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Alcoholics Anonymous

Alcoholics Anonymous (AA) is an informal meeting society for recovering and recovered alcoholics, with the stated purpose to help its members "to stay sober and help other alcoholics to achieve sobriety." AA suggests that alcoholics follow its program of recovery 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.

AA was the first twelve-step program and has been the model for similar recovery groups like Narcotics Anonymous and Gamblers Anonymous. Al-Anon/Alateen are programs designed to provide support for relatives and friends of alcoholics. Although AA is not for everyone and attrition rates are high, there is evidence supporting the effectiveness of AA as a treatment for alcoholism.

History

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 at Charles B. Towns hospital 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 a healing higher power, 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. Wilson and Smith co-founded AA with a word of mouth program to help alcoholics. Smith's last drink on June 10, 1935 is considered by members to be the founding date of AA. By 1937, Wilson and Smith 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, informally referred to by members as "The Big 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 led 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. In this era AA also began its international expansion, and by 2001 the number of members worldwide was estimated at two million.

Organization

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

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. 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.

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. No one is turned away for lack of funds.

AA receives proceeds from books and literature which constitute more than 50% of the income for the General Service Office (GSO), 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

The AA suggested program of recovery for alcoholics includes abstaining from alcohol one day at a time and having a spiritual awakening through following Twelve Steps, helping with duties and service work in AA, and regular AA meeting attendance or contact with AA members. Members are encouraged find 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. The program of action has the goal of producing a "personality change sufficient to recover from alcoholism" . AA promotes the idea that recovery from alcoholism entails more than not drinking.

It is important to distinguish between the AA "program" and the "fellowship" of AA.[citation needed] The fellowship includes meetings and friendships with other AA members, whereas 'the program', refers to the course of action outlined in the first 164 pages of the book Alcoholics Anonymous.

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. There are groups for men or women, groups angled at gay people, and groups for speakers of minority languages. Most AA meetings begin with socializing. Formats vary between meetings, for example, a beginner's 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 of sobriety. A group discussion on topics related to alcoholism and the AA program might follow.

In a typical meeting, the chairperson starts by calling the meeting to order and offering a short prayer, meditation, and/or period of silence. Then, a section from "The Big Book" may be read aloud, usually the beginning of Chapter Five, entitled "How It Works". Announcements from the chairperson and/or group members follow. Many groups celebrate newcomers, visitors, and sobriety anniversaries with rounds of applause. Following the announcements, donations are collected, usually by passing a basket around the room. There is no requirement on anyone to make a donation. Most members contribute a small amount, often just some loose change. The making of large donations is actively discouraged in AA Depending on the type of meeting, there follows either 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, and/or the attendees. A hallmark of these types of AA meeting is the "no crosstalk" suggestion, where responding to another member's comments is discouraged. In many meetings, in order to encourage identification, members confine their comments to their alcoholic drinking and recovery, following the guidelines of "what it was like, what happened and what it's like now". This format is intended to avoid wide ranging debate of other topics from distracting the group from its primary purpose. After the discussion period, the meeting is typically ended with a prayer, usually the Serenity Prayer or often in the US, the Lord's Prayer. These ending prayers are sometimes undertaken by the entire group forming a circle and holding hands. More socializing typically follows the close of the formal meeting, and it is common for members to gather at nearby coffee shops. 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.

AA Considers Alcoholism A Disease

The Basic Text of AA regards alcoholism as an illness. While discussing the term "disease", Bill Wilson once stated that alcoholism was more comparable to an illness or malady, and uses the concept to challenge the belief of chronic, compulsive drinkers that they can stay sober by willpower alone. 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 was the compulsion to continue drinking once the first drink had been taken. Alcoholics, he argued, can never safely use alcohol in any form at all, since once forming the habit, they cannot break it. Note that the definition of "allergy" used in this context is not the same as used in modern medicine.

Demographics

AA's 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. 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. A survey conducted in 2004 showed that AA received 11% of its membership from court ordered attendance. http://www.alcoholics-anonymous.org/en_pdfs/p-48_04survey.pdfAA2004Membership Survey

Effectiveness

Limitations on research

The study of AA tends to polarize observers into believers and non-believers, and discussion of AA often creates argument rather than objective reflection. Many researchers take a skeptical view of AA because some of AA's methods are spiritual, not scientific. A randomized trial of AA is very difficult because members are self-selected, not randomly selected with the exception of court mandated AA attendance. 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. Control groups with AA versus non-AA subjects are also difficult because AA is so easily accessible.

Studies

Many studies have demonstrated an association between AA attendance and increased abstinence or other positive outcomes. Other studies have concluded that AA attendance can lead to poorer outcomes than other therapies.

Attrition

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. 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.

Relationship with institutions

The prison and court systems

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. In the United States the AA General Service Office 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 pamphet instructs members how to work within correctional facilties.

American 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. A reverse influence has also occurred with AA receiving 31% of its membership from treatment center referrals. Alcoholics Anonymous, however, does not endorse and is not allied with any rehabilitation center or outside facility.

In a survey of treatment providers from the National Association of Alcoholism and Drug Abuse Counselors, Rational Recovery Systems and Society of Psychologists in Addictive Behaviors the scores of the treatment provider's responses on the Spiritual Belief Scale (a scale measuring belief in the four spiritual characteristics AA identified by Ernest Kurtz) were found to explain 41% of the variance in the treatment provider's responses on the Addiction Belief Scale (a scale measuring adherence to the disease model or free-will model addiction).

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 (spirituality, god, prayer and proselytism) to make such coercion a violation of the Establishment Clause of the First Amendment of the constitution. 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.

Criticism and controversy

Moderation or abstinence

AA acknowledges that not all drinkers are alcoholics, but advocates total abstinence for those who are. Dr. William D. Silkworth in the Doctor's Opinion in the Big Book of Alcoholics Anonymous states that for the alcoholic, "the only relief we have to suggest is entire abstinence."

Critics argue that some AA groups apply the disease model to all problem drinkers, whether or not they are full-blown alcoholics, and believe that more options should be available to problem drinkers who can manage their drinking with the right treatment.

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. 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". 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.

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. However, a further study concluded that AA's program bore little semblance to a religious cult's because the techniques used appeared beneficial. 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. 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.

Other notable criticism

AA undertakes no external restriction, screening, or vetting of its members.

"Thirteenth-stepping" is a disparaging euphemism used by some AA members to refer to the romantic or sexual involvement of an older male or female member with a newcomer. To avoid this type of behavior, AA suggests men be sponsored by men, and women be sponsored by women.

Critics have noted that some AA members rely too heavily on dogmatic slogans and become overly dependent on the group.

AA has been described as having substantial religious components, one reason for the provision of secular programs by other recovery groups.

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. Even though two people may promise not to disclose a shared confidence, the courts are not bound to honor that promise.