by Lance Dodes
The common thread here is an ongoing tension between the idea of AA as a treatment, and the idea of AA as a “fellowship” whose power lies in a more general model of community. Most proponents of the program say that one cannot be teased apart from the other, that the fellowship (meetings) and the treatment (the Twelve Steps) create a harmonious whole that is greater than the sum of its parts. Yet the question remains: might any group of alcoholics or other drug addicts serve just as well as AA? Are the things that make AA unique—the Twelve Steps, the testimony, the sponsors, and so on—integral to its main action, or are they mostly an overlay that functions to create a structure for the organization, much like the rules and traditions common to other fraternal organizations?
One clue may lie in a piece advice that AA itself gives to new members. As Harris describes, AA “advocates that new members attend different groups until they find one that suits their needs.”5 If the Twelve Steps were a true treatment for addiction, should it matter whether one group is more suitable than another? The recommendation makes far more sense if we think of AA as a fellowship rather than a treatment. If the group is the point, then of course one would need to find the right group to experience the benefits.
THE QUESTION OF SPIRITUALITY
One of the pillars of AA often cited as central to its effectiveness is its strong emphasis on spirituality. The Twelve Steps are explicitly spiritual, and much has been made about the unique benefits of AA’s notion of surrendering to a Higher Power. But the scientific literature is skeptical on this point. In his 2003 paper, Harris and colleagues looked specifically at the attitudes toward spirituality of people who had attended AA. What they found was illuminating:
Roughly equal groups expressed “positive, “neutral” and “negative” current attitudes towards AA (38%, 36% and 26%, respectively). Each of these three AA-attitude groups expressed greater endorsement of “Personal Responsibility” steps than of “Higher Power mediated” steps. . . . A clear and consistent pattern of endorsement was evident . . . with the majority agreeing with steps that do not explicitly mention God or a Higher Power but encourage acceptance, self-examination and reparation (grouped as “Personal Responsibility” steps). A considerable proportion reported the references to God (54.4%) and the Higher Power (62.4%) were “off-putting” (the term most commonly used in pilot interviews for adverse views).6
In other words, the steps that were explicitly spiritual or religious seemed to be more distasteful than useful, even among people who felt positive about their experiences in AA as a whole. In fact, the Harris study reported that “of patients with AA experience . . . [only] 2.8 percent had experienced a spiritual awakening.” The authors added that “‘Higher Power’ endorsement was (p < .001) [very highly] predicted by [prior] religious involvement and lifetime number of AA meetings attended.” In sum, people who came in religious stayed that way, but the majority did not seem to have been markedly affected by the ongoing emphasis on spiritual rebirth.
Another study, by J. Tonigan of the University of New Mexico, concluded that “[c]ontrary to AA doctrine, spirituality does not appear to exert a main effect on drinking reductions. . . . The path between spirituality and drinking reductions was non-significant.”7 A similar result was reported by Owen and colleagues (2003), who found that spirituality is “uniformly and regularly discussed in AA meetings . . . increased spiritual endorsement, however, was not predictive of increased abstinence.”8
One of the interesting wrinkles in this discussion is the fact that AA famously disputes any notion that it’s a religious organization at all. (Bill Wilson once said, without apparent irony, “Our Twelve Steps have no theological content, except that which speaks of ‘God as we understand Him.’ . . . There isn’t the slightest interference with the religious views of any of our membership. The rest of the Twelve Steps define moral attitudes and helpful practices, all of them precisely Christian in character.”)9
Our court system does not agree, however. According to the North Carolina School of Government, in court cases where people have been mandated to attend AA, “[W]hat’s not at issue in these cases is the question of whether AA is, in fact, religion-based. The litigants typically agree that it is, and the courts are unpersuaded by the idea that it’s ‘spiritual’ and not religious.”10 This fact has been echoed in more than ten court rulings across the United States, including this opinion by New York’s Court of Appeals, the state’s highest court:
The foregoing demonstrates beyond peradventure that doctrinally and as actually practiced in the 12-step methodology, adherence to the A.A. fellowship entails engagement in religious activity and religious proselytization. Followers are urged to accept the existence of God as a Supreme Being, Creator, Father of Light and Spirit of the Universe. In “working” the 12 steps, participants become actively involved in seeking such a God through prayer, confessing wrongs and asking for removal of shortcomings. These expressions and practices constitute, as a matter of law, religious exercise for Establishment Clause purposes, no less than the nondenominational prayer in Engel v Vitale (370 US 421), that is, “a solemn avowal of divine faith and a supplication for the blessings of the Almighty. The nature of such a prayer has always been religious.”11
That an organization judged by many unbiased parties to be religious would deny its religious orientation yet still point to those same religious principles as the key to its success, suggests confusion among its members about what makes AA work, and why.
