Does AA Work?

Bill W., co-founder of AA








Adapted from The Chemical Carousel: What Science Tells Us About Beating Addiction © Dirk Hanson 2008, 2009.


Despite recent progress in the medical understanding of addictive disease, the amateur self-help group known as Alcoholics Anonymous, and its affiliate, Narcotics Anonymous, are still regarded by many as the most effective mode of treatment for the ex-addict who is serious about keeping his or her disease in remission. A.A. and N.A. now accept anyone who is chemically dependent on any addictive drug—those battles are history. In today’s A.A. and N.A., an addict is an addict. A pragmatic recognition of pan-addiction makes a hash of strict categories, anyway.

Nonetheless, under the biochemical paradigm of addiction, we have to ask whether the common A.A.-style of group rehabilitation, and its broader expression in the institutionalized form of the Minnesota Model, are nothing more than brainwashing combined with a covert pitch for some of that old-time religion. As Dr. Arnold Ludwig has phrased it, “Why should alcoholism, unlike any other ‘disease,’ be regarded as relatively immune to medical or psychiatric intervention and require, as AA principles insist, a personal relationship with a Higher Power as an essential element for recovery?”

The notion is reminiscent of earlier moralistic approaches to the problem, often couched in strictly religious terms. It conjures up the approach sometimes taken by fundamentalist Christians, in which a conversion experience in the name of Jesus is considered the only possible route to rehabilitation. But if all this is so, why do so many of the hardest of hard scientists in the field continue to recommend A.A. meetings as part of treatment? Desperation? Even researchers and therapists who don’t particularly like anything about the A.A. program often reluctantly recommend it, in the absence of any cheap alternatives.

In 1939, Bill Wilson and the fellowship of non-drinkers that had coalesced around him published the basic textbook of the movement, Alcoholics Anonymous. The book retailed for $3.50, a bit steep for the times, so Bill W. compensated by having it printed on the thickest paper available—hence its nickname, the “Big Book.” The foreword to the first printing stated: “We are not an organization in the conventional sense of the word. There are no fees or dues whatsoever. The only requirement for membership is an honest desire to stop drinking. We are not allied with any particular faith, sect or denomination, nor do we oppose anyone. We simply wish to be helpful to those who are afflicted.”

In short, it sounded like a recipe for complete disaster: naive, hopeful, objective, beyond politics, burdened with an anarchical structure, no official record
keeping, and a membership composed of anonymous, first-name-only alcoholics.
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Amid dozens of case histories of alcoholics, the Big Book contained the original Twelve Steps toward physical and spiritual recovery. There are also Twelve Traditions, the fourth one being, “Each group should be autonomous except in matters affecting other groups or A.A. as a whole.” As elaborated upon in Twelve Steps and Twelve Traditions, “There would be real danger should we commence to call some groups ‘wet’ or ‘dry,’ still others ‘Republican’ or ‘Communist’…. Sobriety had to be its sole objective. In all other respects there was perfect freedom of will and action. Every group had the right to be wrong. The unofficial Rule #62 was: “Don’t take yourself too damn seriously!”

As a well-known celebrity in A.A. put it: “In Bill W.’s last talk, he was asked what the most important aspect of the program was, and he said it was the principle of anonymity. It’s the spiritual foundation.” Co-founder Dr. Bob, for his part, believed the essence of the Twelve Steps could be distilled into two words—“love” and “service.” This clearly links the central thrust of A.A. to religious and mystical practices, although it is easily viewed in strictly secular terms, too.

Alcoholics Anonymous recounts a conversation “our friend” had with Dr. C.G. Jung. Once in a while, Jung wrote, “…alcoholics have had what are called vital spiritual experiences…. They appear to be in the nature of huge emotional displacements and rearrangements.” As stated in Twelve Steps and Twelve Traditions, “Nearly every serious emotional problem can be seen as a case of misdirected instinct. When that happens, our great natural assets, the instincts, have turned into physical and mental liabilities.”

Alcoholics Anonymous asserts that there are times when the addict “has no effective mental defense” against that first drink.

Bill Wilson wrote:
"Some strongly object to the A.A. position that alcoholism is an illness. This concept, they feel, removes moral responsibility from alcoholics. As any A.A. knows, this is far from true. We do not use the concept of sickness to absolve our members from responsibility. On the contrary, we use the fact of fatal illness to clamp the heaviest kind of moral obligation onto the sufferer, the obligation to use A.A.’s Twelve Steps to get well."

This excruciating state of moral and physical sickness—this “incomprehensible demoralization”—is known in A.A. as hitting bottom. “Why is it,” asks Dr. Arnold Ludwig, “that reasonably intelligent men and women remain relatively immune to reason and good advice and only choose to quit drinking when they absolutely must, after so much damage has been wrought? What is there about alcoholism, unlike any other ‘disease’ in medicine except certain drug addictions, that makes being in extremis represent a potentially favorable sign for cure?”

Hitting bottom may come in the form of a wrecked car, a wrecked marriage, a jail term, or simple the inexorable buildup of the solo burden of drug-seeking behavior. While the intrinsically spiritual component of the A.A. program would seem to be inconsistent with the emerging biochemical models of addiction, recall that A.A.’s basic premise has always been that alcoholism and drug addiction are diseases of the body and obsessions of the mind.

When the shocking moment arrives, and the addict hits bottom, he or she enters a “sweetly reasonable” and “softened up” state of mind, as A.A. founder Bill Wilson expressed it. Arnold Ludwig calls this the state of “therapeutic surrender.” It is crucial to everything that follows. It is the stage in their lives when addicts are prepared to consider, if only as a highly disturbing hypothesis, that they have become powerless over their use of addictive drugs. In that sense, their lives have become unmanageable. They have lost control.

A.A.’s contention that there is a power greater than the self can be seen in cybernetic terms—that is to stay, in strictly secular terms. The higher power referred to in A.A. may simply turn out to be the complex dynamics of directed group interaction, i.e., the group as a whole. It is a recognition of holistic processes beyond a single individual—the power of the many over and against the power of one.

“The unit of survival—either in ethics or in evolution—is not the organism or the species,” wrote anthropologist Gregory Bateson, “but the largest system or ‘power’ within which the creature lives.” In behavioral terms, A.A. enshrines this sophisticated understanding as a first principle.

alcoholics anonymous