AA Isn't the Best Solution: Alternatives for Alcoholics
Stanton Peele
addiction expert, psychologist, raconteur
Posted: July 1, 2010 10:20 AM
Building on an essay in Wired magazine by Brendan Koerner, New York Times conservative columnist David Brooks lauds to the sky AA and its founder, Bill Wilson. Both Brooks and Koerner point out the worldwide spread of AA (although it is limited mainly to the U.S. and like-minded countries), and the spread of the 12 steps to nearly all areas of behavior change, indeed, to how we approach social problems of all sorts.
Along the way, Brooks makes the good points that there is no scientific way to program behavior change -- that it is indefinite and rooted in individual choice. He points out the benefits of the social networks AA provides its members, and the decentralization of the AA movement, so that individual chapters are able to organize as its own members see fit. These are strong organization and psychological pluses.
But, unfortunately for a rational conservative, Brooks misses a few downsides to the AA movement.
1. The view AA conveys of alcohol and alcoholism is associated with abstinence-binge tendencies that already dominate America and other temperance nations. AA's approach is completely abstinence oriented. In fact, temperance cultures like America, which are highly suspicious and fearful of alcohol, are characterized by many individuals who restrict their drinking, but then go on benders. Similar Northern European cultures, for example, have several times the death rates due to alcohol of Southern European countries, because the former tend to monumental binges (think Ireland, England, Finland) while in the Southern countries, people drink alcohol causally with meals (think Italy, Spain, Greece, France). All indications are that the latter is much healthier. More particularly, the majority of AA members fall off the wagon. When they do so, they very often return to drinking without restraint.
Brooks, a great trend-spotter, has missed the worldwide movement -- including in the United States -- towards harm reduction. Harm reduction has an opposite approach to substance use and addiction from the 12 steps. It assumes many people will fail to achieve abstinence, and instead works in every possible way to curtail the problems associated with use: infections (through needle exchange), eliminating accidents (through safe driver programs), healthier use (through cutting back drinking, providing shelter, food and medical care for alcoholics and addicts, and, in the drug area, using safe injection methods or substitutes for injectibles).
Just as Brooks and Koerner were announcing their discovery that AA is great, the National Institute on Alcohol Abuse and Alcoholism was announcing that "alcoholism isn't what it used to be," that most people cut back alcoholic drinking without going to treatment -- that is, that most of the benefits of self-improvement occur outside the walls of AA for people who specifically violate the fundamental principles of AA. Brooks rejects science in this area: i.e., the idea "that we will someday find a scientific method that will allow us to predict behavior and design reliable social programs." But let's not reject science that tells us how the majority of people actually behave. That's ignorance.
2. Sorry, AA doesn't work. The goal of AA and comparable methods is to get people sober (which does NOT, outside of AA, mean total abstinence for everyone). But, according to Koerner: "Wilson's success is even more impressive when you consider that AA and its steps have become ubiquitous despite the fact that no one is quite sure how -- or, for that matter, how well -- they work." In other words, Wilson's and AA's triumph has been in marketing, not therapeutics.
In other areas, Brooks is not so quick to jump on the bandwagon of approaches that aren't proven to be successful. Given that AA started in 1935, that it is still not proven to be successful is beginning to be a bit worrisome. Do drinking and drug problems, alcoholism and addiction, seem to be improving in the United States? (Hint: according to the National Survey on Drug Use and Health, 25 percent of 21-year-old Americans have a diagnosable drug or alcohol problem -- far and away most often an alcohol problem.) Don't you think we might be doing a little better in this area after 75 years?
3. American AA is coercive. Brooks wisely notes, in acknowledging that AA doesn't work particularly well, "There is no single program that successfully transforms most people most of the time." But virtually everyone who ends up in AA in the United States is sent (forced) to attend AA or comparable programs -- for example through drug courts, or even municipal traffic courts after a DUI. Why does this occur? Because the AA movement is spearheaded by true believers who believe what was good for them is good for everyone, as Brooks himself hints: "There are millions of people who fervently believed that its 12-step process saved their lives." Naturally, these people are inclined to "recommend" that others follow their one truth path. This, even though Brooks notes, "the majority, even a vast majority, of the people who enroll in the program do not succeed in it."
