Psychiatric Annals Vo1.5 ( 3 ) , 46-51, March 1975.

VI: PROBLEMS IN AFFILIATION By Margaret Bean, M.D.

Nearly every article on the the alcoholics in this country treatment of alcoholism use A.A. Who goes to A.A.? mentions A.A. as either an Which Alcoholics? Do any adjunctive or a primary nonalcoholics go? Who stays component of treatment. away? Who goes but leaves? Who Hundreds of articles repeat the does well, and who has trouble? statement that “A.A. has a Who uses it extensively, and is success rate as good or better this correlated with better than any other treatment,” success? Who becomes a leader? though rarely do they attempt The answers to these questions formal substantiation of this would be of tremendous value in claim. A.A. itself claims a understanding alcoholism and success rate of 75 per cent, 50 its treatment. As they are not per cent on the first approach available, we are left with to A.A. and half of the first- anecdotal information and time failures on their later insubstantial claims, but we return to try again (24,45). can hazard some guesses. Some studies corroborate A.A.’s claim of success with between THE PROCESS OF 50 and 60 per cent of the AFFILIATION alcoholics who use it (68,69). A.A. defines people who From my own observations, fail as “not motivated.” This it seems that for stable mutual places the onus for failure attachment to take place there directly on the alcoholic and must be at least three absolves the organization from interacting characteristics: trying to understand what might 1. The approaching make A.A. difficult to use. alcoholic must have certain Studies suggest that it works psychological and social better for some people than for characteristics that permit him others. A.A. is not a unbiased to use the group and obey its population sample; it is a norms, such as interpersonal heavily selected group of skill and ability to relate middle-aged, middle-class, verbally in a group. These are married white men (70). This also the quality that make him could be explained if attractive to the group. For alcoholism were a disease of example, members see him as this group. But increasingly congenial to themselves, or single people, women, young they see him very much troubled people, blacks, ethnic and want to rescue him. minorities, and lower-and 2. The group must have upper-class people appear who certain characteristics that are alcoholic and wish to use permit it to accept incoming A.A. We have evidence that they alcoholics such as the norm do not always fare well there. that the only requirement for Only 5 to 10 per cent of membership is a desire to stop

drinking, and that makes it A.A. and believe it can help; appealing to new members, such and he must have the as an attractive social milieu information, intelligence, and and the offer of new general competence to get to relationships. A.A. In other words, A.A. will 3. Both sides must not reach the despairing, the perceive profit from a match. ignorant, or the inept. It will Alcoholics, while drinking, not work for the feeble-minded, usually have enormous unmet psychotic, seniledeteriorated, dependency longings. A.A. has or psychopathic (71). It will structures to fulfil these. The be rejected by some alcoholics alcoholic comes, is gratified who can and do use other types and relieved, is able to stop of assistance, such as drinking, and becomes loyal to psychotherapy, Antabuse, and A.A. The alcoholic who needs multimodal programs. It will rescuing is necessary to the not be acceptable to people who ongoing viability of the do not want to be committed to organization. The organization an alaohol-centered existence seeks him; he recovers through for thb rest of their lives, or its ministrations; he is to people who believe that they grateful; and the Twelfth Step can change by themselves. It workers are validated as well will not reach many people who as strengthened in their have a great deal to lose by reaction formation against exposure of their drinking drinking. Both parties are problem, even though they have reinforced in their commitment more to lose from drinking. to each other, and are mutually congratulatory, which is PERSONAL further reinforcing. CHARACTERISTICS Some people are going to AND A.A. MEMBERSHIP fit better into such a system than are others. A.A. Some personal and officially welcomes all who sociologic characteristics wish to use it, and such as marital status, participants are always free to religion, class, sex, leave. Anyone who feels that he ethnicity, age, and personality is not being helped or is being traits – are not randomly harmed will probably not distributed in A.A. return. More to the point, Marital status. Most A.A. anyone who feels that the members are married men. This company is not congenial or could result from the fact that that the A.A. method is not to most alcoholics are married his liking will be unlikely to men, but there are several use it for long. IN view of the additional possibilities. conventional, middle-class, Recovery from alcoholism is religious tone, large segments probably more likely when the of the alcoholic population may alcoholic has a life worth not feel at home in A.A. recovering for – say, with a No one is going to A.A. if job and family, or other he does not want to stop commitments and rewards. drinking. In order to go at Alcoholics frequently report all, a person must acknowledge that they decided to come to his problem with drinking and A.A. when their wives left or want to stop; he must know of threatened to leave. A husband

