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Who is AA for?

3 September 2013

Standard Disclaimer: I do not speak for Alcoholics Anonymous. This is my opinion.

Over the weekend, Michael Tomasson sent me a link to this article by Dr. Markus Heilig in the Washington Post. It correctly identifies that alcoholism remains a vexing problem both societally and from the perspective of medical research. I’m generally unqualified to comment on the state of the medical research in the neuroscience of addiction, but the usual suspects are. However, on the epidemiology side, I have both experience and (some) training. Luckily, my training was not really needed to analyze this minimally researched article. I don’t dispute the numbers, though AA’s own reporting on its retention rate should be considered highly suspect because there’s no systematic means of taking surveys.

Dr. Heilig makes a few basic mistakes, such as the unsupported assertion that “…medications targeting brain function continue to be viewed unfavorably in many 12 step programs.” While it is true I have heard some reluctance to adopt psychoactive medication in AA, I have heard the same reluctance outside of AA. And, I know many people in AA, myself included, who take or have taken psychoactive medicines while members of AA and sober. We do this under the care of physicians. One of AA’s crucial assertions is: “We are not doctors.” Meaning, the principles of AA should not countermand the things your physician tells you about your health, when that physician is fully informed about your addiction. I’ve seen no evidence that psychoactive medicines are preferentially avoided by the population in AA compared with the general populace.

Heilig also makes the mistake of conflating rehab facilities with AA. For example, the Betty Ford Clinic. Now, I know almost nothing about Betty Ford, and I have nothing negative to say about them. But AA does not endorse them, or any other rehab facility. AA runs no rehabs, clinics, hospitals, halfway houses, meeting houses, coffee shops, or anything else along those lines. AA conducts no research, nor supports anyone who does. AA has no governance. That’s explicitly stated in our Traditions: “Our leaders are but trusted servants. They do not govern.” So, quoting how medical facilities react to research availability and evidence based medicine may well be relevant to how alcoholism is treated in America, but it has no relevance to AA.

And obviously, AA doesn’t react to the medical evidence, institutionally. No one has anything like the authority or influence to guide the organization. AA is a bunch of drunks, getting together, working (or not) a program of sobriety and recovery which works for us, and telling our stories. That’s it. Asking AA to react to the medical evidence is like asking traffic to react to the latest city-planning models. Not only is it not equipped to, it’s not the right body to avail itself of the information.

And fundamentally, Heilig misunderstands the nature of AA in another important way. He criticizes AA for “insisting on total abstinence”. But that is not what we do. I had a sponsee once, David. He came to AA. He was a drunk. He did the first five steps. He got a job and moved to Italy. He started drinking socially. He kept drinking socially. Now he’s married with a kid, his lifelong dream. And to my knowledge, he continues to drink socially. And you know what? I’m happy for him! I’m glad he’s drinking socially. I’m glad he’s happy and fulfilled and able to drink like a gentleman.

I cannot. Nor do I any longer have any true desire to. Sure, I still occasionally have wisps of a longing for gentility and sophistication mixed with alcohol. But I am not the kind of alcoholic who can go and drink normally, because I do not have any desire to drink normally. If I could drink normally, I’d get drunk every day. Because I love drunkenness more than I love any other thing about alcohol. I love the taste and the chemistry and the social lubrication and the sophistication, absolutely. But what I really love is the effect of inebriation.

While we in AA welcome anyone with a desire to stop drinking, our program is not really designed for those who have the ability to transition to normal drinking. And those people exist. They exist by the millions. So many people binge-drink when young and then shape up and drink normally as adults. And bless them. I’m so happy they can and do. I’d never change it. Nor would I prescribe abstinence for them.

The people AA helps are the people who have finally limited themselves to jails, institutions, or death. People for whom the only, final choice, is abstinence. People who drank like me: hell-bent on isolation and death. Suicide by alcohol. People for whom alcohol is not only the most important thing, but the only thing that matters. We may be mystified that our lives are not going as we want them to, because we cannot see that alcohol is the only thing we love, but that is the truth of it nevertheless.

When people write essays like Dr. Heilig’s essay, what they’re saying is: “AA doesn’t act like I think it should act.” Generally these people have the best of intentions. They believe that AA would be more effective if only it changed to suit their opinions. Often opinions informed by the best available medical evidence. This pill has been shown to reduce relapse rates in triggering circumstances, Heilig writes. No, thank you. I’m declining not because I think there’s anything wrong with taking medicine, but because I don’t want to offload the responsibility for my sobriety to anyone else.

Taking a pill that curbs cravings may very well curb cravings, and aid my ability to achieve short-term abstinence. But it cannot cure the way I think about alcohol. The way I will tell myself lies and rationalize my use. And the way I will blame anyone other than myself for my failures when I drink. If I take a pill that curbs my cravings, it is easy for me to “forget” to take the pill, suffer a craving, and succumb because I haven’t done what I need to do, haven’t built a support network, haven’t come to understand the reasons I drink. Relying on a pill for abstinence is a recipe for self-sabotage.

It is wonderful that there are strong efforts being made to address alcoholism medically. But to criticize AA for not adopting them betrays a fundamental misunderstanding of what AA is, who we can help, and how we are structured. But most importantly it misunderstands one of the deep contradictions that exists in alcoholics of my type: If I don’t want help, then nothing you have can help me; If I do want help, then (other than acute withdrawal) I don’t need the kind of help that medical science can offer.

