This piece was originally going to be a part of my Marijuana – An Exploration series of long-form posts. However, it quickly became apparent that this topic was very much worthy of its own entry. So here goes.
We will start with the origins of Alcoholics Anonymous.
Founded by Bill Wilson back in 1935, the organization and it’s accompanying 12 step methodology has since become the primary means of dealing with addiction in North America. Borrowing tenants from both Christianity and Philosophy, AA comes together as a biblically structured guide back to sobriety.
In the United States alone, it’s estimated that 23 million people suffer with substance abuse disorders. Of those, 55,000 are said to attend AA meeting groups nationally. Others encounter the AA program though over 11,000 treatment centers of which use the 12 step approach nationwide.
After 2 decades of intensive study both in the fields of medicine and theology, everything would come together while Bill Wilson was laid up in a hospital room back in 1934. Having watched various members of his own family struggle to control their addictions to various substances, Bill had been pondering a new way of tackling substance abuse in his bedridden state. Upon running some of his ideas by NYU’s Dr. Ebby Thacher (addiction specialist), the program they designed and curated would become one of the most well-known treatment programs on the planet.
The only program, according to some doctors.
In my 20 years, I have not seen anything that comes even close to the 12 steps. In my world, if someone says they don’t want to do the 12 steps, I know they aren’t going to get better.
Dr. Drew Pinsky
Unfortunately, what I just said was fiction.
Not the Drew Pinsky quote. Rather, the entire backstory regarding the origins of Alcoholics Anonymous. The truth is far more colourful than the bland lie that I just fed you.
Bill Wilson was layed up in a hospital room back in 1934. And he was indeed visited by a man named Eddy Thacher. Rather than a doctor at NYU, however, Eddy was instead Bill’s old drinking buddy. Ebby had found Christ and given up alcohol, and he thought his friend Bill would benefit from such an epiphany, as well. Since Bill was agnostic at the time, however, he declined his friend’s attempt at help. The thought of devoting himself to a higher power was not at all appealing.
Well, until it was.
In aiding his detox regiment, Bill’s physician (William Silkworth) subjected him to the Belladonna Cure. In a nutshell, he was delivered hourly doses of a poisonous plant called Belladonna (alongside a few other compounds). The rest . . . is history.
But later, as he writhed in his hospital bed, still heavily under the influence of belladonna, Wilson decided to give God a try. “If there is a God, let Him show Himself!” he cried out. “I am ready to do anything. Anything!”
What happened next is an essential piece of AA lore: A white light filled Wilson’s hospital room, and God revealed himself to the shattered stockbroker. “It seemed to me, in the mind’s eye, that I was on a mountain and that a wind not of air but of spirit was blowing,” he later said. “And then it burst upon me that I was a free man.” Wilson would never drink again.
So, this was how the AA program got its start. A man tripping balls on god knows what . . . came to Jesus. Or, Jesus came to him?
Either way, given the typical prognosis of alcoholics at the time, the fact that this happened is not all that surprising.
At that time, the conventional wisdom was that alcoholics simply lacked moral fortitude. The best science could offer was detoxification with an array of purgatives, followed by earnest pleas for the drinker to think of his loved ones. When this approach failed, alcoholics were often consigned to bleak state hospitals.
This also holds true of Bill Wilson. As this was not his first round of Belladonna. It was his 4th.
Perhaps the most famous patient was William Griffith Wilson, better known as Bill W., the co-founder of Alcoholics Anonymous. In the early 1930s, Mr. Wilson was consuming more than two quarts of rotgut whiskey daily, a definite health risk according to Alexander Lambert, who found in his copious research that consumers of cheap or bootlegged alcohol were far more prone to seizures, delirium tremens and brain damage than those who drank the expensive stuff. Between 1933 and 1934, at his wife’s urging and on his wealthy brother-in-law’s dime, Mr. Wilson was admitted to Towns four times. The cost upon admission was steep: up to $350 (roughly $5,610 today) for a four- to five-day stay.
