The Lancet, February 18, 1978. UNDBRSTANDING ALCOBOLICS ANONYMOUS Results from a survey i n England and Wales

Stuart Henry David Robinson

Institute of Psychiatry, Addiction Research Unit, 101 Denmark Hill, London SE5 8AF

Summary A recent national survey indicates what is involved in “being a member” of Alcoholics Anonymous (A.A.) and provides data which should help medical practitioners to make better informed judgments about whether to recommend A.A. to particular alcoholic patients. The survey shows that to be successful in A.A. entails more than just attending the meetings. Involvement in other activities reading the literature, office-holding, twelfth-stepping, sponsorship, and attending formal functions – is routine for the great majority of current members. Members also make new friends in A.A. who replace rather than augment the circle of old ones and who form the basis for a new set of relationships outside the fellowship. These enable the A.A. programme to be carried hqrmil ths meeting into the member’s everyday life and facilitate a co-ntinuity of cmcern which the caring professions cannot provide. INTRODUCTION “It is possible that more contemporary alcoholics have found sobriety through the fellowship of Alcoholics Anonymous than through all other agencies combined. Yet the A.A. recovery program remains an unknown quantity to many, and at least something of an enigma to most” (1). In the thirty years since Alcoholics Anonymous (A.A.) appeared i r r England and Wales, it has built up a reputation among both l~~yrnen and experts as being a majcr szurce af help far people with alcohol-related problems. In 1976, a general population survey revealed that of all the helping professions and organizations involved with alcoholism, A.A. was considered by the public to be the most helpful “for people whose drinking is causing them problems”(2). At about the same time, a study of the community response to problems of alcohol abuse (3) showed that 55% cf general practitioners felt that A.A. had something more to offer than they themselves could provide. Despite t.his confidence in A.A., the ideas that many people have about what A.A. actually does are often based on out-of-date, hearsay information. Indeed, 26% of the general practitioners in the Cartwright study admitted to not knowing what A.A. did and 35% of those general practitioners who felt A.A. had something to offez were unable to cite any specific benefits. As one general practitioner said, “I’ve no experience (of A.A.) ….but it’s a very good thing”(4). It was this kind of response that led the author of

the general population study to observe that, “it is clear that people do not need to have had any personal contact with an organization or to have any detailed knowledge of its day-to-day workings to make a judgment about its potential usefulness in some hypothetical situation1′(5). We hope that this paper, which draws on a national survey of A.A., will provide an up-to-date account of A.A.’s activities so that general practitioners and others in the helping professions will be able to make informed recommendations about A.A. to those of their patients who suffer from a drink-related problem. THE SURVEY After a number of long, informal interviews with A.A. members, a national survey was carried out in November, 1976, with the cooperation of the A.A. General Service Office in London. Detailed, self-completion questionnaires were given to 1 in 4 members attending meetings of a one-in-ten random sample of the groups then operating in England and Wales. One hundred and seventy one questionnaires were completed and returned, which represented a response rate of 85.4%. The survey revealed that, among the current members, there were 1.7 men t e ~ ? e r ywe!^^, k t thdt &nc?r!3th~semembers who joined A.A. in the past 4 years, there were almost equal nunhers ~f wcmen snd Een. The zuerage sqe e f t h e A.B. members in our survey was 46.4 years, with men being slightly older at 48.4 years than women at 42.6 years (6). THE A.A. MEETING AND INVOLVEMENT One of the most widespread beliefs about A.A. is that membership involves no more than attending formal weekly meetings. This idea is not unreasonable since, as Leach has pointed out, the meeting is usually “the first and only distinguishable A.A. activity in which all the members of a local group participate at the same time.” Indeed, it is an accepted part of A.A.’s program to reconmend that newcomers go to “90 meetings in 90 days” when they first join. The survey showed that members went to an average of 2.1 meetings each week. Moreover, it was not just the newcomers who felt the need to go to more than one meeting a week, since 60% of those who had been in A.A. for over 10 years had been to more than one meeting per week in the past month. As well as attending meetings more often than is usually imagined, A.A. members tend to go to the meetings of more than one group. 70% of current members, including those who have been members for six years or more, had attended at least two different groups in the month before the survey, while 30,4% had been to four or more different groups. The survey showed that there was no difference between men and women in their overall level of involvement in A.A. activities. Talking at an A.A. meeting is one of the most direct and common forms of A.A. activity and only 1.8% of current members had never done this, while 62.5% said they spoke regularly. Taking part in discussion groups was felt to be the most helpful form of talking at a meeting, with 75% of members finding it very helpful. Informal chatting before the meeting was said to be very helpful by 51.7% of members, and discussion after the formal meeting had finished was

