Alcoholics Anonymous (AA) is an international mutual aid movement declaring its “primary purpose is to stay sober and help other alcoholics achieve sobriety.” Now claiming more than 2 million members, AA was founded in 1935 by Bill Wilson and Dr. Bob Smith (Bill W. and Dr. Bob) in Akron, Ohio. With other early members Wilson and Smith developed AA’s Twelve Step program of spiritual and character development. AA’s Twelve Traditions were introduced in 1946 to help AA stay unified and grow. The Traditions recommend that members and groups remain anonymous in public media, altruistically help other alcoholics and include all who wish to stop drinking. The Traditions also recommend that AA members acting on behalf of the fellowship steer clear of dogma, governing hierarchies and involvement in public issues. Subsequent fellowships such as Narcotics Anonymous have adopted and adapted the Twelve Steps and the Twelve Traditions to their respective primary purposes.
AA’s first female member Florence Rankin joined in 1936, and the first non-Protestant member, a Roman Catholic, joined in 1939. AA membership has since spread “across diverse cultures holding different beliefs and values”, including geopolitical areas resistant to grassroot movements.
AA generally avoids discussing the medical nature of alcoholism, but nonetheless, AA is regarded as a proponent and popularizer of the disease theory of alcoholism. The American Psychiatric Association has recommended sustained treatment in conjunction with AA’s program, or similar community resources, for chronic alcoholics unresponsive to brief treatment. AA’s own data state that 64% drop out of AA in their first year, but its program is credited with helping many alcoholics achieve and maintain sobriety.
AA’s name derived from its first book, originally titled Alcoholics Anonymous: The Story of How More Than One Hundred Men Have Recovered From Alcoholism, and informally called “The Big Book.”
Beginnings
AA sprang from The Oxford Group, a non-denominational movement modeled after first-century Christianity. Most Group members (“Groupers”) were not concerned with sobriety, but some, such as Ebby Thacher, believed the group was a critical aid in staying sober. Following the Group’s evangelical bent, Thacher sought out former drinking buddy Bill Wilson to tell him he was sober because he had “got religion.” Thacher also told Wilson he could get sober too if he set aside his objections to religion and form a personal conception of God, “another power” or “higher power.”
Feeling a “kinship of common suffering”, and struck that Thacher was sober, Wilson attended his first Group gathering, though he was drunk. Within days Wilson admitted himself for the fourth time to the Charles B.Towns Hospital after stopping on the way to drink four beers – the last amount of alcohol Wilson consumed. Under the care of Dr. William Duncan Silkworth (an early benefactor of A.A.), Wilson’s underwent a detox treatment which included the deliriant Belladonna. At the hospital in a state of despair, Wilson had a physiologically induced ecstatic/hallucinogenic experience in which he saw a bright flash of light, which he profoundly felt to be God revealing himself.
After his hospital discharge, Wilson joined the Oxford Group and recruited other alcoholics to the group. Wilson’s early efforts to help others become sober were ineffective, prompting Dr. Silkworth to suggest that Wilson place less stress on religion and on more on “the science” of treating alcoholism. Wilson’s first success came during a business trip to Akron, Ohio, where he was introduced to Dr. Robert Smith, a surgeon and Oxford Group member who was unable to stay sober. After thirty days of working with Wilson, Smith drank his last drink on June 10, 1935, the date marked by AA for its anniversaries.
Stepping Stones, the Wilsons’ home in later life, now a museum
While Wilson and Smith credited their sustained sobriety to working with alcoholics under the auspices of the Oxford Group, a Group associate pastor sermonized against Wilson and his alcoholic Groupers for forming a “secret, ashamed sub-group” engaged in “divergent works”. By 1937 Wilson separated from the Oxford Group. AA historian Ernest Kurtz explained the split:
…more and more, Bill discovered that new adherents could get sober by believing in each other and in the strength of this group. Men [no women were members yet] who had proven over and over again, by extremely painful experience, that they could not get sober on their own had somehow become more powerful when two or three of them worked on their common problem. This, then—whatever it was that occurred among them—was what they could accept as a power greater than themselves. They did not need the Oxford Group.
In 1955 Wilson acknowledged AA’s debt, saying “The Oxford Groupers had clearly shown us what to do. And just as importantly, we learned from them what not to do.” Among the Oxford Group practices AA retained were informal gatherings, a “changed-life” developed through “stages”, and working with others for no material gain. AA’s analogs for these are meetings, “the steps”, and sponsorship. Anonymity came about as AA wished to avoid the publicity-seeking practices of the Oxford Group and to not promote, Wilson said, “erratic public characters who through broken anonymity might get drunk and destroy confidence in us.”