Other theories about the possible therapeutic action of AA have been floated and discarded. A 2010 study of over seventeen hundred patients concluded, “The Alcoholics Anonymous (AA) literature states that reduction of anger is critical to recovery. . . . However, AA attendance was unrelated to changes in anger.”12 Tonigan and Rice noted that AA strongly encourages its members to develop a relationship with a sponsor. But their results showed that affiliation with a sponsor was unrelated to abstinence past the first months of joining.13
Why is it that no one can seem to isolate the specific things that make AA work for the people who find success in the program? As we will soon see, it is because questions of spirituality and group dynamics are ultimately beside the point. When AA works, it’s due to other factors that are incidental to its main approach but dovetail with some elements of the psychology of addiction.
THE PSYCHOLOGY OF AA’S SUCCESS
You’ll recall that I described addictive behavior as a response to feelings of overwhelming helplessness. It’s what people do to “fight back” against this unbearable feeling. But addictive acts are never a direct way to fight back: they are substitutions (or displacements) for a direct action, taken precisely because taking a direct step is felt to be impossible or forbidden. One of the unique qualities of displacements is that they work in much the same way that the direct action might: for addicts, drinking a beer or placing a bet really does relieve the unbearable sensation that no options are available.
It’s worth remembering as well that this searing, personal version of helplessness takes many forms and is wholly contingent on the psychology of the addict. I’ve seen patients whose most intolerable form of helplessness centers around a sense of abandonment, or being invisible, or feeling undistinguished professionally, or losing an argument. There are, in other words, as many addiction-driving forms of helplessness as there are addicts; no two are precisely the same. Our unique histories inform that which we find untenable.
Yet the number of substitute remedies for helplessness tends to be far lower. As we know, addiction is one of the most common. The causes may be diverse, but the function is always the same: to extinguish helplessness by replacing it with its opposite, empowerment. This fact—that addiction is ultimately a quest for empowerment—is the key to bridging the gap between what AA says and how AA really works. That key rests within the single term higher power.
Most of us start out life without a strong boundary between our individual selves and the world at large. You
ng children in particular tend to engage the world as a sort of composite “we”—part child, part parent. Numerous psychological studies have confirmed that children identify with their parents or caregivers far more when they’re young than when they’re older. And why shouldn’t they? In this identification lies a great reservoir of comfort. When you align yourself with someone bigger and stronger than yourself, you can eliminate many of the scariest feelings of childhood—being weak, small, and unable to do most things. Identifying with a more powerful parent or caregiver is a healthy step in our emotional development, one that enables us to transition gracefully from infant to adult without spending every waking moment in a state of terror and confusion.
This same tendency to identify with powerful figures wends its way through our adulthood in certain ways. Witness the powerful identification many of us feel with great athletes, or entertainment stars, or even brands such as technology companies. (It’s no coincidence that one of the most effective campaigns of the twenty-first century used the phrase, “I’m a Mac.”) Studies have noted the very real sense in which the things that happen to our chosen heroes affect us as well, including a well-cited article that showed that men’s testosterone levels tend to drop when their favorite sports team loses a big game.14 The converse is true as well—we revel in our team’s victories, own them as our own, and feel powerful for sharing the success.
In politics, too, our identities can rapidly become enmeshed with our favorite people and causes. Many leaders throughout history have depended on a similar psychology to powerfully influence their followers; Winston Churchill famously emboldened his people never to yield, and because they identified with his strength, his words proved to be a source of strength for them.
With this in mind, now let us return to the first three steps of Alcoholics Anonymous:
Step 1: “We admitted we were powerless over our addiction–that our lives had become unmanageable.”
Step 2: “Came to believe that a Power greater than ourselves could restore us to sanity.”
Step 3: “Made a decision to turn our will and our lives over to the care of God as we understood God.”
It is hard to imagine a more explicit plea to engage in the same sort of psychology that adults feel with their heroes. What’s interesting about these three steps is how differently addicts react to them. As we’ve seen, the majority of people in AA resist these ideas. These notions seem in a sense tailor-made to exacerbate the powerful sense of helplessness that most addicts are already struggling against.
But there is another possible response: some people, rather than pushing back against the “Higher Power” idea, accept it wholeheartedly. They do not perceive this notion as a threat to their autonomy, but as a great reservoir of power that they can draw upon. Since addiction is ultimately an effort to reverse helplessness, the idea that a benevolent and all-powerful entity is now on their side—in a sense, is a part of them—is deeply compelling. For those who can make use of this concept, it can be a genuine solution. As long as the Higher Power is seen as potent and reliable, a person who identifies with it may be able to abstain from addictive behavior; he or she no longer needs it to relieve helplessness.