very helpful to 66% of the members. As one member told us, “a lot gets done after the meeting. People have coffee and they sit and chat maybe for an hour or two until they get thrown out …Often a lot of the goodies come out then …I can often get more out of the chatting afterwards because I can do the rounds.” The survey showed that 81.9% of members had told their personal stories, 69.5% within 6 months of going to their first A.A. meeting. This means that they had described their experiences while they were drinkers and what had happened to them since they had joined A.A. Anyone who has ever been to an A.A. meeting will know that these statistics support the observation that “talking” is what A.A. members do more than anything else (8). However, there are a number of other activities that go on at a meeting, in which members show a similar high degree of involvement. READING THE LITERATURE One of the low-key, though important, aspects of A.A. is reading its literature. In an important way, the A.A. message is carried by its literature and everyone had come across some kind of A.A. literature very early in their membership. Women tended to be more regular than men. However, irrespective of their sex and length of time in A.A., 10.6% of current members had never read the “Big Book”, Alcoholics Anonymous, and a further 13.5% had only read it very rarely. The Alcoholics Anonymous journal, Share, was the most popular, with two thirds of all members reading it regularly. Surprisingly low on the list was Box 514, A.A.’s main newsletter. Half of the current members of A.A. had never read it. But reading the literature is not in itself enough to ensure recovery from alcohol-related problems. One member said that he certainly “could not have existed on the literature alone. It was the pure understanding of the people I was with. The companionship, compassion, being with other people. I couldn’t have just picked up the literature.” OFFICE HOLDING Another way of becoming more involved with other A.A. members is through office-holding. At every A.A. meeting some members have special responsibilities. In addition to the usual officers – the chairman, secretary, and treasurer – members might be called on to speak, or they may volunteer to make tea, put out chairs, or help collect the contributions. The proportion of members who have held office is very high and the chances of holding office increase steadily with duration of membership. Women tend to be less likely to hold office than men. The importance of office-holding to the individual members should not be underestimated. One A.A. member told us what being a secretary meant to him. “It’s kept me involved. I find that if I’m not involved at one meeting of my home group, I tend to wander.. .It was good for me to speak as well as to sit up front. I couldn’t just hide in the background.”

ATTENDING OTHER KINDS OF A.A. MEETINGS Opportunities for involvement with A.A. exist outside regular meetings. A number of events form a different sort of meeting. These may be concerned with official A.A. business, such as A.A.’s conference, intergroup meetings, the annual convention, miniconventions, or social events such as local dinner-and-dances. Members are less likely to have gone to intergroup meetings, which are a kind of regional A.A. meeting, or to the A.A. conferences, at both of which official A.A. business is discussed, than to an A.A. convention. This is because individuals have to be elected to attend intergroup meetings and the conferences, and long-standing members may feel that newcomers are not sufficiently experienced in A.A. matters to represent their group. Nevertheless, as many as 16.7% of relative newcomers have attended intergroup functions. Also noteworthy is the fact that women are more likely than men to go to conventions but less likely to be representatives at the intergroup and conference meetings. This corresponds to the pattern of office-holding. TWELFTH-STEPPING AND SPONSORSHIP Other important ways in which a member can become involved in the fellowship are through “twelfth-stepping” and “sponsorship,” which not only take the member outside the meeting, but also present an opportunity to “carry the A.A. message.” Outsiders are confused about twelfth-stepping and sponsorship. The last of A.A.’s Twelve Steps states that, “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 affairsN(9). Twelfthstepping is the process of initiating alcoholics into the fellowship. A newcomer may be seen by a member who will tell his personal drinking story, but not force the newcomer to relate his own. As the A.A. General Secretary told us, “One can only hope that whatever they may be thinking, whatever doubts they may have, they may be able to identify with you.” Our survey showed that 74% of all current members have twelfth-stepped a newcomer and also by the time members have been in the fellowship for two years almost 80% have twelfth-stepped someone. Twelfth-stepping gives an A.A. member the opportunity to put his devalued past to good use, by drawing on his drinking history to help other alcoholics. As Bean has said, “this idea, that a person’s experience is of value, is gratifying to anyone and is particularly heady stuff to the chronically self-depreciating alcoholic”(l0). Indeed, she goes on to say that taking the twelfth step is seen by many as a guarantee of recovery. Beyond this initial contact is the sponsorship system, a more intimate relationship between a new and an old member which, like twelfth-stepping, benefits both. One member told us that when he was asked to be a sponsor it seemed “like the final accolade”. He said he then realized that things had moved and that he had got much better: “I’m not boosting myself because I’m his sponsor, but it’s nice to see the program working on someone else and it all seems very worthwhile.”