10 Comments leave one →
  1. 3 September 2013 09:41

    Taking a pill that curbs cravings may very well curb cravings, and aid my ability to achieve short-term abstinence. But it cannot cure the way I think about alcohol.

    But what if there is an ideal medication for alcoholism that does change the way you think about alcohol, just like the ideal medication for depression would make someone feel not-depressed and the ideal medication for schizophrenia would stop hallucinations AND cognitive and social deficits? I believe that if we understand how craving and relapse happen on a neurobiological level, that we could eventually target that with drugs. I hear that you think that is ‘an easy way out’ and that you need to do work and understand yourself and the reasons you have for drinking. But if you have schizophrenia, you don’t need to understand why you have the disease or what triggers an episode if you can take drugs that make it go away. So why would that be different for another psychiatric disorder?

    • 3 September 2013 09:49

      Well, if we’re in the realm of magic pills, then what the hell. A pill that gives me six-pack abs and a better work ethic would be great too!

      Actually no: I’d rather be flawed than pharmaceutically perfect. I am a better person because of the way I addressed my alcoholism. A way that required effort and surrender and understanding and work. If there were a pill that bypassed all that, and simply made me able to be abstinent or able to drink normally, I’d still be the same miserable asshole I was that tried to treat my misery with alcohol. I’d just be that miserable asshole without a desire to fix it with booze.

      But I suppose, there’d be a magic pill for miserable asshole-ness too?

    • 4 September 2013 06:54

      And, I wanted to make sure I said: it’s not that I think that’s an “easy way out”. Believe me, an easier way would be LOVELY. It’s that I believe that using medicine to control intake places the burden for abstinence (or moderation) somewhere other than me. And that will lead me to fail, every time.

  2. inbabyattachmode permalink
    3 September 2013 09:41

    Oops I meant to make your quote italic and not the entire comment. Sorry!

  3. 3 September 2013 09:50

    Great post – like you say people who can “turn around and drink like a gentleman” again I raise my hat to him. I couldn’t. I tried repeatedly and failed repeatedly and was getting to the point where the suicide tape in my head because I couldn’t was beginning to repeat and get louder – that is when I went to a rehab, that used the 12 steps programme and promoted an life to include AA when I left. However AA had no relationship with that rehab, it never will do – you sum that up perfectly. Whilst much was based on the 12 steps much was not, they had other methods they used with addicts alongside that – again nothing to do with AA and should never be confused that it is.

    I’ve just put a post up commenting upon a UK recommendation that addicts be offered information about 12 step fellowships as part of their recovery – which is being roundly ignored by the medical profession it seems.

    There often seems a lot of confusion… In my experience…

    AA has absolutely nothing to do with religion, some of those who I have the greatest regard for who are members of AA and have used it in their recovery significantly are also publicly declared atheists. They have no dilemma with that at all.

    AA is AA – Rehabs are rehabs – they are different. Rehabs may use the 12 step programme and some of the AA philosophy but they are completely separate.

    AA is for people who find they no longer can drink safely and who find that no matter what period of abstinence or what programme they attempt to moderate/control their drinking they continue to drink to excess and they come to a point where they cannot live with alcohol. I made the decision to remain abstinent from alcohol once I was in AA and began to desire what I saw other members had and I could with some sober reflection realise that I’d not drunk safely in years, if indeed ever.

  4. 3 September 2013 10:13

    Thanks for this great post. The article was interesting, but didn’t sit well with me for reasons I couldn’t articulate. I think you hit my issue with:

    When people write essays like Dr. Heilig’s essay, what they’re saying is: “AA doesn’t act like I think it should act.”

    Maybe it’s inevitable for people writing articles professionally to promulgate conflict . It certainly seems like there is space for medical approaches, should they ever prove effective, for people that want or need them. But it is silly for someone to demand that an organic, distributed system like AA change its simple effective approach because one dude thinks he’s got the answers.

  5. Dee permalink
    3 September 2013 12:22

    I also read the article and what stood out for me was this part:

    “states that “available . . . studies did not demonstrate the effectiveness of AA or other 12-step approaches in reducing alcohol use and achieving abstinence compared with other treatments.”AA’s own surveys have indicated that for every 100 alcoholics entering their first meeting, only about 30 will be attending and sober a year later. This is very close to the spontaneous relapse rates consistently found by research over the past four decades.”

    He seemed to be saying that the 30% who do make it to sobriety within AA isn’t that impressive since it happens spontaneously. What this tells me is that we’d have twice as much relapse if we choose one over the other. What works for one person may not work for everyone. For too long we’ve been seeking one-size-fits-all remedies for everything. There may be 10 people for whom 10 different approaches work. Does that make one approach less valid? one may have to try 9 approaches before finally getting to the 10th which does work and another may find it on the first try.

    If AA works then stick with it
    If medication works do it (although that runs the risk of developing a new addiction)
    If will power without AA works that kudos
    If you’re able to step down from alcoholic to social drinker- good for you.

    Do what works for you!!!

  6. 4 September 2013 06:36

    Again, thanks.

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