THE TWELVE STEPS OF ALCOHOLICS ANONYMOUS

AA's program for remaining sober is called the Twelve Steps. They are:

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admit it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

The steps are based on suggestions gleaned from the collective experiences of members about how they achieved sobriety—and then maintained it. In this sense, AA is a collectivity of mutual help groups more than it is discrete individuals engaging in self-help. At meetings both open to the public and "closed" (for members only), the Twelve Steps are closely examined, and members frankly tell their own versions of their drinking histories—their AA "stories"—and describe how the AA program helped them to achieve sobriety.

Membership in AA depends on an individual's declaration of intention to stop drinking. An AA group comes into being when two or more "drunks" join together to practice the AA program. "Loners" are relatively few, but some exist. There are no dues or fees for membership; AA is self-supporting and is not associated with any sect, denomination, political group, or other organization. It neither endorses nor opposes any causes. These points, and other basic descriptions of AA, appear on the first page of AA's monthly magazine, The Grapevine. Although AA is not set up as a centralized organization, a commonly shared set of traditions guides their meetings and treatment strategies. For example, one of the Twelve Traditions sets forth AA's singleness of purpose—to help alcoholics achieve and sustain sobriety; another tradition underscores the necessity for the anonymity of members, as a way to avoid personality inflation and to promote humility. Over time, the Twelve Traditions have come to be as vital a part of AA as the Twelve Steps. They are:

1. Our common welfare should come first; personal recovery depends upon A.A. unity.
2. For our group purpose there is but one ultimate authority… a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants…. They do not govern.
3. The only requirement for A.A. membership is a desire to stop drinking.
4. Each group should be autonomous except in matters affecting other groups or A.A. as a whole.
5. Each group has but one primary purpose… to carry its message to the alcoholic who still suffers.
6. An A.A. group ought never endorse, finance, or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property and prestige divert us from our primary purpose.
7. Every A.A. group ought to be fully self-supporting, declining outside contributions.
8. Alcoholics Anonymous should remain forever nonprofessional, but our service centers may employ special workers.
9. A.A., as such, ought never be organized; but we may create service boards or committees directly responsible to those they serve.
10. Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy.
11. Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, and films.
12. Anonymity is the spiritual foundation of all traditions ever reminding us to place principles before personalities.

Written in 1939, Alcoholics Anonymous (Alcoholics Anonymous World Services, 1939, 1955, 1976) is the basic text that outlines the experiences of the first 100 members in staying sober. It is fondly referred to as "The Big Book."

ORIGINS

The unlikely coming together of the two cofounders of AA, "Bill W." and "Dr. Bob" (William Griffith Wilson, a stockbroker, and Robert Holbrook Smith, a surgeon)—both pronounced alcoholics—is probably the most concrete event in AA's origins. Anonymity was basic, but there were other factors, among them Bill W.'s experiences prior to contact with Dr. Bob. Had it not been for the readiness these experiences generated in Bill W. to interact in a unique way with Dr. Bob, their initial meeting might have turned out to be the fifteen-minute encounter the doctor had initially planned.

First, Bill W. had reached a point of profound hopelessness. Second, he had had a chance encounter with an old drinking friend—Ebby T.—who despite strong and similar feelings of hopelessness had achieved considerable sobriety. Third, Ebby T. attributed this accomplishment to the Oxford Group, a nondenominational movement with no membership lists, rules, or hierarchy. It embraced specific ideas that would soon find their way into AA practice: For example, members alone were powerless to solve their own problems; they must carefully examine their behavior and try to make restitution to others they had damaged; and they practiced helping others, resisting personal prestige in the process.

Next, a severe relapse had forced Bill W. into a hospital, where he had visits from Ebby T. and where Bill W. longed for the sobriety Ebby seemed to have. Following a cry of lonely desperation and agony, he reports that "the result was instant, electric, beyond description. The place lit up, blinding white… came the tremendous thought. 'You are a free man"' (W.W., 1949, p. 372). As a result of these accumulated experiences, Bill W. decided on two strategies. One was to take his story to other alcoholics and the other was to become an evangelist, because of his spiritual experience. Even though he brought many alcoholics home with him and preached at them, he utterly failed and almost returned to drinking himself. But his account underscores how he came to realize that "to talk with another alcoholic, even though I failed with him, was better than to do nothing" (W.W., 1949, p. 374).

