We've got a comment system on Mental Help Net, and lately we've been getting a lot of comments regarding an old essay I wrote concerning Alcoholics Anonymous. The essay, titled "AA is to shame as a hot knife is to butter", presents a generally positive view of the Alcoholic's Anonymous fellowship and twelve step programs in general. The positive view expressed in that essay came out of my experience working for a year (during my postdoctoral fellowship) in a partial hospital program (otherwise known as an IOP or Intensive Outpatient Program) for dually diagnosed people. Dual diagnosis means that you have two diagnoses: one is an addiction, and the other a serious mental disorder. So, we dealt with people who were schizophrenic, and alcoholic, or bipolar and using cocaine. That sort of thing. Many of our clients' lives were complicated by severe poverty and homelessness. The sicker you get, the further down the socio-economic scale you tend to fall.
Our partial hospital program dealt with addiction issues and mental health issues simultaneously, but always prioritized the addictions, on the theory that you cannot benefit much from psychiatric or psychological attention when you are intoxicated. We did drug screenings every day using breath tests, urine, and occasionally blood. Patients found to be intoxicated were sent home for the day. Patients who had recently relapsed into using their drug(s) of choice were asked to talk about it in a group therapy session in which the therapists (sometimes myself) helped the group to identify the behaviors and triggers and thought patterns that had led up to the relapse. There were other forms of therapy, and lots of psychiatric medication, and lots of attention in general. There was also AA, a process deemed so important by my clinical superiors that they had integrated it directly into their program, actually having meetings occur within the hospital, and us bringing our patients there during scheduled time periods.
My positive impression of AA came out of that year of experience; watching the patients rise and fall and noting when people were able to keep it together and when they weren't. You could pretty much tell who was going to use after a little while. The folks most likely to use (or never stop using) were those most deeply in denial about their drug problem; who could not submit to the idea that their drug use was actually a problem. The ones who could never settle on a sponsor; who would lie to you saying that they had not used recently, when you had their positive urine test results in your hand.
My experience with AA was never very much first hand. I have been to exactly two AA meetings in my life. Both were observational in nature, a "field trip" if you will, so that I could see what I was recommending to my patients. What I saw during those two meetings was non-remarkable. People speaking about their drinking issues and receiving support from the group; pretty much what you'd expect. These experiences took the novelty of the thing away from me, but hardly qualify as a good sample of what AA is about. More to the point, my impression of AA's usefulness came from our patients, and from our staff, a few of whom were in recovery themselves. The point was made in my head that addicts are unable at first to control their own behavior, and thus need and benefit from programs like AA that help to set limits on them.
The rub is that AA asks its participants to submit to a higher power, God as you understand him, or "good orderly direction". And many people, addicts and non-addicts alike, deeply dislike the idea of needing to submit to a higher power. They rightly distrust and dislike even more the idea that the higher power they are submitting to might be selfish in nature, or twisted, or power-hungry and looking to dominate. They dislike what they see to be the cultist aspects of AA, as is readily apparent in this comment (which I declined to append to the essay itself because there are already a number of comments there expressing this very point), but which I will reproduce here):
The author is trying real hard to rationalize AA. Being accessible and free means nothing...so are alcohol and drugs and Christ, etc., etc. The "peer support" is not support...it is peer indoctrination. I tried AA for 14 years...I believed it, I "worked it", and it almost killed me.
I believe thatn any professional that reccomends AA or any twelve-step treatment should have their license revoked. It is no different than recommending Scientology to someone with a broken arm, or Islam to someone with cancer, or Catholocism to someone with herpes.
AA is definitely NOT the "feel good peer-driven support group" that everyone touts. It is completely unregulated, and 95% of the people that walk in the door leave...how many of them die? How many recover on their own (like I have now)? How many continue to drink and become burdens on them selves and society (for years...like I did)?
Would you get on an airplane that had only a 5% chance of safely getting you where you wanted to go?
Until you directly answer the question, from all angles: "Does AA do more harm than good?"....then it is a CRIME AGAINST HUMANITY to recommend it or coerce anyone to attend. It is a very pervasive and dangerous cult, so much so that M.D.'s and PhD's recommend it in the absence of ANY valid scientific research showing that it does more good than harm. They should really have their licenses revoked.
It's a bit hard for me to read this sort of thing, because the person who wrote it obviously has felt very damaged by AA, a group that someone recommended to him or her, because they thought it would help. I don't doubt that this person has had a bad experience, has felt abused, perhaps was abused. It's sad.
Its no secret that AA's focus on submission to a higher power has broad potential for abuse. That focus on submission and making ammends is there for a very important reason - it encourages the growth of empathy and social solidarity in participant addicts; qualities which help them resist the lure of their drugs. And yet, that very submission also comes with a terrible vulnerability. it is important that anyone teaching submission as a way of life also be a kind and loving person, because otherwise, that submission becomes the basis for cult-like cohesion, as the commenter points out. Sociopathic types who also tend to be addicts are very likely to get themselves into AA and then use it for their selfish purposes. At any given moment within AA, there are going to be people who are honestly struggling with remaining sober and people who are using and not admitting it, or not taking the steps necessary to end it; people who understand hurt and who want to help others stop hurting and people who are all too willing to use other people for selfish purposes.
"Stick With The Winners" was the slogan I liked the best. Some meetings are better than others, because there is more beneficial order and kindness available there, and less sociopathy and sickness. If you are an addict in a twelve step situation, and you find that situation abusive (and not simply limiting of your urges), it seems to me that you need to find a better meeting; not quit entirely.
What are your thoughts? There must be some people out there who feel they have benefited from AA and twelve step. There must be other people who feel abused or put off by the process too. Do you have any advice or comments for the person who wrote the above comment? For me (grin!), as a doctor (like so many doctors) willing to write about and recommend things he has not lived or experienced first hand himself? Can there be submission to a higher power without abuse taking place? How do you handle abusive attitudes and individuals within AA and other twelve step programs? What are the merits of twelve step. And if you can't think of any merits, what are the better alternatives?