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Alcoholics Anonymous (AA) is a worldwide mutual aid society describing itself as a fellowship of men and women with a desire to stop drinking alcohol and maintain sobriety while helping others to do so through abstinence and "lifelong character development." The first of many twelve-step programs, AA was started by white, middle-class Americans, but the intentionally broad philosophy of the Twelve Steps has aided the spread of AA "across diverse cultures holding different beliefs and values." By shunning any affiliation with outside political and social groups, AA has been successfully introduced to geopolitical areas otherwise resistant to grassroots movements. Although AA has relatively high attrition rates, aspects of its program such as reading AA literature, performing service at meetings, and self-identifying as members of AA, are keys "to interventions achieving and maintaining abstinence" and recovering from the single substance use disorder which AA calls alcoholism.

History

In 1934, after ruining a promising career in finance due to drunkenness, Bill Wilson was introduced to a spiritual solution to his alcoholism by Ebby Thacher, an old drinking buddy who had become a member of a the Oxford Group (A Christian movement that later became Moral Re-Armament). Wilson was treated at Charles B. Towns hospital in New York by Dr. William Silkworth, who promoted a disease concept of alcoholism. While in the hospital, Wilson underwent what he believed to be a spiritual experience and, convinced of the existence of God, he was able to stop drinking.

On a 1935 business trip to Akron, Ohiomarker, Wilson felt the urge to drink again and in an effort to stay sober, he sought another alcoholic to help. Wilson was introduced to Dr. Bob Smith, also a member of the Oxford Group. After some work together, Wilson and Smith co-founded AA (though not yet named as such) with a word of mouth program to help other alcoholics. Smith's last drink on June 10, 1935 is considered by members to be the founding date of AA. By 1937, Wilson and Smith determined that they had helped 40 alcoholics get sober, and two years later, with about 100 members, Wilson expanded the program by writing a book entitled Alcoholics Anonymous which the fellowship then adopted as its name. The book, informally referred to by members as "The Big Book," described a twelve-step program involving admission of powerlessness over alcohol, acceptance of a benevolent higher power, moral inventory, complete and direct restitution to those harmed, and asking for direction, guidance, and power from God. Essential to this process was the idea that the higher power be "of one's own understanding". In 1941, book sales and membership increased after interviews on American radio and favorable articles in US magazines, particularly by Jack Alexander in The Saturday Evening Post.[124]

By 1946, as membership grew, confusion and disputes within groups over practices, finances, and publicity led Wilson to write the guidelines for non-coercive group management, Twelve Points to Assure our Future, that eventually became known as the Twelve Traditions[125]. AA came of age at the 1955 St. Louis convention, in Missouri, when Wilson turned over the stewardship of AA to the General Service Conference. In this era, AA also began its international expansion, and by 2001 the number of members worldwide was estimated at two million.

Organization



In 2006, 1,867,212 members in 106,202 AA groups were reported worldwide. The Twelve Traditions informally guide how AA groups function, and the Twelve Concepts for World Service guide how AA is structured globally.

A member who accepts a service position or an organizing role is a "trusted servant" with terms rotating and limited, typically lasting three months to two years and determined by group vote and/or the nature of the position. Each group is a self-governing entity with AA World Services acting only in an advisory capacity. AA is served entirely by alcoholics, except for seven "nonalcoholic friends of the fellowship" out of twenty-one members of the AA Board of Trustees.

AA groups are self-supporting and not charities. There are no dues or membership fees. Groups rely on voluntary member donations to pay for expenses like room rental, refreshments, and literature. Typically a basket is passed during the meeting while the Twelve Traditions of AA are read (including the 7th Tradition, which states: "Every A.A. group ought to be fully self-supporting, declining outside contributions"). In the U.S., for example, people often put a dollar or two in the basket, but any contribution is voluntary and not required of anyone. AA GSO discourages individuals from making large donations by limiting contributions to US$3,000 per annum, and returns contributions mailed from sources outside of AA. Beyond the group level, AA may hire outside professionals for services that either require specialized expertise and/or are full time responsibilities. As of 2007 GSO in New York employs 40 or so such workers.

