John M. Talmadge, M.D.

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Explaining Alcoholics Anonymous

Last week I attended an Alcoholics Anonymous meeting, one devoted to people who are brand new to AA. For many years I've said that we as a fellowship need to improve our outreach to newcomers. In previous posts and elsewhere on my site (as in the FAQ Frequently Asked Questions section) I state that I am not an evangelist for AA. It doesn't work for everyone. Nonetheless, AA is a powerful movement helping many alcoholics and addicts. I credit AA with helping me find sobriety over 30 years ago, when not much else was available to help alcoholics. Here are some thoughts on the subject of newcomers to AA.

Treatment centers advertising alternatives to AA, or pitching their approach to people who people who (for whatever reason) are opposed to AA, generally don't do a very good job when it comes to staying sober after rehab. Although these programs may offer all sorts of amenities like yoga, hiking, spa treatments, and leisure activities, they do almost nothing regarding follow-up and aftercare. After a few weeks that are more like a vacation than serious treatment, individuals return home with few tools and no plan for what happens next. The reason that better treatment centers endorse AA, and encourage membership, is that AA is widely available and often very helpful.

The logo of AA: Unity, Service, Recovery

In every town or city, almost without exception, AA is easy to find. In smaller communities, there is usually an AA meeting within driving distance nearby. In Dallas, for example, there are hundreds of meetings every week, and at least 20-30 every day. Some meetings have 10-20 people, and some have as many as 100 or more. I once belonged to a meeting that had fewer than 12 members, and we met every week for years.

Old-timers — recovering alcoholics who have been AA members for many years — are familiar with a statement quoted at almost every AA meeting: "ALCOHOLICS ANONYMOUS is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism."

Newcomers to the program of Alcoholics Anonymous often arrive with misconceptions about the program. With the rise of the internet, it's easy to find critical statements about AA, but unless you've attended a few meetings you may not know much about the program itself.

One common misconception is that attending a meeting means "baring your soul" or "having to talk." This is not the case. If you happen to be called on, or asked if you want to share something, you can just say, "I'd just like to listen," or "Thanks, but I'll pass." I've said this myself in many meetings.

And here is a good tip if you're flying solo rather than attending your first meetings with a friend or someone who has invited you. Show up a little early. Old-timers usually arrive early, looking forward to chatting before the meeting and welcoming newcomers. Old-timers also tend to hang around after the meeting to visit with friends and answer questions. Come a little early, and stick around a few minutes after the meeting. You will get a lot more out of the experience if you don't head for the door the minute the meeting ends.

At the end of most AA meetings, we "circle up," and most meetings end with a prayer like the Lord's Prayer or the Serenity Prayer. People gather in a circle and hold hands. If this totally turns you off, that's okay. Even if it feels awkward or doesn't fit your sense of style, it's not the worst experience in the world. It's not as bad as sitting on a barstool dreaming about the life you wish you had instead of the life you actually have.

Here are a few comments about the basics of AA, how it works, and why. The questions, quotations, and bullet points are taken from a brochure, "A Newcomer Asks," published by AA General Services. Additional comments are my own.

Newcomer Asks Pamphlet Image


• The only requirement for membership is a desire to stop drinking. There are no dues or fees for A.A. membership; we are self-supporting through our own contributions.

At every AA meeting, a little basket is passed around the room, and members put in a couple of dollars to support that particular meeting in that particular location. Although very few people arrive intoxicated, many first time visitors have had a drink in the last 24 hours. The message is simple: if you want to get sober, we can help. Honesty, having an open mind, and willingness are the keys to success.

• A.A. is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy; neither endorses nor opposes any causes.

For over 70 years, Alcoholics Anonymous has remained true to this original statement. Although there is often discussion about God — "the higher power" or "the power greater than ourselves" — there is never any discussion or debate about theology. The emphasis is on recognizing that in the great scheme of things, something out there is bigger than we are, and that spiritual experience is part of human nature. Agnostics and atheists are welcome in AA, and many recovering alcoholics are not "church people." The basic idea is that if someone claims that "God does not exist," that person probably has given a lot of thought to the question. An open mind is all that is required to understand why AA's believe in a power greater than the individual.