Two other experiences accumulated. He discovered that some medical authorities considered alcoholism a disease. Almost instantly, he replaced evangelism with science. Finally, in an effort to recoup some financial losses, he pursued a slim business opportunity in Akron, Ohio, on May 11 and 12, 1935. An Episcopalian minister there put him in contact with an Oxford Group member who, in turn, arranged for a meeting the next day with Dr. Bob. Abandoning his evangelical approach, he used his newly found scientific/disease approach with the doctor. An immediate rapport developed between the two men, and they talked until late into the night. Dr. Bob was, in effect, Bill W.'s first follower (Trice & Staudenmeier, 1989). Dr. Bob had only one "slip" during the next month, but soon thereafter the two began working together on other alcoholics, using the sickness/scientific approach. By August 1936, AA meetings, within an Oxford Group context, were being held both in Akron and New York City. Soon, however, both Bill W. and Dr. Bob decided to sever their relationship with the Oxford Groups, and the small AA groups were on their own. By 1940, their newly formed board of trustees listed twenty-two cities in which groups were well established and holding weekly meetings. Soon thereafter, The Saturday Evening Post, a popular magazine with a wide circulation, published an article simply entitled" Alcoholics Anonymous." It proved to be a compelling media event for the AA program, and a flood of positive responses and new groups resulted. Ever since then, AA growth has steadily expanded.

Two coordinating groups have acted to link together the thousands of AA local groups in the United States and abroad. In AA's first year the founders, along with members of the first New York City group, formed a tax-free charitable trust with a board of trustees composed of both alcoholic and nonalcoholic members. It acted as a mechanism for the collection and management of voluntary contributions and as a general repository of the collective experience of all AA groups.

Today the board of trustees consists of fourteen alcoholic and seven nonalcoholic members who meet quarterly. At an annual conference, specific regions elect the alcoholic board members for four-year terms. The board appoints the nonalcoholic members for a maximum of three terms of three years each. An annual conference was established in 1955 at AA's Twentieth Anniversary Convention. It expresses to the trustees the opinions and experiences of AA groups throughout the movement. A General Service office (GSO) in New York City interprets and implements the deliberations of these two groups on a daily basis.

THE PROCESS OF AFFILIATION

Affiliation is a process, not a single, unitary happening within AA. Its elements and phases act to select and make ready certain alcoholics and problem drinkers for affiliation, leaving behind others with less readiness. The process begins before the problem drinker ever goes to a meeting (Trice, 1957). If the person has heard favorable hearsay about AA; if long-time drinking friendships have faded; if no will-power models of self-quitting have existed in the immediate background; and if the drinker has formed a habit of often sharing troubles with others—the stage is set for affiliation. It is further enhanced if, upon first attending meetings, the person has had experiences leading to the decision that the troubles associated with drinking far outweigh the pleasures of drinking (i.e., "hitting bottom"). Typically, this means that affiliates, contrasted with nonaffiliates, had a longer and more severe history of alcoholism—and those with more severe alcohol problems are more likely to make consistent efforts to affiliate than are those with less severe problems (Trice & Wahl, 1958; Emerick, 1989b).

Five other specific phases follow from those forces that make for commitment to the AA program: (1) first-stepping, (2) making a commitment, (3) accepting one's problem, (4) telling one's story, and (5) doing twelfth-step work (Rudy, 1986). First-stepping involves the initial contact with AA; it often entails orientation meetings that dwell on the group's notions of alcoholism as a disease and on step one in the twelve-step program: "We admitted we were powerless over alcohol… that our lives had become unmanageable." The newcomers also will probably become associated with an AA guide, who may soon become the newcomer's sponsor. Quick action by the AA group—closeness of initial contact—to include the newcomer increases the likelihood of affiliation (Sonnenstuhl & Trice, 1987). This expresses itself in pressing any obviously interested newcomer into a challenge of "ninety meetings in ninety days." In effect, the receiving group seeks to keep a close watch over the newcomer, gently forcing the person to forego other commitments and increase commitments to the AA program.