The Big Book, the Twelve Steps and the Twelve Traditions
In 1937, Wilson and Smith could count 40 alcoholic men they had helped to get sober, and two years later they counted 100 members, including one woman. To promote the fellowship, Wilson and other members wrote the initially-titled book, Alcoholics Anonymous: The Story of How More Than One Hundred Men Have Recovered from Alcoholism, from which AA drew its name. Informally known as “The Big Book” (with its first 164 pages virtually unchanged since the 1939 edition), it suggests a twelve-step program in which members admit that they are powerless over alcohol and need help from a “higher power”; seek guidance and strength through prayer and meditation from a god (or Higher Power) of their own understanding; take a moral inventory with care to include resentments; list and become ready to remove character defects; list and make amends to those harmed, and then try to help other alcoholics recover. The second half of the book, “Personal Stories” (subject to additions, removal and retitling in subsequent editions), is made of AA members’ redemptive autobiographical sketches.
In 1941, interviews on American radio and favorable articles in US magazines, including a piece by Jack Alexander in The Saturday Evening Post, led to increased book sales and membership. By 1946, as the growing fellowship quarreled over structure, purpose, and authority, as well as finances and publicity, Wilson began to form and promote what became known as AA’s Twelve Traditions, guidelines for an altruistic, unaffiliated, non-coercive, and non-hierarchical structure that limited AA’s purpose to only helping alcoholics on a non-professional level while shunning publicity. Eventually he gained formal adoption and inclusion of the Twelve Traditions in all future editions of the Big Book. At the 1955 St. Louis convention in Missouri, Wilson relinquished stewardship of AA to the General Service Conference, as AA grew to millions of members internationally.
Organization and finances
AA says it is “not organized in the formal or political sense”, and Bill Wilson called it a “benign anarchy”. In Ireland, Shane Butler said that AA “looks like it couldn’t survive as there’s no leadership or top-level telling local cumanns what to do, but it has worked and proved itself extremely robust.” This was, Butler said, because “AA’s ‘inverted pyramid’ style of governance has helped it to avoid many of the pitfalls that political and religious institutions have encountered since it was established here in 1946.”
In 2006 AA counted 1,867,212 members and 106,202 AA groups worldwide. The Twelve Traditions informally guide how individual AA groups function, and the Twelve Concepts for World Service guide how the organization 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 and 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” of the 21-member AA Board of Trustees.
AA groups are self-supporting, relying on voluntary donations from members to cover expenses. AA GSO limits contributions to US$3,000 a year. Above the group level, AA may hire outside professionals for services that require specialized expertise or full-time responsibilities.
AA receives proceeds from books and literature that constitute more than 50% of the income for its General Service Office (GSO). Unlike individual groups, the GSO is not self-supporting and maintains a small salaried staff. It also maintains service centers which coordinate activities such as 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 (Australia, Costa Rica, Russia, etc.) are independent of AA World Services in New York.
Program
The scope of AA’s program is much broader than just abstinence from drinking alcohol. Its goal is to effect enough change in the alcoholic’s thinking “to bring about recovery from alcoholism” through a spiritual awakening. A spiritual awakening is achieved by following the Twelve Steps, and sobriety is furthered by volunteering for AA and regular AA meeting attendance or contact with AA members. Members are encouraged to find an experienced fellow alcoholic, called a sponsor, to help them understand and follow the AA program. The sponsor should preferably have experience of all twelve of the steps, be the same gender as the sponsored person, and refrain from imposing personal views on the sponsored person. 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.
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 contrary to 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.
Nevertheless, sociologists David Rudy and Arthur Greil evaluated AA’s literature and observed AA meetings for sixteen months. They note that although AA’s ideology denies AA is religious in nature, for an AA member to remain sober a high level of commitment is necessary. This commitment is facilitated by a change in the member’s world view. To help members stay sober AA must, they argue, provide an all-encompassing world view while creating and sustaining an atmosphere of transcendence in the organization. To be all-encompassing AA’s ideology places an emphasis on tolerance rather than on a narrow religious world view that could make the organization unpalatable to potential members and thereby limit its effectiveness. AA’s emphasis on the spiritual nature of its program, however, is necessary to institutionalize a feeling of transcendence. A tension results from the risk that the necessity of transcendence, if taken too literally, would compromise AA’s efforts to maintain a broad appeal. As this tension is an integral part of AA, Rudy and Greil argue that AA is best described as a quasi-religious organization.