AA receives proceeds from books and literature which constitute more than 50% of the income for the General Service Office (GSO), which, unlike individual groups is not self-supporting and maintains a small salaried staff. It also maintains service centers which coordinate activities like printing literature, responding to public inquiries, and organizing conferences. They are funded by local members and responsible to the AA groups they represent. Other International General Service Offices (i.e., Australia, Costa Rica, Russia, etc.) are independent of AA World Services in New York.

Program

The scope of AA's program is much broader than just changing drinking behavior: it's goal is to affect enough change in the alcoholic's personality "to bring about recovery from alcoholism." while abstaining from alcohol, one day at a time. A spiritual awakening is achieved from following the Twelve Steps, and sobriety is furthered by helping with duties and service work in AA, and regular AA meeting attendance or contact with AA members. Members are encouraged to find an experienced fellow alcoholic called a sponsor to help them understand and follow the AA program. Some members suggest the sponsor is preferably one that has maintained sobriety for at least a year and is of the same sex as the sponsored person, and who does not impose personal views on the sponsored person. Following the helper therapy principle, sponsors in AA benefit as much, if not more, from their relationship than do those they sponsor. Helping behaviors correlate with increased abstinence and lower probabilities of binge drinking.

AA's program is an inheritor of Counter-Enlightenment philosophy. AA shares the view that acceptance of one's inherent limitations is critical to finding one's proper place among other humans and God. Such ideas are described as "Counter-Enlightenment" because they are at variance with the Enlightenment's ideal that humans have the capacity to make their lives and societies a heaven on earth using their own power and reason.

AA's literature and most of its members claim that AA is a spiritual program and not a religious one. An ambiguity results because a minority of members view the program as religious, while others hold irreligious views. This dynamic tension is essential to AA ideology, and is perpetuated by the third tradition - which prohibits denying membership to anyone with "a desire to stop drinking" regardless of any other expressed beliefs.

Meetings

AA meetings are "quasi-ritualized therapeutic sessions run by and for any alcoholics." They are usually informal and often feature discussions. Local AA directories list a variety of weekly meetings. Those listed as "closed" are only for those with "a desire to stop drinking", while "open" meeting are available to anyone. Speaker meetings have one or two members tell their stories, while discussion meetings allocate the most time for general discussion. Some meetings are devoted to studying and discussing the Big Book, the Twelve Steps, and other AA texts. Excepting those just for men or women, meetings that focus on specific populations such as beginners, gays, and young people do not exclude other alcoholics. While AA has pamphlets suggesting how meetings can be run, AA groups have the autonomy to hold and conduct meetings as they wish "except in matters affecting other groups or A.A. as a whole." And though different cultures do affect ritual aspects of meetings, internationally "many particularities of the AA meeting format can be observed at almost any A.A. gathering."

Confidentiality

Although a statement is read during meetings that what is said there should remain confidential, AA members, unlike lawyers or clergy, are not legally bound to maintain confidentiality.

Disease of alcoholism

AA regards alcoholism as an illness, and uses the concept to challenge the belief of chronic, compulsive drinkers that they can stay sober by willpower alone.Dr William Silkworth introduced to Wilson and AA the idea that alcoholism is an illness consisting of an obsession to drink alcohol, and an allergy, which triggers a compulsion to continue drinking once the first drink has been taken. (Silkworth's understanding of an allergy in the 1930s differs from that used in modern medicine today.) Alcoholics, he argued, can never safely use alcohol in any form at all, since once forming the habit, they cannot break it.

Demographics

AA's New York General Service Office regularly surveys AA members in North America. Its 2004 survey of over 7,500 members in Canada and the United States concluded that, in North America, AA members who responded to the survey were 65% male/35% female. Average member sobriety is eight years with 36% sober more than ten years, 14% sober from five to ten years, 24% sober from one to five years, and 26% sober less than one year. Before coming to AA, 64% of members received some type of treatment or counseling, such as medical, psychological, or spiritual. After coming to AA, 65% received outside treatment or counseling, and 84% of those members said that that outside help played an important part in their recovery. The same survey showed that AA received 11% of its membership from court ordered attendance.