Although Mr. Wilson made some progress in temporarily abstaining, he relapsed after each of the first three hospitalizations. It was around this time that he reunited with a drinking buddy named Ebby Thacher. Unlike previous times, when they went out on wild binges, Mr. Thacher told him that he quit booze and was a member of the Oxford Group, a church-based association devoted to living on a higher spiritual plane guided by Christianity. As a demonstration, on Dec. 7, 1934, Mr. Thacher took Mr. Wilson to the Calvary Mission on East 23rd Street and Second Avenue, where the most drunken of New York’s Depression-era down-and-outers went to be fed and, it was hoped, “saved.”
A few days later, a drunken Wilson staggered back into the Towns Hospital. There, his physician, William D. Silkworth, sedated him with chloral hydrate and paraldehyde, two agents guaranteed to help an agitated drunk to sleep, albeit lightly. This was especially important because the medical staff members had to wake patients every hour for at least two days to take the various pills, cathartics and tinctures of the belladonna regime.
On the second or third day of his treatment, Mr. Wilson had his now famous spiritual awakening. Earlier that evening, Mr. Thacher had visited and tried to persuade Mr. Wilson to turn himself over to the care of a Christian deity who would liberate him from the ravages of alcohol. Hours later, depressed and delirious, Mr. Wilson cried out: “I’ll do anything! Anything at all! If there be a God, let him show himself!” He then witnessed a blinding light and felt an ecstatic sense of freedom and peace. When Mr. Wilson told Dr. Silkworth about the event, the physician responded: “Something has happened to you I don’t understand. But you had better hang on to it.”
Hang on to it he did. Indeed, this experience ultimately led Mr. Wilson to abstain from alcohol for the remaining 36 years of his life and to co-create the novel program whereby one alcoholic helps another through a commitment to absolute honesty and a belief that a higher power can help one achieve sobriety.
In May 1935, while on an extended business trip to Akron, Ohio, Wilson began attending Oxford Group meetings at the home of a local industrialist. It was through the group that he met a surgeon and closet alcoholic named Robert Smith. For weeks, Wilson urged the oft-soused doctor to admit that only God could eliminate his compulsion to drink. Finally, on June 10, 1935, Smith (known to millions today as Dr. Bob) gave in. The date of Dr. Bob’s surrender became the official founding date of Alcoholics Anonymous.
In its earliest days, AA existed within the confines of the Oxford Group, offering special meetings for members who wished to end their dependence on alcohol. But Wilson and his followers quickly broke away, in large part because Wilson dreamed of creating a truly mass movement, not one confined to the elites Buchman targeted. To spread his message of salvation, Wilson started writing what would become AA’s sacred text: Alcoholics Anonymous, now better known as the Big Book.
The core of AA is found in chapter five, entitled “How It Works.” It is here that Wilson lists the 12 steps, which he first scrawled out in pencil in 1939. Wilson settled on the number 12 because there were 12 apostles.
In writing the steps, Wilson drew on the Oxford Group’s precepts and borrowed heavily from William James’ classic The Varieties of Religious Experience, which Wilson read shortly after his belladonna-fueled revelation at Towns Hospital. He was deeply affected by an observation that James made regarding alcoholism: that the only cure for the affliction is “religiomania.” The steps were thus designed to induce an intense commitment, because Wilson wanted his system to be every bit as habit-forming as booze.
Suddenly, I find myself thinking of James Fry’s controversial memoir titled A Million Little Pieces. Interestingly enough, the title was also released as a movie adaptation last year. Though the ratings are fairly low, I’ll be my own judge.
Of all the problems that exist with the book, however, I can’t help but think that James didn’t embellish his disdain for the 12 step recovery program prescribed by the treatment center in Minnesota. To borrow a quote from the now infamous book (of which I still own a copy):
“I’d rather have that (relapse and death) than spend my life in Church basements listening to people whine and bitch and complain. That’s not productivity to me, nor is it progress. It is the replacement of one addiction with another.”
“I know I won’t ever believe in the Twelve Steps. People like you keep saying it’s the only way, so I’m thinking that I might as well just put myself out of my misery now and save myself and my family the pain.”
“Addiction is not a disease…Diseases are destructive medical conditions that human beings do not control…I don’t think it does me any good to accept anything other than myself and my own weakness as a root cause.”
Though James Fry has not been immune to controversies even following the first book (as per the above link), one thing that seems not to have changed is his sobriety status. An accomplishment that was not achieved through the typical AA 12 step regiment. Not only were the 12 steps not effective in his case, it can be (and is) argued that the program actively undercut his attempts at bettering himself.