Meetings
AA meetings are “quasi-ritualized therapeutic sessions run by and for, alcoholics”. They are usually informal and often feature discussions. Local AA directories list a variety of weekly meetings. Those listed as “closed” are only for those with “a desire to stop drinking”, while “open” meetings are available to anyone. At speaker meetings one or two members tell their stories, while discussion meetings allocate the most time for general discussion. Some meetings are devoted to studying and discussing the AA literature. Except for men’s and women’s meetings, most meetings targeting specific demographics (including newcomers, gays, and young people) do not exclude other alcoholics. While AA has pamphlets that suggest meeting formats, groups have the autonomy to hold and conduct meetings as they wish “except in matters affecting other groups or A.A. as a whole”. Different cultures affect ritual aspects of meetings, but around the world “many particularities of the AA meeting format can be observed at almost any A.A. gathering”.
Confidentiality
Although a statement is sometimes read during meetings saying that what is said there should remain confidential, AA members, unlike lawyers or health care professionals, are not legally bound to maintain confidentiality.
Spirituality
The spiritual aspect of Alcoholics Anonymous is identified in the core AA literature to be central for achieving and sustaining sobriety.
Recent research findings suggest that AA leads to better alcohol use outcomes, in part, by enhancing individuals’ spiritual practices and provides support for AA’s own emphasis on increasing spiritual practices to facilitate recovery from alcohol use disorder. As attendance of AA meetings increase, so do the participants spiritual beliefs, especially in those individuals who had low spirituality at the beginning of the study.
The results indicated that there was a robust association between an increase in attendance to AA meetings with increased spirituality and a decrease in the frequency and intensity of alcohol use over time. One of the most interesting aspects of the research was that the same amount of recovery was seen in both agnostics and atheists, which indicates that while spirituality is an important mechanism of behavioral change for AA, it is not the only method used.
Disease concept of alcoholism
More informally than not, AA’s membership has helped popularize the disease concept of alcoholism, though AA officially has had no part in the development of such postulates which had appeared as early as the late eighteenth century. Though AA initially avoided the term “disease”, in 1973 conference-approved literature categorically stated that “we had the disease of alcoholism.” Regardless of official positions, from AA’s inception most members have believed alcoholism to be a disease.
Though cautious regarding the medical nature of alcoholism, AA has let others voice opinions. The Big Book states “we are told that alcoholism “is an illness which only a spiritual experience will conquer.” Ernest Kurtz says this is “The closest the book Alcoholics Anonymous comes to a definition of alcoholism.” In his introduction to The Big Book, non-member Dr. William Silkworth suggested that those unable to moderate their drinking have an allergy. However, AA said, “The doctor’s theory that we have an allergy to alcohol interests us. As laymen, our opinion as to its soundness may, of course, mean little.” In fact AA later acknowledged that “alcoholism is not a true allergy, the experts now inform us.” Wilson explained in 1960 why AA had refrained from using the term “disease”:
We AAs have never called alcoholism a disease because, technically speaking, it is not a disease entity. For example, there is no such thing as heart disease. Instead there are many separate heart ailments or combinations of them. It is something like that with alcoholism. Therefore, we did not wish to get in wrong with the medical profession by pronouncing alcoholism a disease entity. Hence, we have always called it an illness or a malady – a far safer term for us to use.
Canadian and United States 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 and 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.
Effectiveness
Research limitations
AA tends to polarize observers into believers and non-believers, and discussion of AA often creates controversy rather than objective reflection. Moreover, a randomized study of AA is difficult: AA members are not randomly selected from the population of chronic alcoholics, with the possible exception of those who are mandated by courts to attend AA meetings; they are instead self-selected. There are two opposing types of self-selection bias: (1) drinkers may be motivated to stop drinking before they participate in AA (2) AA may attract the more severe and difficult cases. Controlled experiments with AA versus non-AA subjects are also difficult because AA is so easily accessible. Twelve-step groups, like AA, are not conducive to probability sampling of members. Research on AA is therefore susceptible to sampling bias.
