By Mark Flanagan
Of the 23 million people who struggle with alcohol or drug abuse on a yearly basis, roughly 1.2 million regularly attend Alcoholics Anonymous (AA) meetings as a way to stop drinking. AA was the first 12-step program to be created. Founded on December 14, 1934 by Bill Wilson and Robert or “Dr. Bob” Smith, AA combines self-assessment, reconciliation, group therapy, and surrendering control to a “higher power” in a progressive plan consisting of 12 distinct steps to combat impulsive cravings to use.
“Secret of AA: After 75 Years, We Don’t Know How It Works”, written by Brendan Koerner for Wired, does a thorough job explaining the history and approach of Alcoholics Anonymous in the United States. Koerner writes that, “There’s no doubt that when AA works, it can be transformative. But what aspect of the program deserves most of the credit?… Stunningly, even the most highly regarded AA experts have no idea.”
Koerner then examines how research in the behavioral sciences and neurology can provide insights to AA’s intermittent success. Here we learn that it’s not just the twelve steps but also the power of the group, from the commitment the individual feels to forming close relationships that can provide a sense of security to the opportunity to relearn how to connect to others without alcohol. Koerner also argues that the experience of public confession, both doing it and seeing it, helps individuals strengthen the regulatory powers of their prefrontal cortex, weakened after years of drinking.
However, in trying to account for the modest but significant beneficial effects AA can have for many individuals, Koerner leaves out important “soft sciences”, such as anthropology. Why do people attend AA? It’s not just to strengthen their prefrontal cortices.
In this post I will outline some societal forces that have led to AA’s popularity. I will also argue that the social sciences are integral for crafting new and effective addiction treatments. The ideas and data presented here come in large part from my comparative research on alcohol use and abuse among homeless men, college students, and veterans struggling with post-traumatic stress disorder.
Societal Forces at Play in Biomedicine
AA has been the subject of countless studies, yet reported success rates vary enormously: between 5 and 75 percent. This may be due to AA’s shunning of individual identification and the ease with which members enter and leave the program. However, several studies indicate that AA does not work for everyone and that, for most people, does not work at all.
While scientific support for AA or other 12-step programs is inconclusive, most medical practitioners strongly recommend it as a primary means to treat addiction. In Wired, addiction-medicine specialist Drew Pinsky states: “In my 20 years of treating addicts, I’ve never seen anything that comes close to the 12-steps. In my world, if someone says they don’t want to do the 12-steps, I know they aren’t going to get better.”
This contradiction between the little if any definitive scientific proof that AA reliably treats those suffering from addiction and the wide-spread endorsement of AA by medical and governmental officials raises an important sociological question:
Why do so many science-based medical providers recommend AA?
It’s free.
This is the number one response that has been given to me by a diverse set of experts: medical doctors, counselors, sociologists, anthropologists, and long time AA members. In addition, it’s a response that accounts for socio-economic forces unseen in the nightmarish immediacy of alcohol dependent bodies.
Many individuals suffering from alcohol or drug dependency have gotten to a point where all fiscal resources are dedicated to obtaining more substance to consume. Consequently, addicts may only enter treatment when all money and social support nets have run out. This precludes any possibility of entering a treatment program that costs money.
At a time when the health care industry is much more frugally minded, it makes sense to take advantage of low or no cost treatment options that rival recovery rates of higher cost methods. While it could be argued that other current methods may have a higher success rate, nothing beats the price of AA.
It’s convenient
AA has 55,000 groups globally. There is already a structure in place that has acclaimed effectiveness, whether common or not, from varied demographics. It is much more prevalent than other, lesser known non-12-step addiction treatments, and is found in virtually every major city’s business listing in the United States. This expert, from a life history recorded during my college thesis research, demonstrates the ease of locating a group:
On February 23rd, 1978, Chris [a pseudonym] began complete alcohol abstinence and substance sobriety. His brother, whom he was staying with, forced Chris to either get treatment or leave his home. “‘But I don’t know the first place to start,’ I told my brother,” Chris said. “My brother threw me a phone book and said, ‘start looking’”. Chris soon found a local Alcoholics Anonymous and entered into treatment.