• Our primary purpose is to stay sober and help other alcoholics to achieve sobriety.

For the better part of the past century, AA members have remained true to this simple principle. This is why members do not get side-tracked on other causes, concerns, or social projects. It's all about helping others who struggle with alcohol.

Alcoholics Anonymous asks and answers some basic questions often heard from newcomers.

Am I an alcoholic?

"If you repeatedly drink more than you intend or want to, if you get into trouble, or if you have memory lapses when you drink, you may be an alcoholic. Only you can decide. No one in A.A. will tell you whether you are or not."

Notice that the answer says you may be an alcoholic. Although there are medical and psychological definitions of addiction and alcoholism, AA takes a very practical position. If you think you have a problem, maybe you do. If other people are concerned about your relationship with alcohol, maybe that's worth thinking about. If alcohol seems always to be there when you get in trouble, it's valuable to ask whether you have a drinking problem.

What can I do if I am worried about my drinking?

"Seek help. Alcoholics Anonymous can help."

Alcoholics Anonymous is not an addiction treatment program, and the meetings are not group therapy. To our misfortune, many individuals come to AA after having a somewhat negative experience in a treatment center ("rehab"). The rehab experience is a very mixed bag. Although some treatment centers are excellent, many are not. Many treatment centers are very expensive, with a spa-like atmosphere and lots of amenities like horseback riding, indoor swimming pools, and great food. Some of these centers do not mention AA at all, and very few residential rehabs provide a smooth transition back to the real world and everyday life. Some treatment centers even advertise that they are not 12-Step based, although their success rates are poor.

AA helps in many ways, however, both "in the rooms" (at meetings) and in everyday life. Although AA does not try to explain exactly "why" the fellowship is helpful, psychologists and psychiatrists generally agree that participation in AA has many benefits.

— AA offers hope to people who are suffering because of alcohol. Our greatest enemy when we are suffering is demoralization. When we are demoralized, we consider giving up. We believe that our condition is hopeless. AA demonstrates that we can recover, and AA offers a way back to sanity and health. Hope is very powerful.

— AA encourages the alcoholic to recognize that we all have problems, that the experience of suffering is universal, and that we are all simply human beings struggling with human problems. Universality, as it's called, is fundamental to any therapeutic group process. We all have problems, and together we can forge solutions.

— Learning about the disease is essential to recovery. AA does not get into neuroscience or psychology, but the program helps people understand that the alcoholic really is powerless over alcohol (as well as drugs when it comes to those of us who have abused multiple chemicals). AA also helps us understand that alcohol affects every aspect of our lives, especially our family, our work, and what we care about most. Being a drunk doesn't make anything better in life.

— Altruism, or generously giving to others, is the foundation of the program. The old saying is "service above self, and principles are more important than personalities." In a newcomer's meeting, the attitude is welcoming, friendly, supportive, non-judgmental, and altruistic.

— Alcoholics Anonymous is like a big family. Many people form relationships in AA that help correct the damage suffered during our early years, or the trauma suffered from bad life situations. A good sponsor is like a good aunt or uncle who helps guide the process of recovery. Deep and loving friendships are forged in AA.

— Learning how to live a normal life, socializing with others in the absence of alcohol or mind-altering chemicals, is an essential part of AA. It's rather amazing for the newcomer to see that recovering alcoholics have a lot of fun, enjoy life, and know how to have a party without getting hammered.

— AA folks tend to stick together. Cohesiveness, bonding with others, makes for good health and peace of mind.

— In AA, people learn to see what works by imitating others, not in a false or phony way, but rather through the coaching process. Someone may say, "Try this. It works for me." A newcomer may develop new patterns of behavior because the newcomer sees that there's a different way to act around other people. Although you will hear "fake it until you make it," there is nothing fake or phony about AA. The old saying simply means that if you imitate someone you admire, you can change your own presentation of yourself.