Decisive third and fourth phases are the acceptance of telling one's drinking story, with the beginning phrase, "I'm Chris X and I'm an alcoholic." Throughout the initial weeks and months, newcomers are gently and sometimes bluntly pressed to realize that they are alcoholics. They are encouraged to "go public" and tell their stories before the entire group at an open meeting. In numerous instances, newcomers may already have decided that they are alcoholic. In other cases, it may be a lengthy process of self-examination before this identity transformation occurs. In still others, it may never transpire, making them suspect as real AAs. In any event, the public telling of one's story is an act of commitment that symbolizes a conversion of self into a genuine AA member. Members counsel newcomers on the appropriate first time to tell their stories, and their narrations are cause for many congratulations. Much applause typically attends this open act of commitment.

A final phase involves the literal execution of the program's twelfth step: "Having had a spiritual awakening as a result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs." In essence, doing twelfth-step work exemplifies one of AA's basic philosophies, namely, one is never recovered from the disease; one is only "recovering." As a consequence, a member can maintain sobriety only by remaining active in AA and by steadily engaging in carrying the program to those who are still active alcoholics. In short, by doing twelfth-step work, members reinforce their membership and the new definition of self.

Throughout this affiliation process, another dynamic is also at work—"slipping, "—a relapse into drinking by a recovering AA member. After reviewing six relevant studies, plus a summary of his own fieldwork with AA, Rudy (1980, p. 728) reported that among both newly committed and longer-term members "slipping is a common occurrence, but it is possible that it serves a function in A.A…. [It is] a deviant behavior and the function of this deviance is boundary maintenance." The response of most AA members to another's slipping is sympathy and understanding, sentiments that in turn enhance group solidarity. In essence, "their abstinence is dependent on interaction with those who slip" (Rudy, 1980, p. 731).

WHO AFFILIATES?

What are the characteristics of those who do undergo the affiliation processes, contrasted with those who do not, even though exposed to the possibility? Demographic variables such as age, social class, race, employment status, and parental socio-economic status have been consistently found to be unrelated to membership (Trice & Roman, 1970; Emerick, 1989). These findings provide considerable certainty about the existence of often-alleged demographic barriers to AA affiliation—they, in effect, fail to deter affiliation.

Less certainty can be attributed to significant psychological characteristics that have been found to encourage affiliation. As in evaluations of psychotherapies in general (Eysenck, 1952; Rachman & Wilson, 1980), researchers cannot predict with any certainty who will affiliate. Despite this, certain personality features have been systematically found to distinguish between affiliates and nonaffiliates (Ogborne & Glaser, 1981; Ogborne, 1989).

Several studies have suggested that, among other things, A.A. members can be distinguished from other heavy drinkers with respect to personality and perceptual characteristics…. The authors suggest that A.A. affiliation is associated with authoritarianism and conformist tendencies, high affiliation needs, proneness to guilt, religiosity, external control and field dependency [Ogborne, 1989, p. 59].

Ogborne (1989) also reports on two additional studies that support the belief that AA attracts individuals with certain emotional makeups. Ogborne's overall findings were that alcohol-troubled persons who expressed group adherence, extroversion, submissiveness, and conservatism were attracted to AA and its program. Overall, these findings appear to be consistent with the role demands made on members. For example, the sociability and affiliativeness themes found among those who do affiliate, as compared to nonaffiliates, seem to match the heavy group interactions expected of members.

All things considered, affiliation with AA is a distinctively selective process that fits only a distinct minority of those in the alcohol-abusing population. Although the exact proportion of the population helped by AA is unknown, even AA's critics recognize that it is substantial. Other specific types of therapies may do proportionally somewhat better or worse, but a reasonable estimate would be that AA is associated with fairly typical improvement rates.

Current studies strongly suggest that AA appeals to a highly specific and select segment and, by doing so, further suggest that other therapies are also selective as to their appeal. These points underscore the need for service providers to be aware of the diverse makeup of the problem-drinking population. Assessment and services need to be far more individualized than they have been, so that assignments may be made to the most appropriate organizations, institutions, or therapies.