Effectiveness

Limitations on research

The study of AA tends to polarize observers into believers and non-believers, and discussion of AA often creates controversy rather than objective reflection. A randomized trial of AA is very difficult because members are self-selected, not randomly selected from the population of chronic alcoholics, with the possible exception of those who participate in AA to comply with a court mandate. Two opposing types of self-selection bias are that drinkers may be motivated to stop drinking before they participate in AA, and AA may attract the more severe and difficult cases. Control groups with AA versus non-AA subjects are also difficult because AA is so easily accessible.

Studies

Research into AA's efficacy has led to inconsistent results between studies. While some studies have suggested an association between AA attendance and increased abstinence or other positive outcomes, other studies have not. A Cochrane Review of eight studies, published between 1967 and 2005, measuring the effectiveness of AA, found no significant difference between the results of AA and twelve-step facilitation approaches compared to other treatments. To determine further the effectiveness of AA, the authors suggested that more studies comparing treatment outcomes with control groups were necessary.

Attrition

Most who try AA do not remain with the program, with only about 1/4 of those who start the program remaining after one year. In a 1989 internal AA report based on an average of five surveys, it was estimated that of those who attended AA meetings for the first time, nearly one third (31.5%) leave the program after one month. By the end of the third month, just over half (52.6%) have left. Of those who remain after three months, about half (55.6%) will remain until the twelfth month. After the first year, the rate of attrition slows.

About 40% of the members sober for less than a year will remain another year. About 80% of those sober less than five years will remain sober and active in the fellowship another year. About 90% of the members sober five years or more will remain sober and active in the fellowship another year, however the survey states that this information does not predict the number that will remain sober, and those who remain sober but not in the fellowship cannot be calculated. These figures have been repeated within a few percentage points using the same calculations since 1974.

One survey of members in addiction recovery groups (addiction recovery twelve-step groups such as AA and Narcotics Anonymous (NA), SMART Recovery, Secular Organizations for Sobriety, Women For Sobriety) found participation in any group improved chances of remaining "clean" and sober, and group participation increased when the individual members beliefs matched the those of their primary support group. Analysis of the survey results found a significant positive correlation between the religiosity of members and their participation in twelve-step addiction recovery groups and SMART Recovery, although the correlation factor was three times smaller for SMART Recovery than for the twelve-step addiction recovery groups. Religiosity was inversely related to participation in Secular Organizations for Sobriety.

Health care costs

As a volunteer-supported program AA, as with non-twelve-step support groups, is a free service. This stands in contrast to treatments for alcoholism such as inpatient treatment, drug therapy, psychotherapy and Cognitive Based Therapy. Research has noted that institutional use of AA in certain circumstances has reduced health care expenditures by 45%.

Relationship with institutions

Prisons

In the United Kingdom, Alcoholics Anonymous holds meetings in prisons. AA prison and probation liaisons cooperate with staff and AA volunteers give talks to staff in the legal profession.In the United States AA meetings are held in hundreds of correctional facilities. The AA General Service Office has published a workbook with detailed recommendations for methods to approach correctional facility officials with the intent of developing an in-prison AA program. In addition, a variety of pamphlets are published by AA specifically for the incarcerated alcoholicThe AA General Service Office also provides a pamphlet with guidelines for members involved in doing the twelfth step work, that is "carrying the message to those who still suffer." The pamphlet instructs members how to work within correctional facilities.

Court rulings

Since 1996, courts across the United States, in a number of different cases, have ruled that inmates, parolees, and probationers cannot be ordered to attend AA. Though AA itself was not deemed to be a religion, it was found to contain enough religious components to make such coercion a violation of the Establishment Clause of the First Amendment of the constitution. In September 2007, United States Court of Appeals for the Ninth Circuit stated that a parole office can be sued for ordering a parolee to attend Alcoholics Anonymous.