— In AA, it's okay to let your true feelings come out. Sometimes people laugh, or cry, or even express anger about what's gone on during the day or during a lifetime soaked with booze. Being able to sit with a sponsor and have a good laugh or cry is a therapeutic experience. It really can help.

If I go to an A.A. meeting, does that commit me to anything?

"No. A.A. does not keep membership files, or attendance records. You do not have to reveal anything about yourself. No one will bother you if you don’t want to come back."

This is absolutely true. Alcoholics Anonymous emphasizes a philosophy of attraction, not promotion. This is why you don't see advertisements or billboards or 800 numbers for AA. It's an organization based on helping others who want what AA offers.

What happens if I meet people I know?

"They will be there for the same reason you are there. They will not disclose your identity to outsiders. At A.A. you retain as much anonymity as you wish. That is one of the reasons we call ourselves Alcoholics Anonymous.
What happens at an A.A. meeting? An A.A. meeting may take one of several forms, but at any meeting you will find alcoholics talking about what drinking did to their lives and personalities, what actions they took to help themselves, and how they are living their lives today."

Most newcomers are surprised by how many good and decent people attend AA meetings. Sometimes they run into old drinking buddies who also have decided to sober up. After a month or two, most people will have new friends in AA, and this is a powerful source of support and companionship.

How can this help me with my drinking problem?

"We in A.A. know what it is like to be addicted to alcohol, and to be unable to keep promises made to others and ourselves that we will stop drinking. We are not professional therapists. Our only qualification for helping others to recover from alcoholism is that we have stopped drinking ourselves, but problem drinkers coming to us know that recovery is possible because they see people who have done it."

As I've already said, AA is not a "treatment program," and it is not "therapy." Most people who attend AA get professional help from a therapist, psychiatrist, or counselor on a private basis outside of AA. Membership in AA is about gaining support, understanding, and the plain old love that is the power of the fellowship. I have attended AA meetings since 1983, and the friends I have made there are beyond description. These are friends from all walks of life and all sorts of backgrounds.

Why do A.A.s keep on going to meetings after they are cured?

"We in A.A. believe there is no such thing as a cure for alcoholism. We can never return to normal drinking, and our ability to stay away from alcohol depends on maintaining our physical, mental, and spiritual health. This we can achieve by going to meetings regularly and putting into practice what we learn there. In addition, we find it helps us to stay sober if we help other alcoholics."

Being "cured" of any illness is a relative concept. For example, cancer patients describe themselves as "cancer survivors," and sometimes say that their disease is "in remission." What they mean is that the disease may come back, and they continue to take care of themselves in much the same way that recovering alcoholics take care of themselves."

On a personal note, I attend AA because I have many friends there, I want to help newcomers, and I get a lot out of the meetings. There are times when I am busy or I would rather sit out on the porch in a lawn chair, but I've never come out of an AA meeting regretting that I invested the time in my health a recovery. Not everyone feels this way about AA, of course. It takes awhile to get to know people and to get the rhythm and deeper benefits of the program. In that way, it's not much different from joining any other social organization like the Rotary Club, the Lions Club, or the Elks Lodge. At first you don't know many members, and gradually you are befriended and become part of the regular crowd.

When you find a meeting that feels right, plan to attend that meeting regularly. Having a "home group" is like having a regular group for your weekly bridge game or your weekly service group. You get to know the people. Just bouncing from group to group is certainly okay when starting out, but getting a comfortable home group that feels right is an important step in staying sober.

How do I join A.A.?

"You are an A.A. member if and when you say so. The only requirement for A.A. membership is a desire to stop drinking, and many of us were not very wholehearted about that when we first approached A.A."

How much does A.A. membership cost?