is more likely to stay sober in requires admission of failure, A.A. if his wife uses Al-Anon assumption of the sick role, (72) and a permanent, regressive, This is an interesting dependent stance. It invokes contrast to my impression that the magic power of the A.A. way women in A.A. are usually and does not tolerate insight divorced or, if married, have unless this coincides with the remarried since they joined A.A. point of view. It treats A.A. and became sober. This alcoholism as an illness could result from the occurring in only one form, a possibility that marriage simple and straightforward between an alcoholic and a problem. With the exception of nonalcoholic is stabler when sick role, these are congenial the alcoholic is the husband middle-or lower-middle-class, rather than the wife. One anti-intellectual values. commonly hears of the People who do not share masochistic alcoholic’s wife, these values may not be able to who seems unable or unwilling use A.A. Educated upper-middleto leave her painful marriage. class members are intolerant of The husband of the alcoholic the inspirational qualities woman is a less familiar that discourage thinking. character. It also seems that Demoralizedlower-classmembers Al-Anon is less welcoming to do not expect that any services men married to alcoholics than will be helpful or treat them to women, perhaps because men respectfully. Because of their are in the minority at Al-Anon experience in trapped lives, or because the idea of an they disagree with the idea alcoholic wife is threatening. that they are not helpless and Region. The area of the country can change their lot. where an alcoholic lives T h i s m a y b e influences his access to A.A. counterbalanced by client groups (73). More groups exist participation in self-help in the Northeast for the same groups, and stress on the area than, say in the possibility of recovery. By Southwest. This may be because providing peers with common the Puritan tone of the goals, such groups oppose the organization is more acceptable member’s tendency to isolate there, or because the number of himself. They also create a A.A. groups that are formed is locus for action, motivation a function of population for change, a problem-solving density, greater in the orientation that increases felt Northeast. This is an competence (74-77), a peer intriguingpossibility,because reference group, a it would suggest that A.A. participation model, and social membership is not increasing to re-education. These absorb more and more characteristics may make selfalcoholics, but that it help groups appealing to lowerincreases to a certain class members. percentage of alcoholics and Each group tends to be then stops. homogeneous for class, but Social Class. A.A. is a middle- there is a wide diversity class organization with an between groups. Lofland and inspirational tone and a rather Lejeune attempted to identify rigid and dogmatic method. It factors that lead to selection

of members of the same class. for example, have a higher rate They assumed that selection of alcoholism than do Jews pressure came from the group (81). Whether the different welcome or rejection, not from patterns of abuse would approaching-member-choice, indicate need for different which must also be operating. therapeutic styles has to be They did not find, however, determined. IN any case, in that upper-class groups large cities there are some strongly welcomed upper-class predominantly black A.A. members, but their results may groups, which should help deal have been confounded by the use with their special needs. of middle-class volunteers to Mexican Americans and American impersonate different classes. Indians, who are less numerous, Their findings that upper-class have fewer such options. groups interact more with Sex. There are fewer women than lower-class newcomers may men in A.A. This is likely to reflect a need to do Twelfth reflect the sex distribution in Step work with the down and the population of alcoholics; out, not the wish to have alcoholism rates in women, like lower-class members in the those of smoking, are moving group (78. towards the rates for men, though there are still more male alcoholics. Another “It is a middle-class contributing factor may be the organization with an greater secrecy of women inspirational t o n e and a drinkers. In A.A. women may be rigid, dogmatic method” put off by the public exposure of coming to meetings and acknowledging their drinking Ethnicity. Members of ethnic problem in public. They seem to outgroups experience great be more sensitive about it, difficulty in attempting to use since alcoholism is considered A.A., especially if they are to be worse for women. hostile to the predominant I observed that women and class (79,80). Any organization men are treated differently in that shares society’s biases, A.A. Most sponsor-“pigeon” and many A.A. members are relationships were same-sex, as racist. It is difficult to be a was most casual conversation. “token member” anywhere, Women are often recognized to perhaps even harder in a have a different experience and stigmatized situation. Blacks urged to go to women’s alsoexperience incompatibility meetings. Some members seem to of style and values, and feel more distress at the idea distrust (based on experience) of a woman being alcoholic than of white establishment a man. But an effort was made institutions. Perhaps, also, to include a woman speaker at blacks do not wish to bring every speaker’s meeting. disapproval on their race by In general, the women I making their problem public. met seemed more gregarious, and All these factors contribute to less hostile and withdrawn, the rarity of black members. than the men. This may reflect It is also known that a response to my sex rather patterns of alcohol abuse vary than their character. among ethnic groups. The Irish, Age. The extent of problem

