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?
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.
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.