There are no dues or fees for A.A. membership. An A.A. group will usually have a collection during the meeting to cover expenses, such as rent, coffee, etc., and to this all members are free to contribute as much or as little as they wish.

Is A.A. a religious organization?

"No. Nor is it allied with any religious organization. There’s a lot of talk about God, though, isn’t there?"

"The majority of A.A. members believe that we have found the solution to our drinking problem not through individual willpower, but through a power greater than ourselves. However, everyone defines this power as he or she wishes. Many people call it God, others think it is the A.A. group, still others don’t believe in it at all. There is room in A.A. for people of all shades of belief and non-belief."

Can I bring my family to an A.A. meeting?

"Family members or close friends are welcome at “Open” A.A. meetings. Discuss this with your local contact."

What advice do you give new members?

In our experience, the people who recover in A.A. are those who:
(a) stay away from the first drink;
(b) attend A.A. meetings regularly;
(c) seek out the people in A.A. who have successfully stayed sober for some time;
(d) try to put into practice the A.A. program of recovery;
(e) obtain and study the Big Book, Alcoholics Anonymous.

How can I contact A.A.?

"Look for Alcoholics Anonymous in your local telephone directory. These telephones are answered by A.A. volunteers who will be happy to answer your questions, or put you in touch with those who can. If there is no A.A. telephone service close to you, write or phone the A.A. General Service Office."

There are several websites that are specific for North Texas. For example, the Preston Group has its own website. A directory for the hundreds of AA meetings in the area can be found here at http://aadallas.org.

Science on Will and Willpower - Part I

The fellowship of Alcoholics Anonymous is one of the few places where we will hear discussion of will, willpower, and willingness. Most recovering individuals have never heard of one of the finest philosophers of the 20th Century: Professor Harry Frankfurt of Princeton University. His focus on human will is brilliant, but often overlooked. His analytical philosophy is described in a collection of essays titled The Importance of What We Care About. Early in his career he referred to the study of human will as "the most neglected area in modern philosophy," and he asserted that human will is the characteristic that makes us uniquely human.

We are the only sentient creatures having the capacity to know our own will and assert our will. Frankfurt also observes, in his elegant essays, that human beings are uniquely capable of knowing that there are times when "the will that I have is not the will that I want to have." For example, someone may want to learn to play the piano, but they may say, "I can't find the will to practice." They want to have the will to practice, but somehow it's not there, or it's subordinated to a different expression of will. The same is often true of addicts and alcoholics. Wanting to stay sober, the alcoholic/addict yearns for "the will to stay sober," but often the search for the will comes up empty. Alcoholics Anonymous teaches that alcoholics cannot will themselves to quit drinking—indeed, that self-will and self-centeredness are likely a root cause of the drinking. Yet recovering addicts must be willing. That is, they must be open to the possibility that the group and its principles are powerful enough to trump a compulsive disease.

For decades Frankfurt's scholarship failed to receive the attention it deserved, and then neuroscience became an unexpected ally in the philosophical inquiry. At the University of Illinois, for example, Dr. Ibrahim Senay has studied the concepts of will and willingness from the perspective of clinical psychology. Senay figured out an intriguing way to explore possible connections among will, willingness, intention, motivation and goal-directed actions. In short, he identified some key traits needed to achieve any personal objective, from losing weight to learning to play play piano.

Senay did this by exploring self-talk. Self-talk is just what it sounds like—that voice in your head that articulates what you are thinking, spelling out your options and intentions and hopes and fears, and so forth. It is the ongoing conversation you have with yourself. Senay thought that the form and texture of self-talk—right down to the sentence structure—might be important in shaping plans and actions. What’s more, self-talk might be a tool for exerting the will—or experiencing willingness.

Senay's study involved two groups. One of the groups was told that they might be working on a task (solving a puzzle), and the other group was told that they actually would be working on a task. The first group was instructed to think about whether they would, or would not, be asked to work the puzzles. The second group was told that in a few minutes they would definitely be doing the puzzles. In this clever way, Senay created one group contemplating the question, "Will I be doing this?", and another group thinking, "I will be doing this," declaring their objective to themselves.

