Alcoholics Anonymous

AA meeting sign

Alcoholics Anonymous (AA) is a worldwide fellowship of men and women who share a desire to stop drinking alcohol, and subsequently maintain their sobriety.^[1] AA suggests members to completely abstain from alcohol, regularly attend meetings with other members, and follow its program to help each other with their common purpose; to help members "stay sober and help other alcoholics achieve sobriety."^[2][3] AA created the twelve-step program used by similar recovery groups like Al-Anon, an auxiliary group for friends and family members of alcoholics; and Narcotics Anonymous, a group for substance abusers who may or may not also identify as alcoholics. Although AA's attrition rates are high,^[4] it can be effective as a treatment for alcoholism.^[5]

History

By 1934, American alcoholic Bill Wilson had ruined a promising career in finance because of his constant drunkenness. He was introduced to the idea of a spiritual cure by an old drinking buddy, Ebby Thacher, who had become a member of a Christian movement called the Oxford Group which later turned into the Moral Re-Armament movement. Wilson was treated at Charles B. Towns hospital in New York by Dr. William Silkworth, who promoted a disease concept of alcoholism. While in the hospital, Wilson underwent what he believed to be a spiritual experience and, convinced of the existence of God, 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, also a member of the Oxford Group. After some work together, Wilson and Smith co-founded AA (though not yet named as such) with a word of mouth program to help other alcoholics. Smith's last drink on June 10, 1935 is considered by members to be the founding date of AA.^[6] By 1937, Wilson and Smith determined that they had helped 40 alcoholics get sober, and two years later, with about 100 members, Wilson expanded the program by writing a book entitled Alcoholics Anonymous which the fellowship then adopted as its name. The book, informally referred to by members as "The Big Book," described a twelve-step program involving admission of powerlessness over alcohol, acceptance of a benevolent higher power, moral inventory, complete and direct restitution to those harmed, and asking for direction, guidance, and power from God. Essential to this process was the idea that the higher power be "of one's own understanding". In 1941, book sales and membership increased after interviews on American radio and favorable articles in US magazines, particularly by Jack Alexander in The Saturday Evening Post.[6]

By 1946, as membership grew, confusion and disputes within groups over practices, finances, and publicity led Wilson to write the guidelines for noncoercive group management, Twelve Points to Assure our Future, that eventually became known as the Twelve Traditions[7]. AA came of age at the 1955 St. Louis convention, in Missouri, when Wilson turned over the stewardship of AA to the General Service Conference.^[7] In this era, AA also began its international expansion, and by 2001 the number of members worldwide was estimated at two million.

Organization

A regional service center for Alcoholics Anonymous.

In 2006, 1,867,212 members in 106,202 AA groups were reported worldwide.^[8] The Twelve Traditions informally guide how AA groups function, and the Twelve Concepts for World Service guide how AA is structured globally.^[9]

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 two years and determined by group vote and/or the nature of the position. 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.^[8]

AA groups are self-supporting and not charities. There are no dues or membership fees. Groups rely on voluntary member donations to pay for expenses like room rental, refreshments, and literature. Typically a basket is passed during the meeting while the Twelve Traditions of AA are read (including the 7th Tradition, which states: "Every A.A. group ought to be fully self-supporting, declining outside contributions"). In the U.S., for example, people often put a dollar or two in the basket, but any contribution is voluntary and not required of anyone.^[8] AA GSO discourages individuals from making large donations by limiting contributions to US$3,000 per annum, and returns contributions mailed from sources outside of AA.^[10] Beyond the group level, AA may hire outside professionals for services that either require specialized expertise and/or are full time responsibilities. As of 2007 GSO in New York employs 40 or so such workers.

