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AA is Held to a Higher Standard.

22 January 2015

I’m fond, over on twitter, of saying “AA works”. What I mean by that is too complex for the 140 character medium of twitter, but I’ve described it here many times. AA doesn’t “work” as a treatment for alcoholism the way, say, vaccines work for preventing illness or antibiotics work for treating infection. AA isn’t a medical treatment. What it is is a framework for living and being relieved of the obsession and madness of alcoholism, which, when willingly embraced, allows us to relent from our death-grip on addiction and rejoin the world of humanity, productively.

And I often get pushback from scientists when I say that AA works. I get people who say it doesn’t work for atheists because it has a spiritual element. This is, of course, directly contradicted by the fact that many thousands of atheists recover in AA all the time. I’ve known at least dozens, perhaps hundreds, personally.

I’ve been told AA doesn’t work because it isn’t evidence-based. That trials haven’t proven it’s better than placebo. I’ve addressed this here too: investigating AA doesn’t really work, from a scientific perspective, because retrospective cohorts can’t be developed, and because prospective trials require that researchers participate (even minimally) in the treatment, which often derails it (and means that the program that’s being studied isn’t really the AA program anyway). Trying to produce rigorous scientific evidence of AA is doomed from the outset. And like the parachute review, isn’t needed: some things are self-evident. Like millions of recovered alcoholics.

I’ve been told it doesn’t work because someone’s family member tried it and they continued to drink, or, god forbid, died. This is deeply tragic and my heart spasms with grief for those who’ve lost loved ones to this disease. I have too. But AA doesn’t fix us from without. It provides a framework we can use to fix ourselves from within. And even from the perspective of a “medical treatment”, no medical intervention is 100% effective. But we don’t abandon SSRIs simply because not every depression responds.

I don’t know why people are so eager to hold AA to the standard of “It must help every person who engages for any time to recover completely and irreversibly.” That’s an absurd standard to hold any treatment for any disease to. And even though I don’t consider AA to be a medical treatment, that’s the perspective that nearly every scientist and physician I’ve discussed it with has of it.

Like many things, I think the issue is largely one of control. Because AA was invented by drunks, and not scientists (though, of course, one of the founding members was a physician), it can’t be claimed by science as a developed intervention. I think there’s some resentment there. I think there’s also dismissiveness. They don’t know exactly how AA “works”, and we recovered alcoholics can’t ever seem to explain it in a way that makes sense. So it must not work. It must be a fancy placebo.

I’ve largely stopped trying to convince scientists and physicians that AA is a real thing that works for real people. Some few seem to understand. Some accept it despite not understanding. Most are glad to see people recover but deeply skeptical that AA has anything concrete to do with it. A few are openly contemptuous and think AA should be demolished.

And while I prefer the former reactions to the latter, the truth is that it doesn’t matter. When we come to that place where there is no solution left. When medicine has “failed” us, because we’ve failed to do what is required by medicine. When we stand between recovery and death, and cannot decide which path to take. Then AA will be there. As it has been for more than 80 years. And for many of us, those who find the willingness to engage and participate, it will herald recover and freedom and life. As it has for me and millions of others. And we don’t need others to understand it. Our survival is not your evidence.

And most of us, we addicts, we alcoholics, most of us will die. As we always have. And as we always will. Alone, and lost, and silent, and cold, most of us die. I understand why doctors would like to spare us this fate. I understand why scientists want to learn why so many of us prefer that fate to life. I wish them well. Any effort that lifts any of us from that slough is good.

But I know the way out. And Milton was right: Long is the way, and hard, that out of darkness leads up to light. But I know the way. And I can help you find it.

12 Comments leave one →
  1. 22 January 2015 10:47

    I think you are probably right about the resentment and (my word) jealousy of medical professionals towards AA as a method that they had no part in creating and do not, in any way, control and cannot use within their system of tratment. Just look at how the medical establishment has responded to other movements that remove their hands from the levers of power, like the home birth movement or really, almost any alternative treatment. This is of course, not unique to physicians, but a seemingly universal character trait of humanity. It bewilders and irks me no end that about 95% of everybody has a deep need to convert others to their point of view. And obviously i fight this trait in myself as well.

    One quibble with your post: I think it is probably not inaccurate to describe AA as a placebo. People abuse that word. A placebo, skillfully and deliberately applied, is more effective than many of our best treatments for various conditions. Placebo is not a synonym for “nothing” or “something ineffective.” It’s a very real and very powerful effect that we still don’t understand very well, but which has been used for millenia by practitioners of traditional medicine. It is – or can be – a way of manipulating our brains and bodies towards healing.

    • 22 January 2015 10:51

      I believe in harnessing placebo as possible (and in the absence of effective medicine), just like you do. But I’m with medicine on the Home Birth movement, in general. The research is pretty clear that there are more and worse complications, morbidity, and mortality in home than hospital births. That said, for a family that knows and accepts the risks? Their business, not mine.