American treatment industry

Although Alcoholics Anonymous does not endorse and is not allied with any outside facility, since 1949 when Hazelden treatment center was founded by some AA members, alcoholic rehabilitation clinics have frequently incorporated precepts of the AA program into their own treatment programs. A reverse influence has also occurred with AA receiving 31% of its membership from treatment center referrals.

United Kingdom treatment industry

A cross-sectional survey of substance misuse treatment providers in the West Midlands found fewer than ten percent integrated twelve-step methods in their practice and only a third felt their consumers were suited for Alcoholics Anonymous or Narcotics Anonymous membership. Less than half were likely to recommend self-help groups to their clients. Providers with nursing qualification were more likely to make such referrals than those without. A statistically significant correlation was found between providers self-reported level of spirituality and their likelihood of recommending AA or NA.

Criticism

Moderation or abstinence

AA acknowledges that not all drinkers are alcoholics, but advocates total abstinence for those who are. However, some critics argue that some AA groups apply the disease model to all problem drinkers, whether or not they are full-blown alcoholics, and believe that more options should be available to problem drinkers who can manage their drinking with the right treatment.

A 2002 U.S. study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) showed that 17.7% of individuals diagnosed as alcohol dependent more than one year prior returned to low-risk drinking. However, this group showed fewer initial symptoms of dependency. A follow-up study, using the same NESARC subjects that were judged to be in remission in 2001-2002, examined the rates of return to problem drinking in 2004-2005. The major conclusion made by the authors of this NIAAA study was "Abstinence represents the most stable form of remission for most recovering alcoholics". A long-term (60 year) follow-up of two groups of alcoholic men concluded that "return to controlled drinking rarely persisted for much more than a decade without relapse or evolution into abstinence."

Cultural identity

One review of AA warned of detrimental iatrogenic effects of twelve-step philosophy, and concluded that AA uses many methods that are also used by cults. However, a further study concluded that AA's program bore little semblance to a religious cult's because the techniques used appeared beneficial. Another study found that an AA program's focus on self-admission of having a problem increases deviant stigma and strips members of their previous cultural identity replacing it with the deviant identity. A survey of group members, however, found they had a bicultural identity and saw AA's program as a complement to their other national, ethnic, and religious cultures.

Other notable criticism

  • "Thirteenth-stepping" is a disparaging euphemism used by some AA members to refer to the romantic or sexual involvement of an existing male or female member with a newcomer. To avoid this type of behavior, AA typically suggests that men be sponsored by men, and women be sponsored by women (though in some cases, particularly with members who are homosexual, men may be sponsored by women and vice versa).


  • Critics have argued that some AA members rely too heavily on dogmatic slogans and become overly dependent on the group.


Literature

Alcoholics Anonymous publishes several books, reports, pamphlets and other media including a periodical known as the AA Grapevine. Two books are used primarily, Alcoholics Anonymous (the "Big Book") and the Twelve Steps and Twelve Traditions which explains AA's fundamental principles in depth.