drinking among adolescents is develop in alcohol with-drawl frequently underestimated, for after less than a year of use, several reasons. First, this is unusual. Physical ills drinking is the norm in our due to alcohol abuse are likely society, and a wide range of to occur only when the drinking behavior is tolerated alcoholic is older. But even if (82). Second, adults may regard it takes several years to most teenage drinking as “good develop addiction to alcohol, clean fun.” Parents shocked and there are children of 12 to 15 fearful of “drugs” may be who drink so much that they relieved when their children become addicted by the age of drink alcohol, and may 17. encourage it. Third, social Recently more and more drinking takes practice (83). young people have approached The teenager who drinks to the A.A. They often come with point of making himself sick, multiple addictions and the passing out, or blacking out is usual adolescent conflicts usually seen as inexperienced, about authority and dependence. and often is. But sometimes he A.A. has somewhat ambivalently is not. Because it is seen as accommodated them. Alcoholics inexperience, an adolescent can and abusers of other drugs camouflage his problem drinking traditionally dislike and more easily. distrust each other, and often older alcoholics are as shocked “Women may be put off and fearful of adolescents and by t h e public exposure of multiple-drug use as are coming to meetings and conventional adults. A.A. is acknowledging their drink- currently struggling with the ing problem” question of what attitude it should adopt toward mixed addictions. In some areas it Fourth, alcohol abuse is a has toned down the part of the stigmatized condition, even program galling to touchy among teenagers. “When adolescents, and young people teenagers drink to excess… are beginning to set up their their peers to not report them own A.A. meetings. to the elders. A conspiracy of At least three large silence develops. They remain difficulties hinder the use of silent. protecting insiders A.A. in helping young people from outsiders. Amongst with drinking problems. Many themselves, however, they young people refuse to go; if censure drinking deviants …I1 they go, they refuse to stay; (84). Both the peer group cover and there may be some negative and the drinker’s desire to effects if they attempt to use escape opprobrium decrease the the program. visabilty of pathologic In order to go to A.A. for drinking. Rubington estimates help, a person must believe that 70 to 85 per cent of adult that he has a drinking problem, alcoholics are “hiddenM(85); know how to get to A.A., probably even a higher believe that the organization percentage of adolescent offers the hope of relief, and alcoholics are hidden because decide that the price of that they have not yet been exposed. relief is reasonable. A teenage Through delirium tremens can alcoholic, even more than an

older one, will deny his restore us to sanity. problem to himself as long as 3. Made a decision to turn our possible. If he does admit his will and our lives over to the problem, he may not have the care of God as we understood experience and knowledge to Him. gain access for help. (The To an adolescent all this, situation here is similar to including the religious cast, the difficulties concerning is repellent. It sounds help with contraception and suspiciously childish and abortion.) Teenagers are threatens his precarious exceedingly wary of organized autonomy. “Those alcoholics who adult institutions and share believe that eating ‘humble society’s prejudices against pie’ is a necessary condition alcoholics, even if they of their recovery often prefer themselves are alcoholic. They to go hungry” (87). are likely to disparage any organization founded and run by R T h e greatest obstacle acknowledged drunks. And they for an adolescent is the are not likely to know anyone emotional cost of who has used A.A. successfully accepting help” and is also close enough to them in age for productive A.A. literature for young identification. people tries to play down this But the greatest obstacle aspect with such sayings as “If for an adolescent is the you’re old enough to be an emotional cost of accepting alcoholic you are old enough to help. If he joins A.A., he do something about it” (88). accepts a role including both However, the testimonial stigma and illness. Teenagers stories repeatedly describe are reluctant to do this, apostasy and conversion, because it acknowledges and including confession of wrong. conforms their devalued, The young man who starts out degraded status. The adolescent saying, “I was an intellectual affiliates whenever he can with rebel, an emotional peer cultural ideals (86). In individualist,” actually sees this case his identification the light when he finds with nonalcoholics may be the “willingness to dim my own result of a healthy wish to be fiercely burning little blub, normal, but it keeps him out of and ask for help” (89). The A.A. stories are filled with In addition to stigma, moralizing and there-but-forthere are the problems of the the-grace-of-God-go-Imaterial. sick role and its implied “They stopped in time.” “They dependency. A.A. is constituted nearly lost all. ” “The prisoner partly to satisfy dependency freed.” “Do you want to live or needs. The members begin with die?. . .I said humbly, I suppose three steps that establish I want to live1′(3). “I listened this: and -thank God-I obeyedn(90). 1. We admitted we were Some of this is hard to stomach powerless over alcohol – that even if one is not an our lives had become adolescent. unmanageable. Closely related is the 2. Came to believe that a Power problem of rebellion. Many greater than ourselves could adolescents drink as a gesture