In addition, AA is embedded in the criminal justice/ law enforcement system which tends to have frequent interactions with alcohol dependent individuals.
AA is something immediately and universally available that has been around for 76 years; it is a socially accepted norm that alcoholics go to AA.
Passionate Anecdotal Evidence
While AA does not work for most people, those it does work for are dramatically changed. While conducting my own research, I have encountered numerous individuals from varied backgrounds who swear by AA and claim that without AA, they most likely would not be living. Many people’s lives have been saved by AA, even if those people are a statistical minority.
When individuals experience an event that forever changes his or her life, whether it be good or bad, that event has a large chance of forever coloring future experience. To come out of such a distorting condition as alcohol dependency, I have been told, is like being immersed into a pool of profound clarity. This clarity helps individuals with success through AA to speak with deep conviction and a high level of charisma.
The outsized charisma and passion that emanates from a relatively small number of AA members may be enough for medical providers to overestimate its success level.
How Sociological Insights Can Aid in New Addiction Treatment
David Brooks, in support of Kroener, raises a point that has been echoed by psychologists and addicts alike: perhaps we will never fully understand addiction so as to be able to craft better treatment options. In an Op-Ed in the New York Times, entitled “Bill Wilson’s Gospel”, Brooks states:
“… we should get over the notion that we will someday crack the behavior code — that we will someday find a scientific method that will allow us to predict behavior and design reliable social programs. As Koerner notes, A.A. has been the subject of thousands of studies. Yet “no one has yet satisfactorily explained why some succeed in A.A. while others don’t, or even what percentage of alcoholics who try the steps will eventually become sober as a result.”
Each member of an A.A. group is distinct. Each group is distinct. Each moment is distinct. There is simply no way for social scientists to reduce this kind of complexity into equations and formula that can be replicated one place after another.
While it is true that science may not be able to reduce the complexity of an addict going through recovery into “equations and formula,” this is not the only way to understand “the behavior code.” Social science can provide insight into crafting better, more suitable treatment initiatives for addicts.
Although every addict is an individual, this individual comes from specific social and contextual backgrounds. Each individual also belongs to particular cohorts, or small social groups. Learning how barriers to treatment for alcohol dependency fluctuate with social groups must be addressed in order to know how best to implement successful interventions. This is especially important for disadvantaged socioeconomic groups (i.e. homeless individuals) or groups with syndemic disorders, or secondary health conditions that affect and complicate the overall illness one experiences (i.e. individuals with post-traumatic stress disorder).
The importance of understanding the social component of dependency and addiction through rigorous methodological means cannot be overstated. While tremendous advances in “hard sciences” have demonstrated truly important chemical and biological correlations with addiction, such as the permanent changes in the brain resulting from chronic substance usage, these insights remain hollow without the connection to an addict’s lived experience. By integrating social, contextual, and psychological knowledge with biological and physiological understandings, researchers and clinicians can expect to make unprecedented improvements to the overall treatment provided to substance dependent individuals.
Neuroanthropology 
Interesting. I think you left out one important contributing factor to AAs prevalence and perceived success: Popular culture. American TV-shows and movies are filled with alcoholics that turn to AA and these are often also “cured”. It helps minimise the shame involved and it drives home to people that this is the place to go.
I think you are very right in pointing out that success or not is probably very much a question for the social sciences. Support, acceptance, positive role models – all these things can help some people, depending on the nature of their addiction.
The first question to ask when examining why so many medical practitioners recommend AA isn’t “Why do they recommend it despite the low success rate?” but rather “Could they recommend anything better?”. In other words, AA’s success rate might be relatively low, but is it lower or higher than other treatment programs? Or more importantly, is it lower or higher than other treatment programs for people that are choosing to attend because they themselves want to get better — as opposed to those attending by court order or to make someone happy.
