NEW SOCIETY, 28 May, 1964

The Puzzle of A.A. Alcoholics Anonymous continues to grow and to puzzle psychiatrists by breaking all the rules of psychotherapy yet producing some outstanding successes Griffith Edwards Research Psychiatrist

Hospitals have their failures, but the outlook for this particular man seemed so entirely hopeless that before he was discharged his case was presented at a case conference for psychiatric social workers as a illustration of the fact that their are alcoholics who simply cannot be helped. Psychotherapy had been tried but it had failed because he could not form any useful relationship with the therapist – he put on a front of polite unconcern. He was given antabuse, a drug which makes a man nauseated if he drinks after taking the tablet and which is often a useful aid in the early days of sobriety – this man simply palmed the tablets and slipped out to the pub. A young PSW student became very involved in this case and spent hours talking with the wife and still more hours trying to get the family rehoused and the man working again – the patient was politely grateful but viewed his own problems as distantly as he would have those of the man in the moon. In his early 30s, this man seemed to be heading for the bombed sites and the surgical spirit drinking schools. He did not turn up again until five years later, when he dropped in at the hospital just to tell us how he was getting on. He had by now been in several other hospitals and he had also been in prison. For the last year, however, he had been completely sober, and he had bought himself some very smart clothes as an outward sign of inner change. He was, he claimed, also happy and contented, holding down a job, and planning to take his family on the first holiday they had ever had all together. He was going to an Alcoholics Anonymous meeting every night of the week, and much of his spare time was being spent helping other alcoholics. Any psychiatrist who had in the course of psychotherapy produced such changes would have been pleased with the result. The man’s whole ability to function had altered for the better. He could now handle relationships with other people and he could deal with situations of frustration and conflict which, when we first knew him, he could only respond to by drinking. AA he said, was the answer. Historically, AA was an offshoot of the Oxford Group. Although this origin seems now usually to be forgotten, the ancestral influence of evangelical Christianity can still be identified in most AA practices. AA started in May, 1935, when Bill W, an

alcoholic stockbroker from New York, was desperately looking for help and somehow, as a result of dialling a wrong number, managed to get hold of Bob S., an alcoholic doctor from Akron. They got together that evening and by the following year they had been joined by a handful of other alcoholics who had regular meetings for bible readings, discussion and self analysis. From this earliest stage “confession” was an important part of the activity, as was the idea of restitution. AA had from the start the characteristics of an action group: members were expected not only to talk about their problems but were also expected to do something about these problems and lead a certain sort of life. The link with the Oxford Group was severed in 1937, and since then AA has been completely independent of any affiliation. By 1939, AA had about 100 members and by 1948 membership had grown to 40,000. The number of members at the present time is difficult to estimate. The movement became established in England soon after the war. In London and the Home Countries over 50 meetings are held each week. A commercial traveller could be fairly sure of being able to contact AA in any large town or city – from Exeter to Renfrew – in which he put up for the night. A visiting professor would find active groups in Oxford and in Cambridge. On holiday, whether in Jersey, Tipperary, or Stornoway, AA is still at hand. There is a certain form of words with which the Chairman opens the meeting. He starts with “My name is Joe” – or Jack or Fred as the case may be – “and I’m an alcoholic” without embarrassment, and perhaps sometimes it seems even with a certain inflection of pride, is the badge of the AA member. DESOLATE DEGRADATION ……………….. The evening’s speaker goes on to give his life story. This is a confession, a catharsis, in which the audience, all of whom have themselves been through some similar experience of life, are able intensely to share. The story is likely to be told with sincerity and passion. The speaker tells probably of desolation and degradation and then, with a regularity that makes one feel that one is watching some primitive stylized dramatic form, comes the moment when the man joins AA, drags himself out of the gutter, and finds contented sobriety. There are infinite variations on the theme, but the basic flow of the story seems always to be the same. General Discussion follows, and then comes tea and biscuits. If an attempt is made to analyze the meetings, the analysis must somehow take account of the fact that, as in psychotherapy, it is not only the words which count, but the emotional interactions. However, a superficial content analysis would bring out one point so obvious that it must surely deserve attention: most of what is said about drink and drinking. With what at first appears to be boring reiteration, the meetings drive at the fact that alcoholism is a disease, an allergy, a disorder of metabolism, something akin to diabetes. Drinking story is told after drinking story, and at times the whole meeting seems to lean forward with vicarious pleasure as some particularly momentous drinking spree is described down to the last

