In P. E. Nathan et al. (Eds.), Annual Review of Addictions Research and Treatment (Vol. 1, pp. 387-388), New York: Pergamon, 1991.
Commentary on "The Lay Treatment Community"
Morristown, New Jersey
Margaret Bean-Bayog's article, "The Lay Treatment Community," is a largely benign apologia for Alcoholics Anonymous (AA). It combines in roughly equal measures open-minded ruminations on research revealing substantial spontaneous remission from alcoholism, research on the effectiveness of AA and psychoanalytic and spiritual analyses of why, in Bean-Bayog's view, AA succeeds so well.
The various components of Bean-Bayog's analysis do not fit well together. For example, research does not clearly indicate that AA is effective. The best evaluation of AA's effectiveness among the papers included in the Review (McLatchie & Lomp, 1988) finds that those who attend AA most regularly and those with the least involvement in AA have the best outcomes following alcoholism treatment. These results agree with 5-year follow-up of abstinent alcoholics George Vaillant (1983) described in The Natural History of Alcoholism (see also Peele, 1989, p. 195). In these analyses, alcoholics whose attendance at AA was sporadic or short-term clearly had the worst outcomes.
These data suggest that compelling patients with little sympathy or aptitude for AA to attend this kind of group has substantial potential for damage. Furthermore, those who do not respond to the AA approach seem to comprise by far the largest percentage of alcoholics. Brandsma, Maultsby, and Welsh (1980) found that almost 7 in 10 alcoholics assigned to AA dropped out before 10 meetings. Moreover, reviews like McLatchie and Lomp's examine only treated alcoholics. Untreated populations, such as those examined by Tuchfeld (1981) and Sobell, Sobell, and Toneatto (in press), seem to be even more averse to AA.
The best that can be said of AA is that it succeeds for a small group of true believers who commit themselves sufficiently to the AA process to undergo a personality transformation. This process is best regarded from the sociological perspective of the conversion experience and has been well described by Trice and Roman (1970) and Rudy (1986). AA remains a religiously rooted folk movement that closely resembles the l9th-century American Protestant revivalism from which it sprang. As such, AA's success is not one of clinical outcomes but of public relations and cultural appeal for contemporary Americans. This appeal is most apparent amongin addition to the small minority of alcoholics who attend AAnonalcoholics who have never actually been involved with AA.
AA, like all such religious and conversion-based movements, primarily relies on personal testimony for the evidence of its success. As Rudy (1986) noted in his anthropological work, Becoming Alcoholic, the crucial "rite of passage" in the AA-inspired transformation is the first time members tell their story for the group, beginning by acknowledging, "I am an alcoholic." Rudy described how the alcoholic's highly formalized tale "is made up of two parts: a story about how bad it was before A.A. and a story about how good it is now" (p. 38). This presentation is acclaimed by the rest of the group, and the person is then accepted as an initiate. The problems with testimony of this sort as evidence are as follows:
- As members become committed to the infallibility of the AA process, they become less willing to admit its failures and more prone to exaggerate how their lives have improved as a result of group membership.
- Personal testimony by group members and supporters systematically shortchanges the experiences of (a) those who fail at AA and (b) those who succeed without AA.
Bean-Bayog deals uneasily with the evidence she reviews that AA may not be particularly successful and that substantial numbers of people succeed without AA. Her analysis is limited by her sympathy for the AA process, for which she provides a psychoanalytic justification that closely parallels AA's own spiritual self-description. She is frankly puzzled that so many people can overcome alcoholism without relying on AA. Referring to Tuchfeld's (1981) examination of what he has referred to as the "silent majority" of recovered alcoholics who do not enroll in AA or treatment, Bean-Bayog notes, "Instead of humility, powerlessness, and dependence on a higher power with admission of alcoholism, and focus on abstinence, he found resistance to labeling and rebelliousness or willpower."
Bean-Bayog is intrigued by the natural remission process. However, she seems primarily motivated to learn the lesson of those who recover naturally as a way of enhancing compliance with AA. Her statement, "We may need to examine more complex trajectories of inner transformation such as specification of the exact nature of the resistance to AA use and the evaluations of techniques to overcome it" has a sinister air. It bespeaks the unacknowledged manipulativeness of an observer incapable of an objective respect for how people may choose different paths to recovery, because her sympathy toward AA blinds its author to her own bias.
Indeed, Bean-Bayog's stance points up one strange paradox about groups such as AA. The preassigned title for her review is "The Lay Treatment Community." However, many who sympathize with AA refer to it and similarly organized groups as the self-help movement. But most of these supporters, along with most AA members, are deeply suspicious of those who quit or reduce drinking on their ownin other words, those who in the strict sense help themselves. Typically, AA members and boosters predict dire consequences (often couched in terms of the "dry drunk") for those who sober up without AA.
As a cultural mechanism for reducing alcohol problems, AA has achieved a very overrated status. It is hard to imagine a symptomatic alcoholic who has by now not been exposed in some way to AA, its philosophy, and its adherents given the ubiquitous accolades for AA that appear on the American media and the court-mandated AA attendance for DWI and other crimes that has become a norm during the 1980s (Weisner & Room, 1984). The number of American alcoholics that can be converted to AA would seem to have achieved an equilibrium despite Bean-Bayog's hopes to expand this number by converting those who resist AA and resolve their drinking problems on their own.
Brandsma, J. M., Maultsby, M. C., Jr., & Welsh, R. J. (1980). Outpatient treatment of alcoholism: A review and comparative study. Baltimore: University Park Press.
McLatchie, B. H., & Lomp, K. G. E. (1988). Alcoholics Anonymous affiliation and treatment outcome among a sample of problem drinkers. American Journal of Drug & Alcohol Abuse, 14, 309-324.
Peele, S. (1989). Diseasing of America: Addiction treatment out of control. Lexington, MA: Lexington Books.
Rudy, D. (1986). Becoming alcoholic: Alcoholics Anonymous and the reality of alcoholism. Carbondale IL: Southern Illinois University Press.
Sobell, L. C., Sobell, M. B., & Toneatto, T. (in press). Recovery from alcohol problems without treatment. In N. Heather, W. R. Miller, & J. Creeley (Eds.), Self-control and addictive behaviors. Elmsford, NY: Pergamon Press.
Trice, H. M., & Roman, P. M. (1970). Delabeling, relabeling, and Alcoholics Anonymous. Social Problems, 17, 538-546.
Tuchfeld, B. S. (1981). Spontaneous remission in alcoholics: Empirical observations and theoretical implications. Journal of Studies on Alcohol, 42, 626-641.
Vaillant, C. E. (1983). The natural history of alcoholism. Cambridge, MA: Harvard University Press.
Weisner, C., & Room, R. (1984). Financing and ideology in alcohol treatment. Social Problems, 32, 167-184.