From what I’ve seen, and this is of course anecdotal, but AA works for more people and for a longer period of time than other programs. Yes, it may not work for many — addiction is a tenacious villain — but it’s your best shot at sustained sobriety.
Since I’ve used the program successfully I can speak from the experience of one, and one only, which may or may not be helpful to you since I am one of those that had a spiritual experience and many do not, although the more successful members that I have known did too, to varying degrees. I have often said that not all actors are alcoholics, but all alcoholics are actors. Both of these premises can get us pretty far into the weeds without explaining why AA works or fails, which it did twice in my case before it finally worked the third time through.
There is a tendency to try to reduce extremely complex individuals interacting with each other into simpler terms that non addicts can understand, but each AAer has an individual program that they follow and it has never been done the same way by two of them that I know of, which is a limited number of people because I found that the group was in fact more of a problem than help and quit attending after a little more than a year on my final and successful to this date, run through the program. I still do the middle ten steps, less frequently as time goes by, while maintaining the first daily, and the last as often as chance and circumstances provide me opportunity to do so.
The key to my recovery was to realize that I was there to fix one problem and one problem only, that of an uncontrollable urge to drink after work until I passed out, or ran out of beer. I wasn’t there to quit anything else. Previously I had tried to become sober as a judge which was beyond my capacity at the time, so sober became not drinking. As a toker at the time, that was not acceptable to some within the group, and so there was an added tension to the program which the courts had added by sending people to the program who were not ready to let the bottom hit them, or had not hit the bottom, and so anonymity was compromised as they came and went, and they would make various requests, like signing attendance slips when they either didn’t show up, or you hadn’t and couldn’t verify that they had either. So I resent the hell out of civil authorities using the program in ways it wasn’t intended to be used, for their convenience, however well intentioned that may have been, put my sobriety at risk.
I would like to point out that not in all cases are all monetary resources dedicated to obtaining alcohol or whatever, and that is only one bottom that can be reached, but it does become the thrust of all mental resources, from how to obtain the substance to how to use it within acceptable norms of either family, or workplace, and so one arranges ones life around it, and then tries to arrange other events and people around that. This leads to quite a manipulative lifestyle, and as such we do not belong to social cohorts, they belong to us, if not in fact then in mind.
It is this loss of power in one’s own life that shatters the ego and self esteem, but it is at the level of the loss of all self esteem that the program actually begins to work by rebuilding it in on different things, God, a light switch, anything that will work as a higher power since you are no longer that higher power. But something has to replace the mental processes until the habits of chemical addiction are replaced with new habits and thinking processes and the body learns to burn other fuels. Sometimes this requires a group, and that group does have cultists in it, just as well as it may have me on occasion, a happy heretic from the group, but very much using the twelve steps to stay sober.
The key for me is to have something larger than myself to be constantly involved in, and that may be the function of the group for many people and give the appearance to rest of us a cult. I think I have known both sorts in the groups I have attended, because they react quite differently to people of my sort, although the junkie trigonometry is always present too. I don’t think we should limit any options to individuals early on in recovery, but allow them to progress naturally through their own experiences until they can rearrange their own thought processes around something different than before, because it is their recovery not ours. We cannot recover anyone they must do it, and they can do it many ways, but all I can do is help and do no harm.
As for science, whether soft or hard, I see them as providing tools that may be used in conjunction with the ones I already posses, but I’m not interested in success rates or the scientific understanding of addictions for the sake of the sciences, but for those of the individual I am hoping to help help themselves change the thought processes that got them in to trouble in the first place. Pills or metaphysics are only levers I can give some one else to use, but they have to find the place within to stand on, and that isn’t the same place in all of us.
Hopefully I haven’t told you too much that you already know. Yours…
Let’s say that there are about 20 million problem drinkers in America… 23 million to be consistent. Now, about only half of those are real alcoholics and even need A.A., much less want A.A.
Actually, nobody wants A.A. on the front end. Those that “get to” A.A. and do the steps and get sober are the few that “want” A.A.