The value of his book was his search for a solution for his problems consistent with his own beliefs.
Frey was not religious. Yet he was force fed AA’s Twelve Step philosophy at every turn in his treatment. Frey rejected AA and its whole redemptive approach: “I’d rather have that (relapse and death) than spend my life in Church basements listening to People whine and bitch and complain. That’s not productivity to me, nor is it progress. It is the replacement of one addiction with another.”
The treatment he received actually impeded his efforts to recover: “I know I won’t ever believe in the Twelve Steps. People like you keep saying it’s the only way, so I’m thinking that I might as well just put myself out of my misery now and save myself and my Family the pain.”
Although American treatment programs (including the Betty Ford Center, Hazelden, and virtually every drug and alcohol treatment program in the U.S.) are all predicated on the Twelve Steps, this approach has never been demonstrated to be particularly effective. Among Frey’s true statements was his report that the success rate – “Patients who are sober for a year after they leave here” – was 17 percent at the hospital where he was treated.
Is the AA program an active affront to religious freedom?
In itself, no. As a tool for reform as prescribed by the justice system, potentially.
AA acolytes and others who support the Twelve Steps argue that the steps are not really religiously-oriented. This, although “God,” “Him,” or a “higher power,” is mentioned in half of the Twelve Steps. The third step in particular: “Made a decision to turn our will and our lives over to the care of God as we understood Him,” is often justified by the claim that God can be understood as being anything!
However, every state supreme and federal appeals court which has adjudicated the issue has concluded that AA and its Twelve Steps are religious. Thus, it is illegal – a violation of the First Amendment’s separation of church and state – for courts to “sentence” people to attend Twelve Step programs. This ruling is consistently violated around the United States, while rarely being challenged.
Frey was “not gonna believe in AA or the Twelve Steps. The whole thing is based on belief in God. I don’t have that, and I never will.” Being forced in a supposedly medical treatment to accept God would be a violation of a patient’s rights in anything other than American substance abuse treatment. Aside from violating the principle of informed consent, discounting people’s core beliefs does not enhance their motivation to change.
American society has always been about fitting millions of squared, triangled, hexagonal, and every other shape under the sun into round holes. Standardization is good for the industries that keep America thriving. Or should I say, standardization was good for the industries that kept America thriving until it became cheaper to outsource to cheaper territories of operation.
Now all that remains is but a shell of what once was. Dilapidated factories in depopulated towns and cities. And hundreds of thousands of displaced and obsoleted former workers. Conditioned for a lifetime on the virtues, sense of purpose and accomplishment that a hard-working life brings a person, they now wander aimlessly and jobless, everywhere.
Some take this anger out on their family members (domestic abuse). Others attack whatever minorities the elites in power choose as their scapegoat this era. And others still (including some in the aforementioned groups) self-abuse in various ways, including self-medicating with drugs and alcohol.
As it stands, 23 million Americans are said to struggle with substance abuse issues currently. Taking into account the after-effects of the COVID 19 pandemic (how many people will be out of work even after it’s over?), this number may well grow.
If I look even further down the road and take the next automation revolution into consideration, is it possible that the current 23 million number could double (or even triple)?
Addiction is now such a factor of everyday life in America that addiction treatment is now its own industry, valued at 42 Billion dollars. With the alcohol industry alone taking in 260 billion back in 2018, that is no small figure.
However, everyone knows that there is much money to be made in exploiting the downtrodden (most notably A&E). While that is problematic in itself, it represents an arguably small part of the problem. Only around 3 million people have the resources to come into contact with treatment centers, to begin with. Almost every single one of those people will encounter the 12 steps of the Alcoholics Anonymous program, however.
While AA’s success rate tends to be hard to pin down on account of the anonymous fluidity of the overall organization, it is thought to be around 5 to 10 percent. While it is considered to be better than no recovery program at all, does AA deserve its status as the unofficial gold standard in treatment programs?