      • 23 January 2015 10:41

        That is not true, at least it wasnt according to the research when i was pregnant with Hope. For women in low-risk pregnancies, outcomes are better for both mothers and babies when birth is attended by licensed midwives at home or in a birth center as opposed to attended by obstetricians in a hospital. And the reason is perfectly clear: fewer interventions equals fewer complications, when dealing with a straightforward birth. Standard hospital interventions including continuous fetal monitoring, epidurals, and limited mobility all cause (not infrequently) a cascade of events leading to the slowdown of labor and often, eventual major interventions like pitocin and C-sections. Every intervention has consequences, and generally speaking those are to interupt the natural hormonal event that is labor and birth. All of which completely ignores emotional effects like post traumatic stress and problems with bonding and early nursing that can follow from high-intervention hospital births. This is one topic on which I am willing to do a lot of googling to find the studies I read ten years ago, so be forewarned 😉

      • 23 January 2015 10:47

        Recent (2011) ethical guidelines paper says home birth in the USA is not recommended and has increased risk of morbidity and mortality:

        However, recent large cohort studies in Europe show no difference among healthy, low risk moms:

      • 23 January 2015 13:27

        The first abstract you sent (which is all I can read) provides no stats at all but simply asserts (from the college of obstetricians themselves) that home birth is less safe. Here is a 2014 study with stats in the abstract. Yes, it’s from the journal of midwifery – but hey, you cite obstetricians, I cite midwives.

        AND this one, although from 2005, is another good one with a good sized sample.

        basically the research shows that when properly controlled (i.e., low-risk, planned, in hospital births are compared to low risk, planned, home births, not to unplanned or unattended home births) then morbidity and mortality are essentially the same, but hospital births have a much higher rate of interventions. So they are only equal if you believe that interventions such as episiotomies and C-sections are harmless…. which is patently absurd, in my opinion.

      • 19 February 2015 23:21

        I’m with aimee on home birth. Doctors don’t like the idea because they don’t get to use their toys and women are in control.

  2. John permalink
    22 January 2015 11:36

    You hit the nail on the head when you said “when willingly embraced”. Treatment works 100% when you define the purpose of treatment is to get people off your back. In that case going to a treatment facility accomplishes that 100% of the time or at least until you drink again. The problem is those people (on your back) wanted you to get sober and had an expectation that you wanted the same thing when you entered treatment. The patient had a different agenda. This is the case with AA. You are also right on when you say AA is held to a higher standard. Over 100,000 probationers are ordered into AA each year. The agenda of the court is to be able to say that they did “something”. So AA works for them. The did something. By the way, the same courts will tote the few success stories as proof that this system works. Ignoring the fact that in spite of 100,000 coming into the rooms via this scheme each and every year for 30 years, AA’s population has remained stagnant for those same 30 years. By forcing people into AA, and by AA accepting unwilling parties into its rooms, the probationer is no longer going to AA!! They are going to some hybrid of AA and a punishment. AA as designed advises sober members to not force anyone and to not rush anyone. It knew the value of willingness and that coercing anyone is a waste of time. AA members wanting to be “modern” or to feed their own egos by saying we can be of help where no one else can. It still boils down to the fact that if you don’t do a 1st step 100% you are not going to get sober. That step, as I am sure you know, is “We admitted we were powerless and that our lives had become unmanageable” Not that the judge had declared we needed AA. Not that our boss or spouse had decided we needed to go to AA. And certainly not that it is in my best temporary interested to attend some meetings so some “magic” can occur.

  3. 22 January 2015 11:59

    If a patient dies after an organ transplant do you stop the whole programme? Funny that seems the statement I’ve recently seen espoused by some. It isn’t the only way to get sober but it does work for many thousands right now. The proof is in you Dr 24 hours and in me

  4. 29 January 2015 08:19

    I’m sure it sounds like nonsense to others when we say that you pretty much have to be desperate and at the end to try AA with gusto. But truly, that is my experience. If I thought there was another way I would have tried it. Who likes the idea of surrendering, and relying upon a bunch of drunks for your salvation and doing this for the rest of your life? heck no.

    Unless, of course, you are desperate for help and know you cannot do it yourself. And you have exhausted all your other great ideas.

    Almost invariably, for those who have surrendered their misery, they are repaid 100 fold with a life they could not have dreamed of.

    Sorry for my poor grammar and punctuation. I’m feeling lazy this a.m.

  5. Syd permalink
    8 February 2015 15:53

    Thank you for writing about this. I don’t think how AA works is explainable by scientific standards. I’m okay with that.

  6. 19 February 2015 23:48

    I think AA works at least as well as any other form of therapy. And in many ways it is psychotherapy for poor people. That and empathy is well-proven to have healing benefits. Were else can those of us who hit bottom find empathy from people who really understand? Where else can an addict get a hug? Touch and hugging are shown to aid in healing. How many medical professionals or scientists hug patients or lab subjects? Perhaps it is that I do think like a scientist, I love science, AND I am a drug addict and problem drinker that I am willing to say that the typical methods for testing treatment will never work with alcoholism or addiction. The 12-step program is more like using insulin to manage diabetes than penicillin to cure an infection. And I do know diabetics who get really sick after not checking blood sugar and using insulin, who don’t want to make any lifestyle changes and die. For myself, I don’t need proof, I am proof. Thank you for writing this.


  1. AA is Held to a Higher Standard. – Don't Drink and Don't Die

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