Tuesday, June 29, 2010

How Does Alcoholics Anonymous Work?

Brandon Koerner's excellent article in Wired is entitled: "The Secret of AA: After 75 Years We Don't Know How It Works." Link here. But as he wisely notes, for many people the important thing is not knowing how it works, but knowing that it works. And that it works better than anything else currently on the market.

David Brooks picked up on Koerner's article and offered some good commentary in his column today. Link here. I will also mention that I have discussed this topic in a previous post. Link here.

As a treatment method, 12 step programs are an anomaly. They are effective in treating what we consider to be a medical problem, but they were invented by people who had no training in medicine or psychology. They do not insist on laboratory-like conformity to a specific procedure, but allow different groups to introduce their own modifications. They do not cost anything, and they are completely unregulated by government.

Members of AA groups have sponsors, but you do not need to have any credential to become a sponsor. Those who lead AA meetings do not have to be licensed professionals.

Many trained and licensed therapists are queasy about this exercise in human freedom. Understandingly, they do not like to compete with an alternative that costs nothing, and that, by all indications, works better than what they are offering. They have often warned of the cult-like atmosphere surrounding AA and have decried the absence of licensed professionals.

As Koerner writes: "Addiction-medicine specialists often raise the concern that AA meetings aren't led by professionals. But there is evidence that this may actually help foster a sense of intimacy between members, since the fundamental AA relationship is between fellow alcoholics rather than between alcoholics and the therapist. Those close social bonds allow members to slowly learn how to connect to others without the lubricating effects of alcohol."

With the exception of those alcoholics who are ordered by courts to attend 12 step programs, most who attend meetings are there voluntarily. People are anonymous; they are free to come and go; they can follow the 12 steps or ignore them.

For these, and many other reasons, it is very difficult to determine how well and how consistently the programs work. And yet, as Koerner suggests, most therapists who work with addicts are persuaded that they do work and that they provide a vital service.

Strangely enough, 12 step programs feel like the untherapy. Had Bill Wilson and Bob Smith set out to offer a perfect rebuke to psychotherapy, they could not have done a better job. As Brooks adds, they also repudiate the value system that forms the basis of our therapy culture.

Where modern psychotherapist believed they were inventing a grand theoretical construct, Wilson and Smith had a single criterion for AA: whether or not it worked. As long as it did, people did not much feel the need to ask how it worked.

As Koerner notes, other forms of contemporary therapy, especially those that are based in cognitive psychology or that are solution focused, have also produced positive results with alcoholics and other addicts. And yet, he adds, AA still works better.

No one is still pretending that old style psychotherapy, the kind that involves searching into the root causes of your problems, uncovering your miserable childhood and your repressed traumas, provides an effective treatment for addictive disorders.

Yet, this old form of psychotherapy still survives as a potent cultural phenomenon. Even there, David Brooks notes, AA rejects therapy culture values: "... in a culture that thinks of itself as individualistic, A.A. relies on fellowship. The general idea is that people aren't really captains of their own ship. Successful members become deeply intertwined with one another-- learning, sharing, suffering and mentoring one another. Individual repair is a social effort."

Psychotherapies that try to make you an independent, autonomous, self-sufficient individual fail to acknowledge you as a social being. If they derive from Freud, they do not even allow you to form a connection with the therapist. AA, however, is all about fellowship, about connecting with other people.

In Koerner's words: "To begin with, there is evidence that a big part of AA's effectiveness may have nothing to do with the actual steps. It may derive from something more fundamental: the power of the group. Psychologists have long known that one of the best way to change human behavior is to gather people with similar problems into groups, rather than treat them individually.

AA deviates from old style therapy for not being a mind-over-matter, ego-over-instincts method. If anything it begins by telling the alcoholic that his ego will never be strong enough to control his addiction. Thus, only a higher power, a force greater than his individual will, must be invoked and involved in the treatment.

As Brooks says: "In a culture that generally celebrates empowerment and self-esteem, A.A. begins with disempowerment. The goal is to get people to gain control over their lives, but it all begins with an act of surrender and an admission of weakness."

Rather than seeking to empower the mind or the ego, AA works to involve people in a program, a set of steps, a set of new behaviors, that will hopefully show the way toward a new way to socialize.

Nowadays scientists and physicians are hard at working trying to figure out how AA works. And they have made considerable progress toward understanding the way the different steps influence brain chemistry. Yet, their research has not produced a better or more effective treatment.

In Koerner's words: "What we do know,however, is that despite all we've learned over the past few decades about psychology, neurology, and human behavior, contemporary medicine has yet to devise anything that works markedly better."


Robert Pearson said...

"The truth is what works." I have never read Henry James, but I am a Pragmatist at heart, I suppose. I thought up that phrase when I was 14 and Mom was horrified. Unfortunately, it was already taken...

Stuart Schneiderman said...

Thanks for bringing up William James. Koerner emphasized how important James' book "The Varieties of Religious Experience" was for Bill Wilson, and it is useful to add, as you do, that James was a great pragmatist. His statement: "The truth is what works" was probably one of the inspirations for the 12 steps.

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