THERAPEUTIC MECHANISMS

As with psychotherapies in general, the effectiveness of AA has not been convincingly established. For example, some problem drinkers drop out after the first two or three AA meetings. Nevertheless, for those who remain, AA has unique and distinctive features that contribute to its therapeutic effectiveness.

By definition, as problem drinkers move into addiction, alcohol comes to be central to their lives. How can this centrality be reduced and a new conception of alcohol be put in its place? AA experiences provide a new orientation, not only to alcohol, but to self and to others. "One of A.A.'s great strengths lies in the quality of its social environment: the empathetic understanding, the acceptance and concern which alcoholics experience there which, along with other qualities, make it easier to internalize new ways of feeling, thinking, and doing" (Maxwell, 1982). Even brief exposure to AA introduces the alcoholic to the idea that self-regulation seems to be rarely achieved alone by self-reliance and willpower. Its basic premise describes the compelling sense of ego powerlessness—but immediately offers the potent substitute of a viable community that provides individual attention, an explanation of alcoholism, and simple prescriptions for sobriety. "In a community that shares the same distresses and losses, accepts its members' vulnerabilities and applauds and rewards successes, A.A. provides a stabilizing, sustaining, and ultimately, transforming group experience" (Khantzian & Mack, 1989, 76).

Within the AA community, there are group-based specific therapeutic strategies unlikely to exist in professionally directed psychotherapy. Examples include (1) empirically based hope; (2) direct attack on denials; (3) practical guidelines for achieving sobriety; and (4) one-to-one sponsorship. When problem drinkers first attend meetings they are immediately aware of others who have confronted their very problem, and they hear these people speak about dramatic improvements in their lives via the AA program. Moreover, the AA program consistently reminds them that denial of the realities surrounding their drinking is a major barrier to any change. Telling one's story, either publicly or in closed sessions, helps to dissolve the entrenched denial systems that ward off therapeutic changes.

The Twelve Steps are structured phases that provide an organized approach to the confusions and frustrations of an individual's attempt to cope with alcohol problems. This is especially so when members reach the developmental stage where twelfth-step work is indicated. They dramatically see themselves as they once had been, and this reinforces their need to "work the program." In addition, simple, practical guidelines are repeated as group-tested ways to avoid using alcohol as an adjustment technique: "First things first," "one day at a time," "easy does it," and practical advice about how to work the program.

AA typically arranges for the informal sponsorship of newcomers—who often identify with and closely relate to their sponsors. Sponsors are recovering alcoholics typically available at all hours of the day and night for phone or in-person discussions and crises. These valuable treatment strategies are voluntary and free of any monetary cost or financial obligation. Drinkers who drop out or who reject active membership in AA may nevertheless be substantially helped by primary or secondary exposure to AA and its unique but widely publicized or modified therapeutic mechanisms. (Several organizations in the alcohol or drug recovery field have been working along similar but modified lines.) It is impossible to estimate the numbers of those helped by such exposure, but they are surely numerous and should not be discounted.

CRITICAL EVALUATIONS

Probably the most widespread and long-standing critical assessment of AA centers around the question of the selective nature of membership. Thus, critic Stanton Peele (1989, 57) bluntly insists: "In fact, research has not found A.A. to be an effective treatment for general populations of alcoholics." Again, however, neither has any given professional psychotherapeutic method been found to be effective for general populations of the psychoneurotic. In 1981, Ogborne and Glaser predicted that evidence will soon be found for the effectiveness of AA, but "it will be limited to a particular, identifiable subgroup of persons with alcohol problems." This concern had been expressed since the 1950s (Trice & Staudenmeier 1989), and more evidence of AA's selective nature came from Walsh et al. (1991).

Walsh and her colleagues randomized 227 employed problem drinkers into compulsory inpatient treatment, compulsory attendance at AA, and a choice of options. During a two-year follow up, the researchers used measures of performance with drinking and drug use to gauge effectiveness. They concluded that the hospital group fared best and that the group assigned to AA fared least well. Many of those randomly assigned to AA probably lacked the readiness and the emotional makeup that appear to be required for affiliation. Matching patients to specific treatments has been advocated for many years (Ogborne & Glaser 1981; Pattison 1982), and the Walsh study certainly indicates the importance of matching in the case of AA.