AA receives proceeds from books and literature which constitute more than 50% of the income for the General Service Office (GSO),^[11] 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. Other International General Service Offices (i.e., Australia, Costa Rica, Russia, etc.) are independent of AA World Services in New York.^[12]

Program

The scope of AA's program is much broader than just changing drinking behavior.^[13] AA process encourages the transformation of the alcoholic's character, producing a "personality change sufficient to recover from alcoholism"^[14] while abstaining from alcohol, one day at a time. The personality change is believed to be brought about by means of a spiritual awakening achieved from following the Twelve Steps,^[15] helping with duties and service work in AA,^[16] and regular AA meeting attendance^[17] or contact with AA members.^[15] Members are encouraged to find an experienced fellow alcoholic called a sponsor to help them understand and follow the AA program. Some members suggest the sponsor is preferably one that has maintained sobriety for at least a year and is of the same sex as the sponsored person, and who does not impose personal views on the sponsored person.^[18] Following the helper therapy principle, sponsors in AA benefit as much, if not more, from their relationship than do those they sponsor. Helping behaviors correlate with increased abstinence and lower probabilities of binge drinking.^[19]

AA's program is an inheritor of Counter-Enlightenment philosophy. AA shares the view that acceptance of one's inherent limitations is critical to finding one's proper place among other humans and God. Such ideas are described as "Counter-Enlightenment" because they are at variance with the Enlightenment's ideal that humans have the capacity to make their lives and societies a heaven on earth using their own power and reason.^[13]

Meetings

Anyone, including non-alcoholics, is allowed to attend "open" AA meetings, while "closed" meetings are reserved to those who have a desire to stop drinking.^[20] There are also specialized meetings, for example; groups for men or women; groups angled at gay people; and groups for speakers of languages other than English, in general, however, no one is excluded from these specific meetings. Most AA meetings begin with socializing. Formats vary between meetings, for example, a beginners' meeting might include a talk by a long-time sober member about his or her personal experience of drinking, coming to AA and what was learned there about sobriety. A group discussion on topics related to alcoholism and the AA program might follow.^[21]

In a typical meeting, the chairperson starts by calling the meeting to order and offering a short prayer, meditation, and/or period of silence (practice varies by meeting). Then, a section from the book Alcoholics Anonymous may be read aloud, usually the beginning of Chapter Five, entitled "How It Works". Announcements from the chairperson and group members follow. Many groups celebrate newcomers, visitors, and sobriety anniversaries with rounds of applause. At half time, donations are collected, usually by passing a basket around the room. There is no requirement to make a donation. Depending on the type of meeting, a talk by a speaker relating their personal experience with alcoholism and AA or a discussion session with topics chosen by the chairperson, the speaker, or the attendees follows.^[22] Sharing at meetings is not required. A hallmark of AA meetings is the "no cross-talk" suggestion, which discourages talking while another member is taking a turn or directing expansive questions to another attendee. During sharing, members may share about their alcoholic drinking and recovery, following the guidelines of "what we were like, what happened and what we are like now", or they may share with something they need to "get off their chest." When an individual chooses to speak, he or she is expected to begin with the statement, “ My name is __________ and I am an alcoholic (or visitor, or friend)”.^[23] . The meeting is typically ended with a prayer, usually the Serenity Prayer and / or the Lord's Prayer. The whole group usually forms a circle holding hands and recites these prayers together. Socializing typically follows the close of the meeting, and it is common for members to gather at a nearby café. Other meeting formats also exist where specific AA related topics are discussed in more detail, a common example is a Step Study meeting where one or more of the 12 steps are discussed at length.

During AA meetings, some 'in-group' language is used, for example, members will freely use idiomatic and metaphorical phrases such as “Keep it simple”, “Let go and let God”, and “If you turn it over, but don’t let go, you end up upside-down."

Confidentiality

Although a statement is read during meetings that what is said there should remain confidential, AA members, unlike lawyers or clergy, are not legally bound to maintain confidentiality.^[24][25][26]

Disease of alcoholism

AA regards alcoholism as an illness,^[27][28] and uses the concept to challenge the belief of chronic, compulsive drinkers that they can stay sober by willpower alone.^[29] Dr William Silkworth introduced to Wilson and AA the idea that alcoholism is an illness consisting of an obsession to drink alcohol, and an allergy, which triggers a compulsion to continue drinking once the first drink has been taken.^[30] (Silkworth's understanding of an allergy in the 1930s differs from that used in modern medicine today.)^[31] Alcoholics, he argued, can never safely use alcohol in any form at all, since once forming the habit, they cannot break it.^[32]