See also



Notes

  1. Alcoholics Anonymous as a mutual-help movement: a study in eight societies By Klaus Mäkelä, Alcoholics Anonymous, World Health Organization. Regional Office for Europe, p.3
  2. http://www.ncl.ac.uk/nnp/teaching/disorders/substance/alcrx.html
  3. [1] AA GSO Guidelines pdf
  4. (Alcoholics Anonymous, Appendix II)
  5. This is AA pamphlet
  6. http://www.aa.org/pdf/products/p-15_Q&AonSpon.pdf
  7. [2] Questions and Answers on Sponsorship pamphlet
  8. Alcoholics Anonymous as a mutual-help movement: a study in eight societies By Klaus Mäkelä, Alcoholics Anonymous, World Health Organization. Regional Office for Europe, p.10
  9. http://www.aa.org/pdf/products/p-16_theaagroup.pdf. The A.A. Group
  10. http://www.alcoholics-anonymous.org/en_pdfs/mu-1_begmeetings.pdf
  11. Alcoholics Anonymous as a mutual-help movement: a study in eight societies By Klaus Mäkelä, Alcoholics Anonymous, World Health Organization. Regional Office for Europe, p.149-50
  12. A Newcomer Asks (AA pamphlet)
  13. The Alcoholic Can Recover (AA pamphlet)
  14. Dale Mitchel, Silkworth: The Little Doctor Who Loved Drunks. Hazelden, 2002.
  15. Alcoholics Anonymous The Doctor's Opinion page xxviii.
  16. http://www.alcoholics-anonymous.org/en_pdfs/p-48_04survey.pdf AA 2004 Membership Survey issued by AA World Services' General Service Office - www.aa.org
  17. The nature of the survey questions asked do not allow a direct comparison between the twelfth month of the first year and the first month of the second year. Only those in the first year are recorded by month.
  18. "Comments On A.A. Triennial Surveys" (PDF, 2 MB), Dec. 1990, Alcoholics Anonymous World Services.
  19. Humphreys K., Moos R. Can encouraging substance abuse patients to participate in self-help groups reduce the demand for continuing outpatient care? A quasiexperimental study. Alcohol Clin Exp Res 2001; 25: 711–16
  20. Corrections Workbook, Alcoholics Anonymous World Services, Inc. Grand Central Station, Box 459, New York, NY 10163
  21. Carrying the Message into Correctional Facilities, Where Do I Go From Here?, A.A. in Prison: Inmate to Inmate, A.A. in Correctional Facilities, It Sure Beats Sitting in a Cell Memo to an Inmate Who May be an Alcoholic, A Message to Corrections Administrators. Alcoholics Anonymous World Services, Inc. Grand Central Station, Box 459, New York, NY 10163
  22. AA Guidelines from GSO, "Cooperating with Court, DWI and Similar Programs. http://alcoholics-anonymous.org/en_pdfs/mg-o5_coopwithcourt.pdf
  23. Columbia Law Review March 1997, Vol. 97 No.2 , Honeymar Jr., Michael G. "Alcoholics Anonymous As a Condition of Drunk Driving Probation: When Does It Amount to Establishment of Religion"
  24. N. Roberson, Getting Better:Inside Alcoholics Anonymous (London: Macmillan, 1988), p 220
  25. Dr. William D. Silkworth in the Doctor's Opinion in the Big Book of Alcoholics Anonymous states that for the alcoholic, "the only relief we have to suggest is entire abstinence".
  26. Stanton Peele The Diseasing of America. Lexington, MA: Lexington Books, 1989, http://www.peele.net/lib/diseasing.html
  27. [3]
  28. Dawson DA, Grant BF, Stinson FS, Chou PS, Huang B, Ruan WJ. 2005. Recovery from DSM-IV alcohol dependence: United States, 2001-2002. : Addiction. Mar;100(3):281-92
  29. Dawson DA, Goldstein RB, Grant BF. 2007. Rates and correlates of relapse among individuals in remission from DSM-IV alcohol dependence: a 3-year follow-up. Alcohol Clin Exp Res. 2007 Dec;31(12):2036-45.
  30. Vaillant GE. A 60-year follow-up of alcoholic men. Addiction. 2003 98, 1043-51. PMID: 12873238
  31. Wright, K (1997) "Shared Ideology in Alcoholics Anonymous: A Grounded Theory Approach". Journal of Health Communication, Volume 2, pp. 83–99
  32. Questions and Answers on Sponsorship, Alcoholics Anonymous World Services, Inc., page 10. [4]
  33. Arthur H. Cain, " Alcoholics Anonymous: Cult or Cure?." Harper's Magazine, February 1963
  34. A Worldcat search for materials authored by Alcoholics Anonymous and more specific divisions of the organization ( AA Grapevine, World Services, General Service Conference, World Service Meeting) yields well over 500 results.


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