But A.A. isn’t so unsuccessful. 36% stay beyond their first year. That doesn’t take into consideration those who were sent there and still don’t want to nor need to be there.
Raise your hand if your life ambition is to join A.A. Nobody? Hmmm… 1.2 million? Nice.
Another question is this: why are the opinions of AA proponents given so much weight? It’s one thing to note the exuberance of certain AA members as we muse about why AA dominates the treatment community, but the real question is why the voices of proponents drown out those of the majority who aren’t helped by the program.
I find it very unfortunate that Dr. Drew’s world–one in which 12 step is viewed as the ONLY path to recovery–has come to so monopolize the discourse on this issue that common sense has been turned on its head. People who aren’t being helped by the 12 step approach are provided with…more 12 step treatment!
Once often hears that the definition of insanity is doing the same thing over and over again, expecting different results. It is hard to think of a better example of this definition in action than the world of 12 step based addiction treatment.
I am a little annoyed at the persistent aura of “mystery” that surrounds AA and alcoholism. If people buy into the mystery quotient, then AA can be that mysterious working solution to that mysterious, complex, unknowable problem! This isn’t 1934 and the tools we can use to dissect complex situations and arrive at improved solutions were not even science fiction in 1934. The concept of a super computer with thousands of compute nodes to model and run simulations of behavioral patterns wasn’t in anyones mind in 1934 but is commonplace, though little used for that purpose, today.
The approach that we should just throw up our hands and admit some kind of defeat is inane and moronic.
“… we should get over the notion that we will someday crack the behavior code(Why? Exactly?) — that we will someday find a scientific method that will allow us to predict behavior and design reliable social programs ( Admit defeat before trying to decipher the characteristics of a huge problem and find a solution? Why? Who says? The key is to keep pushing for answers. Look past those that have a vested interest in keeping a faith-healing model that is a revolving door cash cow for the “treatment” industry). As Koerner notes, A.A. has been the subject of thousands of studies( No,No,No. And here’s why – numbers! Let’s say there have only been 2,000 studies over 75 years – the implication of “thousands” is probably meant to convey more studies than that, which makes it more wrong. But, just 2,000 would be 26.666… studies per year. That is at least one professional study every 2 weeks for 75 years – Sorry, not buying it. It is more bluster to try to convince people that this is some kind of thoroughly studied, impossible to solve problem – it isn’t.) Yet “no one has yet satisfactorily explained why some succeed in A.A. while others don’t, or even what percentage of alcoholics who try the steps will eventually become sober as a result.” ( There is no mystery here. The ones that are motivated enough to stop drinking “succeed”. Dissecting the motivations to stop drinking is easy. Just ask. The most common one I have run into is, ” I didn’t want to die so I quit drinking”. That is soooo mysterious.)
“Each member of an A.A. group is distinct. Each group is distinct. Each moment is distinct. There is simply no way for social scientists to reduce this kind of complexity into equations and formula that can be replicated one place after another.” ( We are so complex, it’s simply unknowable, so take your social microscopes someplace else and leave us alone with our diversity, complexity and all around distinctiveness – WRONG ! I have been to thousands* approx 4,000)of AA meetings and there is pronounced commonality of thought and behavior – this could easily be studied and general trends would emerge. To say this is so complex, and, therefore, we’ll never figure it out is absurd and needlessly defeatest. That mindset more closely resembles a protector of a religious faith than an inquisitive scientist.
There is no mystery when it comes to how Naltrexone works. It is well documented and works for many. RET works by learning to not drink when you feel like having a drink. No mystery there. Support groups work because there are like minded people providing encouragement towards a common goal without all the woo woo of the Steps. I see no mystery there either. It only becomes mysterious with the application of faith-healing to get a positive result. The mysterious disease requires a mysterious, higher-power solution. Bullocks!