4. The government, especially, should not be involved in spiritual salvation and identity change. As Brooks correctly states, people become sober when they "achieve broad spiritual awakenings, and abstinence from alcohol ... [is then] a byproduct of that larger salvation." Fair enough, but how does this go with point three, that people are routinely sent to AA by courts and social agencies? Four of nine federal circuit courts (as well as New York's and several other states' highest courts) have ruled that people with religious objections (Buddhists, atheists, Jews) cannot be compelled to attend AA or a 12-step program, and must be permitted alternatives. I know, I know ... AA isn't religious, and Step 3, "Made a decision to turn our will and our lives over to the care of God as we understood Him," isn't really about that God -- you know, the Christian one. But those dang courts keep begging to differ -- forcing people to bow to any form of God is just not part of the Constitution.
5. We need to be encouraging alternatives to AA. Brooks does not make the proper deduction from noting that, "There is no single program that successfully transforms most people most of the time." Since AA and the 12 steps are used in over 90 percent of American treatment programs, we need to provide more ready alternatives to AA, not inject more resources and energy into the system that has been around three-quarters of a century, will little noticeable society-wide improvement in our drinking. Therapeutically, providing choice is a powerful tool, since it turns around many people's resistance to AA's Step 1 -- acknowledging that you are powerless. People tend to do better pursuing programs they believe in.
The most promising trends in alcoholism treatment are motivation enhancement (developed by psychologist William Miller), which avoids dictating to clients and instead allows them to express and pursue their own values, and mindfulness (developed by psychologist Alan Marlatt), the Zen Buddhist technique of meditation and focusing on inner states and needs. I use these techniques in my Life Process Program, which provides a non-12-step alternative that many people welcome, and in fact do better at.
And, while I'm at it, let me mention that I have recently written a foreword for Amy Lee Coy's From Death Do I Part, which is the story of a 34-year-old woman's quitting drinking after two decades of alcoholism (and assorted other addictions) and a dozen, at least, exposures to AA and 12-step rehab. She did so when she finally took ultimate responsibility for her own life.
P.S. Dave, read the comments, especially the ones that say any alcoholics who read this will die.
From the comments:
Brandsma JM, Maultsby MC, & Welsh RJ. (1980). Outpatient treatment of alcoholism: A review and comparative study. Baltimore: University Park Press.
Dodes, LM. (2002). The Heart of Addiction: A New Approach to Understanding and Managing Alcoholism and Other Addictive Behaviors. New York: HarperCollins.
NIAAA Five Year Strategic Plan FY07-11
Vaillant GE. (1995).The natural history of alcoholism revisited. Cambridge, Mass. Harvard University Press.
In particular, Vaillant's is the only cohort study where the 12 steps are compared to a control group. There were no advantages of the 12 step group compared to the control group in improvements in drinking behaviors over the course of several decades. The Brandsma study found that the 12 step group was comparable to the control group whereas the groups receiving cognitive or psychodynamic therapies did better than either the 12 step group or the control group. Vaillant is not anti-AA--he was a member of their board.
It is your constitutional right to use AA for your alcohol problem just as it is your constitutional right to use Christian Science for your cancer. Many people attend and swear by the Church of Christian Science just as many people attend and swear by AA. This does not prove that either is better than a no-treatment control group. If it helps you--then fine--go for it. Do not claim that "it works" however, unless you can find a scientific study to back you up. There are none.
The Brandsma study took people arrested for alcohol offenses and placed them into three groups. The AA group were fives times as likely to engage in binge drinking as the group that received no treatment, nine times as much as the group that received rational behavior therapy.
Teaching people that they have a lifelong disease that they are powerless over appears to turn any slip into a full blown relapse. This has become known as the "abstinence violation effect", and it happens with people whether they are mandated or not.