Studies
Studies of AA’s efficacy have produced inconsistent results. While some studies have suggested an association between AA attendance and increased abstinence or other positive outcomes, other studies have not. It should be noted, however, that the book Alcoholics Anonymous does not suggest meeting attendance as a program of recovery, but instead suggests the Twelve Steps. A Cochrane Review of eight studies, published between 1967 and 2005, measuring the effectiveness of AA, found “no experimental studies unequivocally demonstrated the effectiveness of AA” in treating alcoholism, based on a meta-analysis of the results of eight trials involving a total of 3,417 individuals. To determine further the effectiveness of AA, the authors suggested that more studies comparing treatment outcomes with control groups were necessary.
Survey results
Every third year since 1968, AA has issued a pamphlet summarizing its latest triennial survey of meeting attendants. Additional published comments and analysis for academics and professionals have supplemented the survey results from 1970 through 1990. The 1990 commentary evaluated data of triennial surveys from 1977 through 1989 and found that one quarter (26%) of those who first attend an AA meeting are still attending after one year. Furthermore, nearly one third (31.5%) leave the program after one month, and by the end of the third month, over half (52.6%) leave. After the first year, the rate of attrition slows. Only those in the first year were recorded by month. 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. Those who remained sober outside the fellowship could not be calculated using the survey results.
Health-care costs
As a volunteer-supported program, AA is free of charge. This contrasts with treatments for alcoholism such as inpatient treatment, drug therapy, psychotherapy and cognitive-based therapy. Still some research has found that institutional use of AA in certain circumstances has reduced health-care expenditures by 45%.
Relationship with institutions
Prisons
In the United States and Canada AA meetings are held in hundreds of correctional facilities. The AA General Service Office has published a workbook with detailed recommendations for methods of approaching correctional-facility officials with the intent of developing an in-prison AA program. In addition, AA publishes a variety of pamphlets specifically for the incarcerated alcoholic. Additionally, the AA General Service Office provides a pamphlet with guidelines for members working with incarcerated alcoholics.
United States Court rulings
United States courts have ruled that inmates, parolees, and probationers cannot be ordered to attend AA. Though AA itself was not deemed a religion, it was ruled that it contained enough religious components (variously described in GRIFFIN v. COUGHLIN below as, inter alia, “religion”, “religious activity”, “religious exercise”) to make coerced attendance at AA meetings 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 AA.
American treatment industry
In 1949 the Hazelden treatment center was founded by AA members, and since then many alcoholic rehabilitation clinics have often incorporated AA’s precepts into their treatment programs. 31% of AA’s membership results from treatment centers referrals.
United Kingdom treatment industry
A cross-sectional survey of substance-misuse treatment providers in the West Midlands found fewer than 10% 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.
Criticism
Moderation or abstinence
Stanton Peele argued that some AA groups apply the disease model to all problem drinkers, whether or not they are “full-blown” alcoholics. Along with Nancy Shute, Peele has advocated that besides AA, other options should be available to problem drinkers who can manage their drinking with the right treatment. The Big Book, however, acknowledges “moderate drinkers” and “a certain type of hard drinker” able to stop or moderate their drinking. The Big Book suggests no program for these drinkers, but instead seeks to help drinkers without “power of choice in drink.”
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. A subsequent study concluded, however, that AA’s program bore little semblance to religious cults because the techniques used appeared beneficial. Another difference is that, unlike what happens in cults, AA does not seek to prevent a member leaving or renouncing the movement. Another study found that the AA program’s focus on 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 criticisms
“Thirteenth-stepping” is a disparaging euphemism referring to AA members who approach new members for dates or sex. The Journal of Addiction Nursing reported that 50% of the women that participated in a survey (55 in all) experienced 13-stepping behavior from others. To avoid this type of behavior, AA suggests that typically men be sponsored by men and women be sponsored by women.
In 1964 Arthur H. Cain – by his own count – had attended over 500 AA meetings since 1947. Cain insisted that “I do not suggest for a moment that a single A.A. quit the fellowship. On the contrary, I strongly urge sticking with it. To anyone who is having trouble with alcohol I say: try A.A. first; it’s the answer for most people”. Even so Cain thought that AA had become the domain of irreligious misfits “Dogmatic and opinionated in their nonbeliefs”, who scorned other societies such as the the Kiwanis Club. Cain said AA had come to rely heavily on dogmatic slogans and the group. Without referencing or fashioning a definition of the term, Cain called AA a “cult” and “a hindrance to research, psychiatry, and to many alcoholics who need a different kind of help”.