Let’s consider some of the alternatives. Though there are many more than I had previously realized, I’m going to stick to the most common ones (though you can find many more HERE). The most well-known alternatives appear to be:
Again, that list is far from exhaustive in terms of the options available, both online and IRL. Though all options are likely not available where everyone resides, one would hope at least one or 2 exist. At the very least, the online communities are available wherever you are.
Let’s start with SMART Recovery. They appear to employ what they call a four-point program which helps guide there members to continued abstinence-based sobriety. From their website:
Key Areas of Awareness and Change
SMART Recovery’s approach to behavioral change is built around our 4-Point Program®: (1) Building and maintaining the motivation to change. (2) Coping with urges to use. (3) Managing thoughts, feelings, and behaviors in an effective way without addictive behaviors. (4) Living a balanced, positive, and healthy life.
Motives and Goals
Motivation is a key element in nearly all you do. Consider that all human beings share several primary goals: survival, the avoidance of pain, happiness. Any addictive behaviors you engage in are to pursue these primary goals. We can help you see that you may be meeting these goals short-term but impairing your ability to meet them in the long-term.
What you believe about addiction is important, and there are many beliefs to choose from. You may believe, for example, that you’re powerless, or that after the first drink you lose all control and can’t stop. These beliefs may actually be damaging to you. Similar examples include, “I’ve tried and failed, so I can’t do it. I need alcohol to cope.” Or, “Because I’ve tried to quit and failed, I’m no good.” Those beliefs, and many like them, can’t be justified because the evidence just doesn’t support them. We will help you identify, examine, and modify your beliefs about yourself, your problems, and how to change.
People often engage in addictive behavior to cope with emotional problems, including anger, guilt, anxiety, and low self-esteem. SMART Recovery teaches you how to diminish your emotional disturbances and increase self-acceptance. Then you can have greater motivation and the ability to change and to live more happily.
Changes in thinking and emotions alone are not enough. Commitment and follow-through are essential. We encourage participants to become involved in enjoyable activities that replace their problematic addictive behaviors.
How SMART Provides Help
Our meeting format is straightforward and organized. Our facilitators are trained to follow the SMART Recovery program and principles to help participants change their behavior. Some of them have had addictive problems, and some haven’t. That doesn’t seem to make any difference. Remember, SMART Recovery is a mental health and educational program, focused on changing human behavior. SMART Recovery meetings are serious but often fun. We don’t dredge up the past, about which we can do nothing. We can do something about the present and the future. Our meeting discussions focus on how to apply SMART’s tools for change so that you can go on to lead a more productive and connected life. Near the end of the meeting, the “hat” is passed for donations, which are encouraged but not required.
I like what I see, so far. But more importantly, is it effective?
According to a study (which I learned of HERE, in the name of full disclosure), the answer appears to be yes.
Background: Overcoming Addictions (OA) is an abstinence-oriented, cognitive behavioral, Web application based on the program of SMART Recovery. SMART Recovery is an organization that has adapted empirically supported treatment strategies for use in a mutual help framework with in-person meetings, online meetings, a forum, and other resources.
Objective: To evaluate the effectiveness of OA and SMART Recovery (SR) with problem drinkers who were new to SMART Recovery. Our experimental hypotheses were: (1) all groups will reduce their drinking and alcohol/drug-related consequences at follow-up compared to their baseline levels, (2) the OA condition will reduce their drinking and alcohol/drug-related consequences more than the control group (SR), and (3) the OA+SR condition will reduce their drinking and alcohol/drug-related consequences more than the control group (SR only).
Methods: We recruited 189 heavy problem drinkers primarily through SMART Recovery’s website and in-person meetings throughout the United States. We randomly assigned participants to (1) OA alone, (2) OA+attend SMART Recovery (SR) meetings (OA+SR), or (3) attend SR only. Baseline and follow-ups were conducted via GoToMeeting sessions with a Research Assistant (RA) and the study participant. We interviewed significant others to corroborate the participant’s self-report. Primary outcome measures included percent days abstinent (PDA), mean drinks per drinking day (DDD), and alcohol/drug-related consequences.