But the primary concern about this method of achieving sobriety is its precarious quality. The relief afforded by the notion of a higher power is commensurate with the great disappointment one feels when that higher power turns out to be an illusion—or worse, an abusive force. This revelation is in a sense multiplied in its effect by the very scale of the power: the increase in confidence is great, and the betrayal can be just as devastating.
In 12-step programs, one of the most common ways the Higher Power can tumble is through a fault line in the sponsor-sponsee relationship. One of AA’s founding principles is the notion that members who have achieved sobriety have useful wisdom and support to offer by virtue of their own success in holding off addiction. Alas, these people are typically as fallible as anyone else, and even long-standing members can lapse or even withdraw from the program. To sponsees—or “pigeons” in AA language—whose notion of the organization’s power is intertwined with the sponsor’s success story, events such as these can be devastating, leading to the return of addictive behavior.
Imagining AA itself as the Higher Power is equally problematic, since the organization can fail its members as well. Many addicts report bad experiences in groups they had hoped to rely upon, and the effects of these incidents can be far more damaging if they carry the meaning that the Higher Power has clay feet. Administrative slights, abusive members, and unwanted advances (a problem so common it’s been given its own nickname: 13th stepping) can all poke holes in the idealized notion that many members cultivate around AA. To those whose sense of identity has become enmeshed with the group, exposing the man behind the curtain can be debilitating. At the very least, it leaves addicts who had relied on a Higher Power without emotional recourse.
If AA were more appropriately aware of how this mechanism works psychologically, it could make needed changes. But because AA’s own theories about how it helps people are unsound, the organization tends to repeat the same problems in the same ways, disappointing and ultimately losing the vast majority of the people who try to benefit. Indeed, one of the most frustrating aspects of the program for many potential members is its repetitiveness in the face of clear contradictory evidence: AA members who lapse or struggle are prescribed nothing more or less than the original advice, perhaps delivered more loudly. Even those who can make use of AA as a remedy for helplessness are never taught or warned of the implicit dangers that come with this sort of powerful identification.
Another consequence of identifying strongly with an external Higher Power is that people are often left with little more understanding of themselves than when they began. The Twelve Steps strongly encourage members to seek power, solace, and strength from the group or from their notion of a High Power, but not from within themselves. (Some members do describe an increase in humility as a consequence of acknowledging their diagnosis and their step 4 “flaws,” but greater humility is not relevant to the treatment of addiction.) Because no lasting psychological insights about addiction have been absorbed, gains made throughout sobriety can quickly evaporate as the addict discovers that the very same feelings of intolerable helplessness have returned, precisely as they were. For 12-step members who experience a Higher Power’s fall from grace, as it were, the sensation can be like losing a limb—the thing they had leaned on for strength has vanished into thin air. People who grow to understand the psychology of addiction, on the other hand, are better prepared to deal with their addiction. Insight is a form of empowerment that cannot be wrested from your grasp.
One of the unfortunate consequences of AA’s Higher Power success stories is the sensitivity that such a dependency foments. Since, for many of these people, sobriety depends on the integrity of what they believe, any challenge to those beliefs is felt to be a dangerous assault on the very thing that keeps them sober. The result is a well-documented tendency among AA members to aggressively defend the organization and its precepts without giving consideration to opposing ideas. Often AA skeptics and lapsed members find that current members respond with rage when pressed to consider different viewpoints or countermanding data. The visceral power of these responses should be a clue to the psychology behind them: we save our fiercest defenses for an attack on that which keeps us whole.
Speaking to professional groups around the country, I have regularly witnessed firsthand the energetic pushback AA members will typically deliver to anyone who dares to challenge AA dogma. Many times at these talks, I’ve been approached by therapists who tell me, often in a near-whisper, that they are deeply discouraged by the 12-step approach but are literally afraid to say anything for fear of losing their jobs. Their stories are awful, but the consequences are more so: if alternative views may not be uttered in these treatment centers, patients are prevented from hearing and thinking about them.
/> Because so many leaders and counselors within our nation’s treatment programs are “recovering” addicts themselves, it can be tremendously difficult to begin a civil public conversation about the shortcomings of the approach, and more or less impossible to produce change in their treatment programs. The dominance of AA devotees in the addiction treatment industry extends as well to government agencies charged with providing services to addicts.
AA’s views about how it works are largely based on foundational beliefs and fail to include any insight into what drives addiction or how AA disrupts or amplifies those drivers. One of the principal ways AA helps people is in its capacity as a community, where it supplies a number of general attributes that are universally present in any religious or fraternal group.
But there are some occasions when AA inadvertently meets an individual’s need to feel powerful against helplessness, addressing the underlying psychology of addiction without intending to. AA’s lack of insight, however, leaves it without any consistent capacity to correct its problems or expand its effectiveness. The same lack of awareness in those for whom AA “works,” leads to a hostile incapacity to be thoughtful when presented with views that challenge their belief system.