Alcoholics Anonymous: Still Sober After 75 Years

ALCOHOLICS ANONYMOUS (AA) marks its 75th anniversary in 2010, its founding identified with the sobriety date of its cofounder, Bob Smith, MD: June 10, 1935.1 The encounter between the Akron, Ohio, surgeon Smith (or Dr Bob, as he is identified within the AA fellowship) and Bill Wilson, a newly sober visiting stockbroker and entrepreneur from New York City, was Wilson's first success at “fixing drunks,” and in the 75 years since that encounter, AA has grown to some 2 million members in more than 160 countries, including more than 1.2 million US members.2 The first printing of Alcoholics Anonymous—the basic text outlining the 12-step AA program (Figure 1)—bore the subtitle “How Over 100 Men Have Recovered From Alcoholism,” but according to a 2007 AA membership survey, women accounted for one third of US and Canadian respondents.3 AA's program stems from tenets of the Oxford Group, a religious sect that sought to reproduce the practice of first century Christianity, but its absence of religious doctrine has accommodated agnostics, atheists, and believers in nontheistic religions such as Buddhism. Programs modeled on AA have proliferated: for example, Narcotics Anonymous, which emerged in the 1950s and elaborated on the AA program in its own basic texts, reports members in 130 countries,4 including almost 200 000 in the United States.5 For advanced alcoholics, treatment 75 years ago typically meant inpatient detoxification, plus psychoanalysis for the minority who could afford it. As a multimodal treatment apparatus emerged, AA and derivative 12-step fellowships became interwoven into drug and alcohol treatment6 and aftercare.7 Almost half of US and Canadian members reported in the 2007 survey that treatment or counseling “played an important part in directing them to AA” and almost two thirds of members accessed medical, psychosocial, or spiritual treatment or counseling before or after coming to AA.3 Although AA does not embrace research as part of its mission,8 addiction researchers have undertaken thousands of studies of AA since the 1970s. Early work typically lacked rigor but, by the 1990s, the methodological quality of such studies had improved and the preponderance of evidence supports the effectiveness of 12-step program involvement in sustaining abstinence9 outweighing putative harms cited by its critics10 (e.g., that AA involvement is worse than doing nothing, that a negative response to AA engenders relapse, that acknowledging powerlessness causes binges more severe than among AA nonattendees). Despite the interpenetration of treatment and 12-step fellowship programs, AA warns that it is neither cure11 nor treatment.8 The essence of 12-step programs—one alcoholic or addict helping another—starkly differentiates them from the credentialed, hierarchical, and commercial structures of formal treatment systems. Historians have shown how key formative events that shaped AA distinguish it from treatment; conflating these distinctive and complementary approaches threatens the integrity and effectiveness of both.12 Thirty years before the encounter between Wilson and Smith, William James' Varieties of Religious Experience recounted examples of spiritual transformation effecting an abrupt and sustained remission of alcoholism.13 But Wilson, like many other alcoholics, was agnostic. Hopelessness—his willpower repeatedly ineffectual, and the best medical help unavailing—opened Wilson's mind to the suggestion of his friend Ebby Thatcher, who had recently become sober himself as a member of the Oxford Group, to “choose your own conception of God… . Thus was I convinced that God is concerned with us humans when we want him enough.”1 Seeking to live by Oxford Group tenets, Wilson assiduously began preaching to fellow alcoholics, who listened dutifully and kept drinking.14 Alone in Akron after a failed business trip, fearing he would resume drinking, Wilson sought out another alcoholic—Smith—to sustain his own sobriety. As Wilson put it, “I had quit preaching. I knew that I needed this alcoholic as much as he needed me. This was it.”15 Smith had attended weekly Oxford Group meetings for two and a half years, studied the Bible, did the “immense amount of reading they recommended,” and “cultivate[d] the habit of prayer… . at least to a considerable extent for me. But I got tight every night, and I mean that… . But the one thing they hadn't told me was the one thing that Bill did that Sunday—attempt to be helpful to somebody else.”16 And that is precisely what the two men set out to do, painstakingly working with other alcoholics, who in turn were inspired by the same vision that Bill experienced while sobering up after his last binge: “that there were thousands of hopeless alcoholics who might be glad to have what had been so freely given me. Perhaps I could help some of them. They in turn might work with others.”1 FIGURE 1 The Twelve Steps and Twelve Traditions of Alcoholics Anonymous. Source. Reprinted with permission from A Brief Guide to Alchoholics Anonymous (New York, NY: Alcoholics Anonymous World Services, 1972). Why did AA flourish where religious movements to address alcoholism had previously foundered? It remains a spiritual, not a religious, program. Wilson subordinated his entrepreneurial, capital-intensive, donor-dependent instincts to the guidance of “group conscience”17—deliberation and endorsement by the membership of the growing fellowship—and he came to appreciate the wisdom of AA's frugally reluctant yet otherwise enthusiastic benefactor, John D. Rockefeller, Jr, who recognized that an ethos of voluntary service was integral to the success of the nascent fellowship.14 Refusal to endorse other worthy causes or accept outside contributions spared it the fate of temperance movements such as the Washingtonians and the Oxford Group, which expanded rapidly and collapsed just as quickly. As AA's operating principles (Figure 1)18 evolved, they upended virtually every convention of organizational structure in a capitalist society. From what looks like anarchy—traditions (“AA ought …”) rather than rules (“you must …”), maximum local autonomy and independence, and absence of centralized or layered tiers of authority—emerges consistency and stability. Without certification, evaluation, supervision, or internal or external monitoring, tradition sustains fidelity to the basic framework of meetings and work on the program's steps. AA eschews property ownership and rigorously refrains from soliciting support from sources other than its own members, whose voluntary contributions barely cover the cost of meetings and such basic services as phone lines, meeting lists, and dissemination of free literature. A minimal cadre of paid staff serves the membership rather than the reverse. Rigorously refraining from self-promotion, it depends upon the objective appraisals of outside observers and the testimonials of members during meetings and in one-on-one contacts. Wilson's words from a half century ago pithily recount the genesis of the AA program and fellowship. The next half century would amply justify Wilson's jubilation at the success of the 12-step recovery program and the capacity of the organizational framework embodied in its traditions to sustain exponential growth without dilution or diversion from its primary purpose and its principles.