by other changes in their lives.
As regards AA, there are additional measuring problems: first of all, the voluntary nature of AA membership – the only requirement is "an honest desire to stop drinking" (Alcoholics Anonymous 1994: iv) – indicates that the ones attending meetings are not only recognising their drinking problem but are motivated to change (DiClemente et al. 1999 are critical of this assumption). "Because of this self-selection it becomes impossible to know whether it is AA efficacy or member motivation that is being measured" (Bebbington 1976 in Le, Ingvarson & Page 1995). Then there is the "on and off the wagon"-phenomenon (Ludwig 1989: 51-52) that complicates research. Further problems for research include: member anonymity, lack of control groups, the confounding effects of other treatment programs, frequency of attendance, and the informal nature of the movement (Le, Ingvarson and Page 1995; Glaser and Ogborne 1982). Moreover: "Not only does each person respond to personal events in different ways, but what moves one person toward sobriety may not affect another at all" (Ludwig 1989: 71). In sum, from a scientific point of view: the effectiveness of AA has yet to be proven.