As it turned out, people with wondering minds (contemplating what might possibly happen) completed significantly more puzzles than did those with willful minds (thinking what they definitely were about to do). In other words, the people who kept their minds open were more goal-directed and more motivated than those who declared their objective to themselves.

The point is that questions, by their nature, speak to possibility and freedom of choice. Meditating on them might enhance feelings of autonomy and intrinsic motivation, creating a mind-set that promotes success. There is a scientifically verifiable difference between asking, and contemplating, the question "Will I?" versus narrowing the focus to a willful, determined statement, "I will."

What’s more, when the volunteers were questioned about why they felt they would be newly motivated to get to the gym more often, those primed with the question said things like: “Because I want to take more responsibility for my own health.” Those primed with “I will” offered strikingly different explanations, such as: “Because I would feel guilty or ashamed of myself if I did not.”

According to Wray Herbert, who summarized the research in Scientific American magazine, "This last finding is crucial. It indicates that those with questioning minds were more intrinsically motivated to change. They were looking for a positive inspiration from within, rather than attempting to hold themselves to a rigid standard." And there was more: "Those asserting will lacked this internal inspiration, which explains in part their weak commitment to future change. Put in terms of addiction recovery and self-improvement in general, those who were asserting their willpower were in effect closing their minds and narrowing their view of their future. Those who were questioning and wondering were open-minded—and therefore willing to see new possibilities for the days ahead."

In terms of Professor Frankfurt's metaphysical philosophy, the individual who thinks about his will and asks, "Will I?" opens the door to possibility and freedom of choice. The key to satisfaction, Frankfurt says, is "taking ourselves seriously, and getting it right."

In terms of Alcoholics Anonymous, the person who seeks to exercise willpower and "an iron will with grim determination" is much less likely to succeed. The person who struggles with AA is the person who says, "I know what I need to do, and now I just need to do it." The more successful person asks, "If I knew what I need to do, I probably would have done it by now, so I wonder what I will do?"

Do 12-Step Programs Work?

Do mutual help organizations like Alcoholics Anonymous really work? Last year, The Carlat Report on Addiction Treatment reviewed the research on AA and reported positive findings. I've summarized that report and included the references here. AA and other 12 Step programs provide many of the elements found in formal treatment. More importantly, the recovering fellowship creates a framework for support over the long term, helping individuals stay sober longer, have fewer drinking days, and have shorter periods of relapse. Twelve Step Facilitation (TSF) has been found as effective as cognitive behavioral therapy in addressing alcohol-related issues.

Since the 1930's when Bill W. and Dr. Bob started Alcoholics Anonymous (AA) the fellowship has grown to over two million members. Meeting in rented rooms, school halls, hospitals, and the storied church basement, AA and similar 12-step organizations (eg, Narcotics Anonymous [NA]) remain the most commonly sought sources of help for substance-related problems in the United States (Substance Abuse and Mental Health Services Administration. Results from the 2007 National Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies; 2008).

Research has shown that attending AA, either alone or during and following professional treatment, enhances outcomes. One naturalistic study, for example, followed 466 previously untreated individuals with problem drinking for eight years. Participants self-selected into one of four groups: no treatment, AA alone, formal treatment alone, and formal treatment plus AA. Those who received some sort of help—AA, formal treatment, or both—had higher rates of abstinence at all time points. At eight years, 26% of patients in the no treatment group were abstinent from alcohol compared to 49% who received AA alone, 46% who received formal treatment alone, and 58% who received the combination of treatment plus AA (Timko C et al, J Stud Alcohol 2000;61(4):529–540).

A systematic Cochrane review of the best scientific studies on AA and TSF found that they were as effective as any of the interventions to which they were compared for some factors, such as retention in treatment, but found that no studies unequivocally proved AA and TSF were superior to other treatments (Ferri M et al, Cochrane Database Syst Rev 2006;(3):CD005032).

