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Alcohol & Substance Abuse - A Better Meeting
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A Better Meeting
Mark Dombeck, Ph.D.

This essay is an attempt to continue the dialog that got started up around my previous essay "Alcoholics Anonymous is a Cult?". That former essay concerned the notion that many people have that AA is a cult-like organization that does more harm to its members than good. A whole lot of responses were generated to that essay, many lending support to the notion and others speaking against it. Clearly, AA is at least polarizing if it is nothing else. I'm still in the middle of my essay series on Psychotherapy Technique, but we'll continue holding off on that for a while until this interesting thread has run its course.

I'd like to take the discussion in what I hope is a productive direction by addressing the question "What would a useful alternative to AA look like?" What parts of AA are useful and should be incorporated into this new alternative, and what parts need to be left behind? What reforms and innovations should be added so that the resulting program is more useful to its members? Constructive answers to these questions (rather than rants) can contribute to a plan, and perhaps someone can work with that plan to create constructive change.

I'll start by restating the major objections to AA that were raised in discussion of the previous essay. Here is my short list; hopefully, I've not missed anything important.

  1. AA is a thinly disguised religious program (atheists, non-Christians don't fit in)

  2. It is ridiculous that your higher power can be a thing (like a motorcycle, etc.). This makes a mockery of the concept of higher power.

  3. AA attracts and retains sociopaths in their organization. They are not self-policing and therefore set newcomers up for abuse.

  4. People are mandated by the courts into AA. This sucks for personal liberty reasons, and also because of reasons #1 and #3.

  5. AA is ineffective as a treatment (only 5% stay sober within a given year). I've not verified this figure and am not sure how I could, but let's go with it for now.

  6. AA is fundamentally disempowering. It encourages you to distrust your own thinking. It does not support your efforts to think on your own. There is no way out; no way to graduate.

  7. Many AA sponsors prescribe bad, sometimes dangerous advice to sponsees. Among this dangerous advice is advice that people should stop taking doctor-prescribed medication. Many sponsors are hypocrites. They want you to "do as I say, not as I do".

We could start to describe an alternative group by saying that these "abuses" (if that is what they are) should be corrected. The alternative group might be:

  • secular in orientation

  • self-policing (on the lookout for sociopaths and abusive behavior)

  • empowering

  • open minded with regard to professional treatments.

  • based on some system (yet to be described) that produces a better sobriety outcome than is typical of AA groups. Minimally, we'd want more than 5% of participants (or whatever the proper figure is) to be sober at the end of the year.

I personally feel stronger about some of these points than others.

It seems to me that helping the group to self-police is important and imperative if that group is going to be maximally supportive for its members. I have run psychotherapy groups in my work as a psychologist, and I have run an online community as well. There are always members who try to dominate groups, and there must always be an 'immune system' for any group that exists to minimize abuses. In a psychotherapy situation, that immune system is called the therapist. In an online group, it is called the moderator. In an anonymous group with no real leader, the group itself has to have a way to keep itself in check. Now - I have no idea how AA groups perform this function, or if they do. I can only suggest that it would be a good idea that they figure out a method for doing this sort of thing in order to keep the group healthy. One way to do this, without compromising anonymity, would be to use a "reputation" system such as exists on eBay. Group members would get a handle, and periodically, members could vote on how each other member was behaving. The system would need to get sophisticated in order to keep it from being spammed and gamed. Some members would be framed, even as real problem members would be brought to the attention of the group. Such a system would never satisfy all members, but it might go some distance towards helping the group to know who its potential abusive members were so that their 'sponsorship' privileges might be suspended or something like that.

The matter of being open minded to professional treatments is a no-brainer. No member of a peer support group (or religious group for that matter) should be in the business of advising someone to ignore the medical advice of their doctor. Anyone who does this sort of thing is clearly giving bad advice. It's not that doctors are all-knowing beings who never make mistakes. In fact (as we all know), many of them have their own narcissism problems. They are, however and most importantly, properly trained to give medical advice, while group members are not. Medicine is not perfect, but it is better than most people's unfounded opinion (no matter how dear that opinion may be), and the stakes are way too high to play games. So far as I am concerned, any support group member who gives medical advice or contradicts medical advice is doing a terribly dangerous Bad Thing and should stop doing so immediately. This much is true even if the member is him or herself a doctor. Only someone's personal doctor should be giving medical advice.

