Who is AA for?
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.