Demographics

AA's New York General Service Office regularly surveys AA members in North America. Its 2004 survey of over 7,500 members in Canada and the United States concluded that, in North America, AA members who responded to the survey were 65% male/35% female. 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. Before coming to AA, 64% of members received some type of treatment or counseling, such as medical, psychological, or spiritual. After coming to AA, 65% received outside treatment or counseling, and 84% of those members said that that outside help played an important part in their recovery. The same survey showed that AA received 11% of its membership from court ordered attendance.^[33]

Effectiveness

Limitations on research

The study of AA tends to polarize observers into believers and non-believers, and discussion of AA often creates controversy rather than objective reflection. A randomized trial of AA is very difficult because members are self-selected, not randomly selected from the population of chronic alcoholics,^[34] with the possible exception of those who participate in AA to comply with a court mandate. Two opposing types of self-selection bias are that drinkers may be motivated to stop drinking before they participate in AA, and AA may attract the more severe and difficult cases.^[35] Control groups with AA versus non-AA subjects are also difficult because AA is so easily accessible.^[35]

Studies

Research into AA's efficacy has led to inconsistent results between studies. While some studies have suggested an association between AA attendance and increased abstinence or other positive outcomes,^{[36][37][38][39][40][41][42][43]} other studies have not.^{[40][44][45][46][47]} A Cochrane Review of eight studies, published between 1967 and 2005, measuring the effectiveness of AA, found no significant difference between the results of AA and twelve-step facilitation approaches compared to other treatments. To determine further the effectiveness of AA, the authors suggested that more studies comparing treatment outcomes with control groups were necessary.^[48]

Attrition

Most who try AA do not remain with the program, with only about 1/4 of those who start the program remaining after one year. In a 1989 internal AA report based on an average of five surveys, it was estimated that of those who attended AA meetings for the first time, nearly one third (31.5%) leave the program after one month. By the end of the third month, just over half (52.6%) have left. Of those who remain after three months, about half (55.6%) will remain until the twelfth month.^[49] After the first year, the rate of attrition slows.

About 40% of the members sober for less than a year will remain another year. About 80% of those sober less than five years will remain sober and active in the fellowship another year. About 90% of the members sober five years or more will remain sober and active in the fellowship another year, however the survey states that this information does not predict the number that will remain sober, and those who remain sober but not in the fellowship cannot be calculated. These figures have been repeated within a few percentage points using the same calculations since 1974.^[50]

Healthcare costs

As a volunteer-supported program, Alcoholics Anonymous, as with non-12-step support groups, is a free service. This stands in contrast to treatments for alcoholism such as inpatient treatment, drug therapy, psychotherapy and Cognitive Based Therapy. Research has noted that institutional use of AA in certain circumstances has reduced healthcare expenditures by 45%. ^[51]

Relationship with institutions

Prisons

In the United Kingdom, Alcoholics Anonymous holds meetings in prisons. AA prison and probation liaisons cooperate with staff and AA volunteers give talks to staff in the legal profession.^[52] In the United States AA meetings are held in hundreds of correctional facilities.^[53] The AA General Service Office has published a workbook with detailed recommendations for methods to approach correctional facility officials with the intent of developing an in-prison AA program.^[53] In addition, a variety of pamphlets are published by AA specifically for the incarcerated alcoholic ^[54] The AA General Service Office also provides a pamphlet with guidelines for members involved in doing the twelfth step work, that is "carrying the message to those who still suffer." The pamphlet instructs members how to work within correctional facilties.^[55]

Court rulings

Since 1996, courts across the United States, in a number of different cases, have ruled that inmates, parolees, and probationers cannot be ordered to attend AA. Though AA itself was not deemed to be a religion, it was found to contain enough religious components to make such coercion a violation of the Establishment Clause of the First Amendment of the constitution.^[56] In September 2007, United States Court of Appeals for the Ninth Circuit stated that a parole office can be sued for ordering a parolee to attend Alcoholics Anonymous.^[57][58]

American treatment industry

Although Alcoholics Anonymous does not endorse and is not allied with any outside facility, since 1949 when Hazelden treatment center was founded by some AA members, alcoholic rehabilitation clinics have frequently incorporated precepts of the AA program into their own treatment programs.^[59] A reverse influence has also occurred with AA receiving 31% of its membership from treatment center referrals.^[33]

