Attacking Alcoholics Anonymous (A.A.) and 12-step oriented addiction treatment has become a specialized industry with its own genre of literature, celebrity authors and speakers, single-focus websites, and promoted alternatives. Collectively, these critics suggest that A.A. is an anachronism whose effectiveness has been exaggerated and whose time in the sun has passed. A.A.'s institutional response to these? criticisms has been a consistent pattern of private self-reflection (e.g., Bill Wilson's "Our Critics can be Our Benefactors") and public silence (e.g., no opinion on outside controversial issues, personal anonymity at level of press, and public relations based on attraction rather than promotion--as dictated by A.A.'s Traditions).
The concept of organizational resilience suggests not just an institution's longevity, but the capacity to survive in the face of significant threats to its character and existence. Such threats faced by A.A., including the intensity and endurance of polemical assaults on A.A., raise the question of how A.A. survived these challenges to become such a dominant cultural force. We have investigated the history of a broad spectrum of secular, spiritual, and religious frameworks of addiction recovery, and we believe there are several factors that contribute to A.A.'s vitality and survival that warrant the attention of those interested in the resolution of alcohol and other drug (AOD) problems. We discuss below some of the more important of such criteria.
Attraction: Will those experiencing AOD problems be attracted to seek help from this solution?A.A. meets this criterion, as evidenced by its pattern of growth over the past eight decades. The primary mechanism of attraction has been the power of mutual identification experienced through an endless chain of one alcoholic telling his or her story to another alcoholic. The personal transformations and social fellowship that flow from such exchanges are at the core of the A.A. experience. A.A. also draws prospective members by promising protection from social stigma via its membership criteria ("a desire to stop drinking"), its closed meeting structure, and its encouragement of personal anonymity. Put simply, the first point of accountability for any addiction recovery support program is the number of people with AOD problems who choose it. It is only their votes that ultimately matter.
Accessibility: Is the proffered solution locally available, culturally acceptable, personally accessible (at high risk times, e.g., evenings, nights, and holidays), and affordable A.A. has met these criteria through its sustained national, international, and transcultural growth (including growth within communities of color and other historically disempowered groups), its 24-hour availability (via the mechanisms of sponsorship, phone number exchanges, and its 12th Step service ethic), and its policy of no dues or fees. At present, A.A. and other 12-step programs represent the most accessible addiction recovery support framework in the world. While recovery mutual aid alternatives to A.A. have a much shorter history, each must pass this accessibility litmus test if it is to survive as a viable recovery support option.
Engagement: Is the proposed remedy capable of sustaining involvement for a sufficient duration of time to achieve recovery stabilization, transition to sustainable recovery maintenance, and enhanced quality of personal/family life in long-term recovery? The greatest challenge of all health management programs, particularly those addressing problems distinguished by severity and chronicity (e.g., obesity, cancer, diabetes, and heart disease) is sustaining commitment to daily recovery management practices. A.A. enhances such adherence through its "one day at a time" philosophy, Step-guided prescriptions for recovery maintenance, its rationale for sustained A.A. participation, and using small-group affiliation and its resulting friendships as a medium and motivational fulcrum for sustained involvement. A.A. hasbeen more effective than many of its mutual aid alternatives (as measured by average duration of participation) and more effective than addiction treatment in sustaining involvement for the 4-5 years researchers have found to be the best predictor of lifetime recovery. Any reference to A.A. drop-out rates must be balanced by comparison of such rates to other addiction recovery mutual aid groups, addiction treatment and allied health management frameworks, e.g., health clubs, weight loss programs, and smoking cessation support groups.
Adaptability: Is the proposed solution adaptable across evolving cultural contexts and applicable to the variability of AOD problems and the needs of diverse individuals seeking recovery? A.A. has stretched the boundaries of its inclusion via the growth of A.A. meetings within diverse cultural settings, by the growth in specialty meetings of people with AOD problems who share another defining characteristic, e.g., age, gender, ethnicity, sexual orientation, religious orientation (or its absence), primary language, problem severity (low-bottom versus high bottom groups), co-occurring disorders, occupation, etc. The varieties of A.A. groups and varieties of A.A. experience suggest that A.A. has made substantial progress in meeting this criterion.
Organizational Viability and Longevity Can the organizational framework within which the recovery solution is nested withstand the forces that have led to the self-destruction of recovery mutual aid organizations (and addiction treatment organizations) for more than 150 years? Many of A.A.'s predecessors offered a viable program of personal recovery but failed to survive as an organization. A.A. found creative solutions to the forces that had limited or destroyed its predecessors. Through the principles imbedded in its Twelve Traditions, A.A. forged solutions to the pitfalls of charismatic and centralized leadership, mission diversion, colonization by other organizations, ideological extremism and schisms, professionalization, commercialization, and relationships with other organizations and the media. A.A. created a historically unique organizational structure (a blend of anarchy and radical democracy relying on rotating leadership, group conscience, intentional corporate poverty, etc.) that even its most devoted early professional allies believed could not work. That structure and those principles have protected A.A. through eight decades. A.A. offers a case study in organizational resilience.
Scientific Validity Are claims of success in the resolution of alcohol and other drug problems validated by scientific study? Studies of A.A. have grown in number and methodological rigor in recent years. Though continuing to focus primarily on A.A. participation during and following addiction treatment, these studies confirm that:
- A.A. participation enhances long-term abstinence, global health, and social functioning;
- these benefits can be amplified when combined with professionally-directed addiction treatment;
- A.A. oriented-treatment is as effective as its alternatives (e.g., cognitive behavioral therapy, and motivational interviewing) and superior in elevating post-treatment abstinence outcomes;
- the benefits of A.A. participation extend to diverse populations, including women, youth, people of color, people with co-occurring disorders, and people without religious or spiritual orientation;
- the mechanisms of change in A.A. include? problem recognition, enhancement of motivation and self-efficacy, exposure to sober role models, social support, increased coping skills, enhanced spiritual orientation, and helping others;and
- the response to A.A. (like responses to other addiction recovery mutual-aid groups and to addiction treatment) is not uniform, with responses varying from optimal effects, partial effects, to no effects. (For a review, see White, 2009).
Cultural Contribution: Does the recovery support option offer any added value to the culture beyond its contribution to the recovery of the individual? A.A.'s cultural prominence derives from areas in which it adds social value:
First, participation in A.A. has been found to reduce social costs of AOD problems at no cost to the society: A.A. refuses to accept any outside funds for support of its organization.
Second, A.A.'s Twelve Steps have been widely adapted to address other problems of living, extending A.A.'s social benefit far beyond the arena of alcoholism recovery.
?Third, Robin Room and others have suggested that A.A.'s unique organizational structure and its principles of organizational management (Twelve Traditions and Twelve Concepts) may be as historically noteworthy as its solution to the problem of alcoholism.
?Fourth, A.A.'s model of "fellowship" based on shared experience marks a new form of social affiliation and a new source of "community" among people lacking ties of blood, geography, faith, or profession.
Finally, A.A. merits recognition within the history of ideas for its disentanglement of spirituality from religion, its assertion of limitation and imperfection as the essential human condition, and its elevation of transcendent experience and helping others as antidotes to human isolation and shame.
It would be well to apply criteria such as these to any proposed solution for alcohol and other drug problems.
About the Authors: Bill White is author of Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Ernie Kurtz is Author of Not-God: A History of Alcoholics Anonymous.