Emerick (1989) has broadened the array of criticisms of AA to include (1) that AA has denounced in the media scientific discoveries that contradict its "formal ideology" and dogma: (2) AA has brought pressures to bear in an effort to suppress various psychological findings. Emerick quickly acknowledges, however, that "it is these very characteristics… that provide for AA's strength and effectively preserve its boundaries and identity" (p. 5). This criticism boils down to charges that AA is anti-intellectual and antiprofessional. Second, harmful effects may come to those who "do not fit comfortably in the organization" (p. 9). These harmful effects include beliefs that "slipping" inevitably leads to loss of control, making for more problems than otherwise. Some members may despair and lose hope when they discover they do not mesh with AA's norms and beliefs. Third, there is a risk of becoming "AA addicts" who spend so much time and energy on the AA program that they neglect other areas of life such as family and job. Fourth, AA groups may contain alcohol-troubled persons who also suffer from other psychiatric disorders—i.e., schizophrenia and anxiety disorders—that should be directly treated, but are covered up by AA ideologies. Finally, AA members may develop dual overlapping relationships inside AA that are ultimately harmful, i.e., a newcomer becomes the lover of an established member, or a sponsor enters into an unfortunate business partnership with a sponsoree.

Other negative judgments of AA that have been voiced at one time or another are that it is tilted toward being a religion by too much emphasis on a "higher power"; local groups are not nearly as accepting of drunks as advertised; it suffers from too much adulation and consequently often becomes a "dumping ground" at which companies and courts require compulsory attendance; and it insists that members come to accept the label of "alcoholic"—a label that continues to be highly stigmatic outside AA and tends to repel many of those who are inclined to affiliate.

Understandably, these criticisms have fueled alternative groups that claim to help members cope with alcohol problems but without many of the beliefs and rituals of AA. Apparently, many of the members of these groups are AA dropouts. Beyond this observation, no systematic research efforts have been mounted to determine how affiliation is achieved, and with what kinds of problem drinkers these alternatives to AA are effective. For example, RATIONAL RECOVERY (RR), SECULAR ORGANIZA-TION FOR SOBRIETY (SOS), and WOMEN FOR SOBRI-ETY (WFS) have all claimed to be alternative self-help groups for alcoholics. They tend to reject the notion that alcoholism is a disease and advocate instead personal responsibility. Also, they underscore individual willpower rather than AA's belief in a higher power (Gelman, Leonard, & Fisher, 1991). Regarding the charge that AA is overly religious, numerous close observers, including the present writer, have concluded that religion plays a minor role in the practical day-to-day effort of AAs to "work the program."

ADAPTATION OF AA TO OTHER DISORDERS

Despite the criticisms that have been directed against AA, its format and beliefs have nevertheless been applied to a wide variety of other addictions and behavior disorders. For example, NARCOTICS ANONYMOUS (NA) (estimated in 1979 to have about 700 groups in practically every U.S. state and in several other countries) first applied the AA pattern to drug addicts at the U.S. PUBLIC HEALTH SERVICE HOSPITAL at Lexington, Kentucky, in 1947. In 1948, and in 1953, groups of AA members who were also drug addicts formed an independent NA group in New York City and in Sun Valley, California. The resemblance to AA was made even more remarkable by the fact that the magazine that had made AA well-known (The Saturday Evening Post) also gave NA a national audience through a lengthy piece that played up similarities with AA (Ellison, 1954).

Similarly, AA's beliefs and strategies have been adapted to help people with a broad spectrum of other problems, including excessive buying, sexual excesses or deviations, gambling, child abuse, overdependence on others, eating disorders, and excessive shame and guilt. In addition, AL-ANON family groups and ALATEEN groups have adapted AA's philosophy to family, children, and friends of problem drinkers. Many others could be cited. Veteran AA members point to this great proliferation as evidence that AA's influence goes well beyond its impact on AA members. They argue that this widespread adaptation to other disorders demonstrates the essential value and appeal of the AA program.

(SEE ALSO: Alcoholism; Gambling as an Addiction; Treatment)

HARRISON M. TRICE