The matters of secularity and effectiveness can be combined by saying that the group should be based on scientifically established treatment principles, such as Relapse Prevention. The problem with this sort of statement is that relapse prevention works best when a trained professional group leader is present, and this sort of thing costs money. Making this group cost any amount of money will make it impractical. For that matter, declaring the group to be secular in nature will probably be just as alienating as declaring it to be religious. Alcoholics come in all religious and non-religious varieties and no one wants to be excluded. Scientifically derived principles can be used on a self-help basis, but this is frankly difficult to accomplish, and we're looking for something that will work better than AA's method of surrender to a higher power. I'm not sure what the right response is here.

The matter of whether the support group is best off being empowering or not is debatable too. It sounds, on the surface of things, that encouraging people to think for themselves is a good idea. And it is, within limits. Teaching people the principles of relapse prevention so that they can become responsible for recognizing that they are in danger of relapse is important, for instance. However, encouraging people to surrender their judgment also has a lot going for it. Many addicts are good at lying to themselves and to other people; they are not always the most mature people, and they can be **selfish**. If such people are encouraged to think for themselves, they are going to rationalize more selfish behavior, quite frankly. Encouraging such people to look beyond their own judgment to a "higher authority" is a good thing, IMHO. This is what we ask of naturally selfish children, who look to their parents for a higher authority; and if parents do their job reasonably well, those children are helped to grow into more mature, self-governing adults. I think the 12 steps are trying to perform the same sort of function for alcoholic addicts. Maybe the proper solution is that both empowerment and "surrender" are important and neither should be discouraged in our new group.

It is entirely possible to work the 12 steps I think and gain nothing in the way of maturity. It is also possible to work them and really undertake a "spiritual" transformation. Or, if you don't like that work spiritual, try this one on for size: "Epistemological". Epistemology is the branch of philosophy that has to do with how people understand things: their theory of knowledge. When you undergo what is usually known as a spiritual transformation you are also undergoing an epistemological transformation. That is to say, your way of knowing what is right and wrong, true and false changes. When an addict shifts from a mind set and way of knowing that says "I am the center of my universe" to a way of knowing that says "I have only limited control even over myself; there are larger forces at work that I am subject to", this is a change in epistemology and spirituality (even if you are not spiritual). You can't make this sort of mental switchover without a certain amount of submission occurring; but it is ultimately submission to a more mature picture of the world (vs. a less mature one) that is happening, not submission to a sponsor or a set of principles.

The question of coercion needs to be addressed. I'm thinking that this is not something that really is within AA's control (whether or not people are mandated to join them). This is a legal issue, instead. Personally, I'd like to see a whole lot more public money be put into professional treatment programs based on sound scientifically based principles, and for courts to mandate people into such programs. This isn't entirely practical, however. This money is just never made available at the level where enormous numbers of people can be helped on a daily drop-in basis, and hence AA is pushed because it is ubiquitous. I can see how it can be a procrustean bed for some, but it is perhaps a better fate than jail for most. Of course, if drinking persists and people get hurt, jail time may follow anyway. There should be some sort of scientific evaluation of the efficacy of the programs available to addicts if they are to be mandated, or at least people ought to be able to choose from amongst approved programs if they are to be mandated in this fashion. But apparently, this is an area for further advocacy and not yet a reality.

As a sort of final statement for this essay, I'll note that there are groups out there, including SMART Recovery, Rational Recovery, and a host of others that have some of the characteristics I've described above. These groups are available online or in select communities only, however. They aren't as well known as AA or as easy to access, but they do exist.

Anyway, those are my thoughts for what they are worth. I'll put the questions to you again, because I am interested in your answers to them more than my own: What would a useful alternative to AA look like? What parts of AA are useful and should be incorporated into this new alternative, and what parts need to be left behind? What reforms and innovations should be added so that the resulting program is more useful to its members?