of defiance, and “a drinking strength of A.A. is its alcoholic acts like an flexibility. As soon as there adolescent rebelW(91). are many members with a Rebellion is normal in this age defining characteristic, they group. If going to A.A. means can form a subgroup – a young renouncing rebellion, the people’s A.A., a woman’s group, adolescent, when he feels or a black group – where they impelled to rebel, may leave feel less outcast and where A.A. and return to self- their special needs are destructive drinking. recognized within the context What are the effects if he of their alcohol problem. stays? If he uses the group Personality traits. Evidence with its support, reaction suggests that A.A. may work formation, and catharsis to particularly well for a person control his powerful symptom, with certain characteristics that may be worth all the attributed to alcoholics. This disadvantages mentioned. But is a controversial area, since this may present another several studies failed to find problem for teenagers. They are personalitydifferencesbetween acutely sensitive to peer group alcoholics and nonalcoholics pressures, and if they accept (92,93). Others do find A.A. as a peer group, they are differences. likely to absorb its norms. One study determined that These include the dogmas of alcoholics show “marked “Once an alcoholic, always an p e r c e p t u a l f i e l d alcoholic”; “People don’t dependenceM(94). Field change”; The alcoholic needs dependence is an index of the A.A., the only road to extent to which a person relies recovery, daily and on feedback from the indefinitely.” Non-A.A. social environment more than from his connections are to be shunned. own body. If placed in an At a time when a person is experimental room that is trying to work out who he is tilted, the field-dependent and what he can be, these act person will report that he is to confirm an identity as standing straight when he is stigmatized, defective, aligned with the walls of the degraded, weak, dependent, room. A field independent alcoholic, and without hope of person will feel straight when change. he is aligned with gravity but The normal adolescent may tilted in respect to the room. participate in deviant behavior The study found that alcoholics without being, or seeing are more field-dependent than himself as, a “deviant” with an controls and that this was not inflexible character structure. decreased to control levels in During this formative time many sober alcoholics attending A.A. behavior patterns are Whether field dependence temporary. It is true that, and emotional dependence are because of addiction and associated is not clear. A.A. withdrawal, alcohol use may specifically appeals to, and generate its own momentum and may perpetuate, emotional develop a life of its own; but dependence. the young person has more hope Trice did a series of of change than an older one. studies concerning the question Again, for this group the of affiliation from the

viewpoint of what traits in the specifically religious tone and applicant permit him to numerous concepts borrowed from affiliate, not what in the religion. Members whose organization attracts or repels personalities tend to respond a new member. He found that to such an orientation are more some people cannot affiliate, likely to function well in A.A. though A.A. does not than those who reject it. This acknowledge the existence of emphasis on religion has been these (95). In a group of 370 equated with dependency, but male alcoholics in a state the question is more complex hospital, affiliation with A.A. than that, involving response at 18 months from admission was to ritual, hierarchy, positively correlated with affiliation with a group felt physical characteristics to possess power or knowledge, (stable health) and and evangelization. In psychological ones ( group particular, the effectiveness dependency needs, guilt of the religious aspect depends proneness, and experiences with on the person’s outlook, social processes labelled as whether he tends to see deviant, such as arrest). It experience in terms of did not correlate with absolutes or as gradations of sociological characteristics, relative values. These such as social stability and questions deserve a section of membership in the middle class. their own. It did not correlate with ego strength, either – not a surprising finding, since A.A. assumes low capacity and attempts to provide external strength rather than develop autonomy (96). ” A – A , specifically appeals to, and m a y perpetuate, emotional d e p e n d e n c e w In another study people who joined had the habit of sharing feelings, concern with friendship, acceptance, and more anxiety about separation and rejection than nonaffiliated (97). Machover found that people did better in A.A. if they were well integrated, tended to sublimate rather than act out homosexual concerns, and dealt in positive ways with authority figures (98). Any consideration of personality traits must deal with the fact that A.A. was developed on a model that uses

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