So, who benefits by keeping alcohol abuse and the solution shrouded in unknowable mystery? Guess who? AA and its supporters want to keep the shroud of mystery thing going because it benefits them. Period. A real, proven medical solution would threaten the AA monoploy, and some say a religious movement, and that prospect is not to be assisted. There has been no attempt from the AA ecosystem to accelerate any science around solving the substance abuse problem outside of using the faith-healing approach of the 12 Steps. That behavior should be considered an affront to science and a danger to society. They are stuck in the 30′s, clinging to a modified Buchmanism and the writings of a lunatic and seem content to stay that way.
I believe a team of experienced addiction specialists, social scientists and programmers could take a Cray supercomputer and model a wide swath of the thinking and behavioral characteristics of substance abusers and examine how their behavior could be modified by changing certain attributes. It would not give all the answers, but it would be revealing and is certainly better than throwing up our hands and admitting that faith-healing is the best and only approach we can come up with to address a huge societal problem.
In a blog dedicated to neuroanthropology, I notice that there has been no reference made to Gregory Bateson’s paper, “Cybernetics of ‘Self’: A Theory of Alcoholism”. This provides an excellent theory on the role of behavioural contexts (what has been called ego) in cases of addiction. Without getting too far into Bateson’s often misunderstood ideas on cybernetics and epistemologies, the crux of the theory is that the success of AA depends mostly on the first two steps ability, in appropriate cases, to “reboot” the context of self, in particular the control issues that are so prevalent in cases of addiction. One of the most conspicous behaivors of the addiction situation (whether substance abuse is involved or not, and it’s very important to note that substance abuse is almost epiphenomenal to addictive behaivor patterns) is the need to assert self or reestablish control over the immediate environment, an ultimately futile act. This pattern, placed in a social setting that refuses to allow such control (which of course is virtually all social settings), will compound frustration and anger in cyclical manner. The temporary abandon of alcohol or the narcotica high allows an escape from the cycle of the “self’s attack on the self,” but the return to sobriety will heighten the need to take control, to become “captain of one’s soul.” This myth of self power and self control, and the tendency for unwitting friends and family to reinforce such an illusion, creates an oscialltion between attempts at sobriety and abandon that should sound quite familiar to those experienced with the addictive situation.
Bateson’s theory suggests that it is not the steps themselves, but the personal decision to finally abandon this pattern of behaivor, by the realization of your own powerlessness and your choice to develop a more societally integrated self. The actual steps themselves are meaningless, except in that they may elicit such a recontextualization, or at least spell it out formally and explicitly.
I think Gordon W’s comments here are illuminating: “It is this loss of power in one’s own life that shatters the ego and self esteem, but it is at the level of the loss of all self esteem that the program actually begins to work by rebuilding it in on different things, God, a light switch, anything that will work as a higher power since you are no longer that higher power…. The key for me is to have something larger than myself to be constantly involved in, and that may be the function of the group for many people….”
In my own addiction to heroin and my subsequent six year entrappment in a methadone maintenance program (the continuance of these programs is one of the worst crimes of the medical community), I never once attended an NA meeting. Drew Pinsky’s statement that anyone who refuses the twelve steps will not get better reveals the misunderstanding of the medical community at large, at the gross division between the treaters and treated. My own “recontextualization” came by a slow reintergration into a new lifestyle, and a slow abandoning of my own control issues with the daily help of a sedating narcotic and its concurrent effects on the brain and neuro-transmitters, then finally consecrated by months of agonizing pain in withdrawal when I could no longer afford to pay for the treatment.
The point is, there are many avenues for scientific study and progress, although the current paradigm of using only the quantitative and analytic tools of the “hard” (better read as “simple”) sciences will perhaps leave such phenomena as AA inscrutable. The anger and vitriol that SoberPJ has spewed forth demonstrates that the cure for substance abuse (which could be purely medical) and the cure for addiction are too very different things. After all, a simple lobotomy will successfully modify behaivor for a lot cheaper than a Cray super computer, but perhaps this is not the best way to approach social issues? A more integrated approach, including the “soft” (better read as “complex”) sciences will yield fuller results, giving insight at the neurological, psychological, and sociological levels. These are of course only delimitations of the same subject for the ease of analysis, and should never be regarded as seperate endeavors.