United Kingdom treatment industry

A cross-sectional survey of substance misuse treatment providers in the West Midlands found fewer than ten percent integrated twelve-step methods in their practice and only a third felt their consumers were suited for Alcoholics Anonymous or Narcotics Anonymous membership. Less than half were likely to recommend self-help groups to their clients. Providers with nursing qualification were more likely to make such referrals than those without. A statistically significant correlation was found between providers self-reported level of spirituality and their likelihood of recommending AA or NA.^[60]

Criticism

Moderation or abstinence

AA acknowledges that not all drinkers are alcoholics, but advocates total abstinence for those who are.^[61][62] However, some critics argue that some AA groups apply the disease model to all problem drinkers, whether or not they are full-blown alcoholics,^[63] and believe that more options should be available to problem drinkers who can manage their drinking with the right treatment.^[64]

A 2002 U.S. study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) showed that 17.7% of individuals diagnosed as alcohol dependent more than one year prior returned to low-risk drinking. However, this group showed fewer initial symptoms of dependency.^[65] A follow-up study, using the same NESARC subjects that were judged to be in remission in 2001-2002, examined the rates of return to problem drinking in 2004-2005. The major conclusion made by the authors of this NIAAA study was "Abstinence represents the most stable form of remission for most recovering alcoholics".^[66] A long-term (60 year) follow-up of two groups of alcoholic men concluded that "return to controlled drinking rarely persisted for much more than a decade without relapse or evolution into abstinence."^[67]

Religiosity or Worldview

One study found that attendance and active participation in any of the mutual support groups surveyed (AA, SMART Recovery, SOS, Women For Sobriety) improved chances of remaining clean and sober, but that attendance and participation reflected the attendee's level of religiosity or world view.^[43] It was found that those attendees with a theistic perspective, embracing a Higher Power viz. God as the agency for recovery, were more likely to participate in AA 12-step, while those with a more secular worldview which could range from atheists to Deists, hence no god or a God who does not intervene to remove "defects of character", were more likely to actively participate in the secular groups studied including SMART Recovery and SOS.

Cultural identity

One review of AA warned of detrimental iatrogenic effects of twelve-step philosophy, and concluded that AA uses many methods that are also used by cults.^[68] However, a further study concluded that AA's program bore little semblance to a religious cult's because the techniques used appeared beneficial.^[69] Another study found that an AA program's focus on self-admission of having a problem increases deviant stigma and strips members of their previous cultural identity replacing it with the deviant identity.^[70] A survey of group members, however, found they had a bicultural identity and saw AA's program as a complement to their other national, ethnic, and religious cultures.^[71]

Other notable criticism

• "Thirteenth-stepping" is a disparaging euphemism used by some AA members to refer to the romantic or sexual involvement of an existing male or female member with a newcomer.^[72] To avoid this type of behavior, AA typically suggests that men be sponsored by men, and women be sponsored by women (though in some cases, particularly with members who are homosexual, men may be sponsored by women and vice versa).^[73]

• Critics have argued that some AA members rely too heavily on dogmatic slogans and become overly dependent on the group.^[74]

Literature

Alcoholics Anonymous publishes several books, reports, pamphlets and other media including a periodical known as the AA Grapevine.^[75] Two books are used primarily, Alcoholics Anonymous (the "Big Book") and the Twelve Steps and Twelve Traditions which explains AA's fundamental principles in depth.

• Alcoholics Anonymous (June 1, 1976). Alcoholics Anonymous. Alcoholics Anonymous World Services. ISBN 0916856593. OCLC 2353981. http://www.aa.org/bigbookonline/. 
• Alcoholics Anonymous (February 10, 2002). Twelve Steps and Twelve Traditions. Alcoholics Anonymous World Services. ISBN 0916856011. OCLC 13572433. 
• The A.A. Grapevine (Alcoholics Anonymous). ISSN 0362-2584. OCLC 50379271. http://www.aagrapevine.org/index.php. 

See also

• Addiction recovery groups
• Alcoholism
• List of twelve-step groups
• Recovery model
• Self-help groups for mental health
• Substance abuse

Notes

External links

Wikimedia Commons has media related to: Alcoholics Anonymous

• AA official website
• Works by or about Alcoholics Anonymous in libraries (WorldCat catalog)