Other studies have found a linear dose-response relationship between AA attendance and favorable drinking outcomes (Kaskutas LA, J Addict Dis 2009;28(2):145–157). Attending one meeting per week, on average, appears to be the minimum threshold to realize benefit and increasing meeting frequency is associated with progressively greater rates of abstinence. In addition, research has shown that women engage with AA as much as men, become more involved with the 12 Steps, and derive similar benefit. In 1990, the Institute of Medicine called for more research on how AA works. Since then, research has revealed that AA aids recovery through multiple mechanisms, many of which are also activated by professional behavioral treatments (Kelly J et al, Addict Res Theory 2009:17(3):236–259).

Most consistently and strongly, AA appears to work by helping people make positive changes in their social networks (eg, by dropping heavy drinkers/drug users and increasing abstainers/low risk drinkers), and by enhancing coping skills and self-efficacy for abstinence when encountering high-risk social situations (see for example, Kelly JF et al, Drug Alcohol Depend 2011;114(2–3):119–126).

Among more severely addicted people, AA also appears to work by enhancing spiritual practices, reducing depression, and increasing individuals’ confidence in their ability to cope with negative emotion (Kelly JF et al, Addiction 2012;107(2)289–299). Thus, AA appears to work through diverse mechanisms and may work differently for different people. Stated another way: individuals may use AA differently, depending on their unique needs and challenges.

Research has shown that involvement in 12-step work can reduce the need for more costly treatments while simultaneously improving outcomes. A large multicenter study of over 1,700 patients found those treated in professional 12-step treatment went on to participate in community-based AA and NA meetings at a higher rate than those from professional cognitive behavioral therapy (CBT) programs, who relied more heavily on professional services. This translated into a two-year savings of over $8,000 per patient among 12-step treated patients, without compromising outcomes. In fact, those treated in the 12-step treatment programs had one-third higher rates of abstinence across follow-up (Humphreys K & Moos R, Clin Exp Res 2001;25(5):711–716; Humphreys & Moos, Alcohol Clin Exp Res 2007;31(1):64–68).

Project MATCH was a large randomized trial comparing three individually-delivered psychosocial treatments for alcohol use disorder—TSF, CBT, and Motivational Enhancement Therapy (MET)—that was funded by NIAAA. It included 1,726 patients from nine clinical sites across the US (Project Match Research Group, J Stud Alcohol 1997;58(1):7–29). TSF was found to be as effective as the more empirically supported CBT and MET interventions at reducing the quantity and frequency of alcohol use post-treatment and at one- and three-year follow-ups. Moreover, TSF was superior to CBT and MET at increasing rates of continuous abstinence, such that 24 percent of the outpatients in the TSF condition were continuously abstinent at one year after treatment, compared with 15 percent and 14 percent in CBT and MET, respectively (Tonigan JS et al,Participation and involvement in Alcoholics Anonymous. In: Babor TF & Del Boca FK, eds. Treatment Matching in Alcoholism. New York: Cambridge University Press;2003:184–204).

Abstinence rates at three years continued to favor TSF, with 36 percet reporting complete abstinence, compared with 24 percent in CBT, and 27 percent in MET (Cooney N et al. Clinical and scientific implications of Project MATCH. In: Babor TF & Del Boca FK, eds. Treatment Matching in Alcoholism. New York: Cambridge University Press; 2003:222–237).

In light of findings from several such RCTs that demonstrated the efficacy of TSF, this therapy was added to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Practices and Programs (NREPP) in 2008.

The overwhelming majority of research has been conducted on AA. More research is needed on other MHOs, such as SMART Recovery, LifeRing, Celebrate Recovery, Women for Sobriety, Moderation Management, and others, so that more objective evidence is gathered on secular, religious, and non-abstinence-based AA alternatives (see the article "Alternatives to 12-Step Recovery" for more on these groups).