Results: The intent-to-treat analysis of the 3-month outcomes supported the first hypothesis but not the others. Participants in all groups significantly increased their percent days abstinent from 44% to 72% (P<.001), decreased their mean drinks per drinking day from 8.0 to 4.6 (P<.001), and decreased their alcohol/drug-related problems (P<.001). Actual use relationships were found for the OA groups, between SR online meetings and improvement in PDA (r=.261, P=.033). In addition in the OA groups, the number of total sessions of support (including SR & other meetings, counselor visits) was significantly related to PDA (r=.306, P=012) and amount of improvement in alcohol-related problems (r=.305, P=.012). In the SR only group, the number of face-to-face meetings was significantly related to all three dependent variables, and predicted increased PDA (r=.358, P=.003), fewer mean DDD (r=–.250, P=.039), and fewer alcohol-related problems (r=-.244, P=.045), as well as to the amount of improvement in all three of these variables. Six-month follow-ups have been completed, and the results are currently being analyzed.
Conclusions: These results support our first experimental hypothesis but not the second or third. All groups significantly increased their PDA and decreased both their mean DDD and their alcohol-related problems, which indicates that both interventions being investigated were equally effective in helping people recover from their problem drinking.
Since that comes across as rather self-serving, how does SMART compare to other alternatives (AA included?).
A Longitudinal Study of the Comparative Efficacy of Women for Sobriety, LifeRing, SMART Recovery, and 12-step Groups for Those With AUD
Background: Despite the effectiveness of 12-step groups, most people reporting a prior alcohol use disorder (AUD) do not sustain involvement in such groups at beneficial levels. This highlights the need for research on other mutual help groups that address alcohol problems and may attract those who avoid 12-step groups. The current study addresses this need, offering outcome data from the first longitudinal, comparative study of 12-step groups and their alternatives: The Peer ALlternatives for Addiction (PAL) Study.
Methods: Adults with a lifetime AUD were surveyed at baseline (N=647), 6months (81% response rate) and 12months (83% response rate). Members of the largest known secular mutual help alternatives, namely Women for Sobriety (WFS), LifeRing, and SMART, were recruited in collaboration with group directors; current 12-step attendees were recruited from an online meeting hub. Online surveys assessed demographic and clinical variables; mutual help involvement; and alcohol and drug use and severity. Analyses involved multivariate logistic GEEs separately modelling alcohol abstinence, alcohol problems, and total abstinence across 6 and 12months. Key predictors were baseline primary group affiliation (PGA); primary group involvement (PGI) at both baseline and 6months; and the interaction between baseline PGA and 6-month PGI. The critical effects of interest were the interactions, expressing whether associations between changes in PGI from baseline to 6months and substance use outcomes differed by primary group.
Results: None of the interactions between baseline PGA and 6-month PGI were significant, suggesting no differences in the efficacy of WFS, LifeRing, or SMART, vs. 12-step groups. Nevertheless, some PGA main effects emerged. Compared to 12-step members, those identifying SMART as their primary group at baseline fared worse across outcomes, and those affiliating with LifeRing showed lower odds of total abstinence. Still, these effects became nonsignificant when controlling for baseline alcohol recovery goal, suggesting that any group differences may be explained by selection of those with weaker abstinence motivation into LifeRing and (especially) SMART.
Conclusions: This study makes a valuable contribution in view of the extremely limited evidence on mutual help alternatives. Results tentatively suggest that WFS, LifeRing, and SMART are as effective as 12-step groups for those with AUDs, and that this population has the best odds of success when committing to lifetime total abstinence. An optimal care plan may thus involve facilitating involvement in a broad array of mutual help groups and supporting abstinence motivation
While one could read this and come away with the message that SMART is no better than any of the other options, the final paragraph above makes me think that I may be approaching this the wrong way. Frankly, in the one size fits all fashion of the pro-AA proponents I am arguing against.
In the realm of addiction (or substance misuse management, to borrow a term from Russell Brand), there will be no clear winners (in terms of best recovery options). And even if I do end up eating that statement at some point later, it should be less about crowning a king and more about acknowledging options for an incredibly diverse populace.
Since many of these programs call themselves abstinence-based, it also makes me wonder if that must be the only option for a population as diverse as . . . the world.
The expectation of total abstinence from something one considers pleasurable has always struck me as a tall order. Don’t get me wrong, people get there in various ways. But it seems that is an incredibly high expectation to hold any person to, considering that most of us engage in some form of habit that could cause us grief if we tried to go abstinent cold turkey. Whether or not the habit (or addiction) is harmful is not the point.