bottle and the last blackout. In these stories the danger of “the first drink” is stressed and stressed again, and there is a frequently repeated phrase about one drink being too many and one hundred not enough. An alcoholic, according to the doctrine which is reiterated at these meetings, must accept his alcoholism as a physical fact, and if he refuses to accept this fact “and makes an experiment” he is beckoning disaster. Such a blunt and unsophisticated emphasis on drinking rather than on supposed underlying emotional causes of drinking is in contrast to the approach which the alcoholic is likely to encounter with many psychotherapists. Psychotherapists can even be found who make the statement that, basically, alcoholism has nothing to do with alcohol. It would be wrong to suppose that A.A. gives no attention at all to problems other than the immediate problem of alcohol. Part of the time at a meeting may be spent in discussing “thinking.” There is a phrase of admonition which is sometimes heard to the effect that “it’s not your drinking but your stinking thinking,” and it is held in A.A. that there are faulty attitudes which can be identified as “alcoholic thinking.” For instance, the alcoholic is seen as a man who has a tendency to put the blame on others. He is always looking for excuses. He is someone who is always in a hurry, trying to do too much too soon, a fault which is corrected by the AA teaching that you keep sober “just for today.” The individual is invited to search himself for a number of wrong headed stereotypes of reaction pattern. Although there is now what amounts to a large body of uncodified doctrine – the host of familiar catch phrases that go to and fro at every AA meeting – the actual official doctrine remains small. There are Twelve Steps, which are the individual’s guide to sobriety, and the Twelve Traditions, which are the guide to AA organization. The Twelve Steps 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 whenever possible, except when to do so would injure them or others. 10. Continued to take personal inventory and when we were wrong, promptly admitted 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 the 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. ON TO THE SPIRITUAL A feature of the twelve steps – as opposed to the manifest content of any AA discussion – is that alcohol and alcoholism are each only mentioned once while God is mentioned five times. At American meetings, the Lord’s Prayer will often be said, but English AA puts a less conscious emphasis on religion. A recurrent problem arises in interpreting the twelve steps in such a way as to make AA acceptable to the alcoholic who is not theistic, and arguments go on around the “as we understood him,” a clause which seems to embrace even denying his existence. Sometimes however an alcoholic who at first sees in AA only a method of keeping dry, will later “go on to get the spiritual side.” The Twelve Traditions lay down a simple framework for organization and administration. Central control is to be kept to a minimum. Groups are to avoid the entanglements of big funds, and AA is to be self supporting. Members are to speak for themselves and not for AA. One of the reasons it has burgeoned into an international organization seems to be that the right balance has been struck between central control and group autonomy. None of this provides the whole explanation of how a man who has failed completely to benefit from everything which psychiatry could provide, should come back five years later sober and wearing a new suit and saying “I don’t let things get on my nerves the way they used to do.” AA eschews psychiatric jargon, and yet some effort at interpretation in terms of group dynamics seems necessary for complete understanding although not for its functioning. The most immediately apparent fact about the dynamics of AA is that the AA group is a group without a leader. Group therapy, which like AA has burgeoned since the war, has as its uncodified first step the assumption that group therapists are the prerequisite of group therapy. The training of the group therapist has given him awareness and skills which are used by him to direct and interpret the processes of group interaction. Yet AA has no trained person to control its interactions, and all the mistakes which the trained therapist would wish the group to avoid, the AA group presumably goes straight ahead and makes. All the uncontrolled and devious manifestations of projected aggression and projected anxiety presumably leap like lightening about the room. The absence of a leader tempts the psychiatrist to try to detect substitute and symbolic leaders. AA itself can be conceived of as an abstract “good object.” One could errect a number of other hypotheses: that God is the group’s symbolic leader, the chairman plays the role of therapist, that Bob S and Bill W have in some ways taken on symbolic stature, but the fact is that AA works through undirected group processes. The absence of a therapist may in part be responsible for the strength of group cohesion: there is no father-protector to hold the group together and for this reason if the group is to survive (and it badly wants to survive) anxieties must be very quickly dealt with. The absence of a

therapist seems also sometimes to result in anxieties being repressed rather than resolved: there are taboo subjects, such as homosexuality. Another interesting aspect of AA dynamics is that interaction is not limited to the meeting. In conventional group therapy the therapist hopes to work through a network of transference and counter transference and verbal interactions, and he hopes very much to avoid acting out. Aggression must be at a verbal level rather than an exchange of blows, and sympathy must be verbal rather than a loan of money. His patients gather in his room, and he will probably feel that the therapeutic process will work best if they go their ways until the next meeting. In AA the state of affairs is very different. A well established AA member will accept responsibility as sponsor for the newly joined member, and will go round to the new member’s house, and spend hours talking to him over cups of tea. An AA member has even been know to stop a divorce by going round to give a solicitor a lecture on the disease concept of alcoholism. The sponsor is not held back by any of the qualms about involvement which might inhibit the well trained social worker. But even in AA the older hands will caution against over involvement and will insist that no one can be helped until that person really wants help. AA is not simply a crutch who offers the abnormal personality mere support in contrast to psychotherapeutic processes which actually correct the abnormality, although there are indeed occasional cases where AA does no more than support a man in a chronic state of neurotic maladjustment. Alas, psychiatry can often do no better. Sobriety itself, however achieved, can sometimes allow a spontaneous maturation of personality, but AA seems often to exert a specific and positive psychotherapeutic effect by offering a man what is at first the experience of an accepting group. Experience of the group later breaks down into a network of individual relationships which may often be the first warm and meaningful relationship which the alcoholic has been able to experience. AA is seldom able to help the drifting, rootless man who has very limited powers to form relationships of any sort: the skid-row alcoholic is as poor a candidate for AA as he is for psychotherapy. There are also people with a rather introverted nature who find AA meetings disconcerting, and who feel more able to work out their problems with an individual doctor. AA in London cooperates very successfully with the medical profession and the experienced AA sponsor will not infrequently persuade an alcoholic to seek psychiatric help. In some mental hospitals regular AA meetings are held. AA thus has a double importance: firstly as a therapeutic organization of energy and ubiquity, and secondly as a puzzle of extreme theoretical interest. Therapy without therapists, sponsors manifesting unashamed involvement, groups demanding repression, emphasis on the symptom rather than the disease – and all this producing therapeutic successes sometimes of startling brilliance. If we could understand AA we should in the process come to understand a great deal about human interaction.