It all boils down to guilt.
I’m reminded of 13 years ago when I decided to quit smoking. Don’t get me wrong, I wasn’t a heavy smoker. None the less, close friends introduced me to flavoured cigarillos. And a job at a c-store introduced me to initially menthol cigarettes, than regular cigarettes. Though you never think you can’t quit, it seems that you don’t know until you try.
With the expectation of abstinence comes an inevitable feeling of guilt if you happen to be human and fall off the wagon. Thus begins the vicious cycle.
I remember going through it when I quit smoking. Though I was far from a 50 year 3 pack a day smoker, it was still a struggle. Looking back, had I known not to feel guilty every time I relapsed, I may have kicked the habit even sooner.
Even though this all happened over a decade ago, I still get the occasional craving for a cigarette. It has nothing to do with stress or situation, it’s more time of year. Involving a seemingly innocuous memory of all things.
A close friend of mine had planned a Halloween party, which was to occur in 2 or 3 days. I was walking home from either his place or my job (at the time), both of which had me use the same route. All I remember is looking forward to that party as I smoked a menthol cigarette. It was around 11pm. The moon was out, the air was cool and crisp, and the leaves were falling all around me.
In the years since, pumpkin spice season has always marked my most difficult period to stay smoke-free. Don’t get me wrong . . . now that menthol cigarettes and flavoured cigarillos are illegal in Canada, it’s easier. But it’s still an interesting reoccurring phenomenon.
Interestingly enough, we’re still catching up in terms of the flavoured vaping juices that were used to addict a whole new generation to nicotine.
Either way, I have gotten off-topic.
In the same way that expecting every addict to conform their recovery around the tenants of AA and the 12 steps are harming some people’s chances of recovery, the expectation that recovery is defined as abstinence may well also be doing more harm than good.
While this argument would seem asinine to the purveyors of an ideology that grounds itself on the concept that is “You are not strong. You need *Insert Deity Here*”, this ideology would seem to provide a terribly limited path forward. Particularly if ignorant or disingenuous people on your journey convince you that this is the only way to go forward. If this won’t work, then what chance do I have?
It makes one wonder how many family members or friends have washed their hands of problematic friends or relatives based on their failure to take to a ridiculously hard to maintain future lifestyle. A liftstyle that is almost certainly primed for failure.
Interestingly enough, such recovery programs do exist.
What is Moderation Management?
Moderation Management (MM) is a behavioral change program and national support group network for people concerned about their drinking and who desire to make positive lifestyle changes. MM empowers individuals to accept personal responsibility for choosing and maintaining their own path, whether moderation or abstinence. MM promotes early self-recognition of risky drinking behavior, when moderate drinking is a more easily achievable goal. MM is run by lay members who came to the organization to resolve personal issues and stayed to help others.
From the same website, I like this particularly honest and helpful entry.
Is MM for every person with a drinking problem?
No. Research suggests that no one solution is best for all people with drinking problems. There are many possible solutions available to each individual, and MM suggests the each person finds the solution that is best for him or her.
MM is good place to begin to address a drinking problem. If MM proves to be an ineffective solution, the individual is encouraged to progress to a more radical solution.
I may as well conclude this entry here.
When I started this entry, I asked the question Do 12 step programs harm more people than they help?. If I am perfectly honest, I thought I know the answers before I even started my research. I know . . . someone with a non-theistic point of view would approach this topic from a biased point of view. Shocker!
In reality, however, there are many nuances to be considered. As such, the answer to that question would have to be Yes and No.
Should the un-medicine based regiment that is Alcoholics Anonymous be the standard of rehabilitation (as is often the case)?
Should the success stories of the AA regiment (be they because of, or in spite of) be disregarded on account of its abysmal overall success rate?
If this research has taught me anything, it’s that the word recovery may mean many different things for many different people. In fact, it SHOULD mean many different things to many different people, if the personal welfare of the person is really the end goal.
Am I highly amused by the fact that the most common recovery regiment in North America was the result of a drug-induced hallucination brought on by a 4th attempt at attaining the incredibly difficult?
If it works for you . . . you do you. Just remember that the rest of us are not necessarily like you.