Our survey showed that just over half the current members had been a sponsor at some time and that, on average, members had sponsored 2 . 9 people. Sponsoring is related to the length of time a person has been an A.A. member, with 2 years being an important landmark. After 2 years membership, the likelihood that a member will sponsor someone is, on average, 4 . 5 times as great as before 2 years. 90% of members who became sponsors did so within 3 years of attending their first meeting and 80% of those who have acted as sponsors are still in touch with the person they first sponsored. It is also interesting that, on average, over 1 in 4 of those members who have been in the fellowship for 6 years or more have never been a sponsor, which suggests that sponsoring someone, though desirable, is not essential for continued A.A. membership. However, those who have been A.A. members for 6 or more years stand 2 . 4 times the chance of dropping out more than once if they do not sponsor someone. There are at least two major benefits for a member who is involved in twelfth-stepping and sponsorship. The first is that these activities change the member’s focus of attention from himself and his problems to other people’s problems. When a sponsor calls on the person he sponsors to go to a meeting he is doing it as much for himself as for the newcomer. As one member told us, “While I’m thinking about someone else, I’m not thinking about me and all my problems.” This thinking about one’s own problems is what makes the A.A. say that theirs is a “selfish” programme. The second benefit of Twelfth-stepping and sponsorship is that these activities provide new non-drinking experiences. TALKING TO OUTSIDE ORGANIZATIONS Unlike twelfth-stepping and sponsorship, talking ab0utA.A. to outside organizations requires the member to leave the comfort of the group and place himself in a minority among non-A.A. members. Just over a third of current members had done this and of those members who had done so, 60.1% had been members for more than 4 years. One member, who had spoken to schools, prison groups, and Eighteen Plus groups, told us, “It was good to realize that there are groups around us who are interested enough to call on us to talk.” BEYOND THE MEETING An important test of the A.A. member’s sobriety comes when he is neither attending A.A. meetings nor doing formal A.A. work. Those who are unaware of what A.A. does might accept that the fellowship works while members are attending formal meetings so that it appears no different from other methods of handling alcohol-related problems. The crucial difference, however, is that for many alcoholics A.A. work continues after a meeting and helps them to maintain their sobriety until the next meeting. Apart form just being involved in formal A.A. activities membership means forming relationships and friendships with other A.A. members which in turn leads to informal activities such as

attending ordinary social events with other A.A. members. These extra activities are not merely “optional extras,” but for most members, an integral part of the self-help process of the fellowship(l1). For example, three-quarters of the members in the survey said that they had made new friends in A.A. and this was true for 61.1% of members who had been in A.A. for less than a year. This was not just a case of making additional friends, since only 30.8% of members still saw most of the friends they had before they first came to A.A.. Harrison Trice was one of the first commentators to recognize that leisure spent with A.A. members helped to maintain the member’s sobriety. He pointed out that, “individual members get together to eat lunch, drink coffee. They meet after work, to bowl, fish, and play cards. These informal contacts extend the relationships developed in formal meetings (12). Our survey shows that A.A. members do see each other outside the meetings, at each others homes, at work, and on social occasions and, as our study of other mutual-aid groups has shown (13), these relationships are very important. They carry the group’s programme beyond the meeting into the members’ everyday life. In this context, it is interesting that only 17.1% of current members have never had another A.A. member as a guest in their homes and that as many as 47.3% of those who had been in A.A. for less than a year saw other members in their homes at least occasionally. Almost half of those who had been in A.A. over 6 years had other A.A. members to their homes regularly. As well as meeting at home, 38.2% of members met informally at a range of social, sporting, and leisure occasions – most commonly when they went out together for meals, to cafes, to discs and, surprisingly, to pubs, bars, and cocktail parties. Members also met for more relaxed pastimes such as music, chess, and bridge, and accompanied each other to films, plays, concerts, and on outings and holidays. 19.3% of members felt that such social meetings between A.A. members were an essential part of the A.A. programme. DISCUSSION The informal network of friendships and social contacts within A.A., like the other form of involvement, is related to whether or not a person stays in or drops out of the group. However, this is a complex relationship since, for long-standing members who have exceeded the average of 5.3 years of membership (6), an increase in informal activities with other A.A. members may lead to a progressive decline in the regular attendance at formal meetings. This might reflect a growing out of, rather than a dropping out of, the fellowship. Indeed, such a maturing process may be the ultimate way in which A.A. “cures” alcoholism. The network of informal friendships, which ensures that the A.A. programme continues beyond the meeting, fosters a feeling that help is always available – it also enables people to offer help unsolicited instead of waiting to be asked for help. It would be peculiar, if not practically impossible, for general practitioners to telephone “out of the blue” to ask their patients how they are. But in A.A. that is exactly what happens. One member we interviewed

told us that he would “phone at tea breaks. To make a little call is enough. It’s just that idea that somebody suddenly thought,’I wonder how Steve’s doing?’ It can make you feel good.” By removing from the person with drink-related problems the onus of always asking for help, this network of informal A . A . contacts makes it unremarkable both to have problems and to be concerned about them this is how the A . A . ‘ s programme diverges most widely from conventional forms of help. No appointments have to be made and unlike other helping services, there are no appropriate times to ‘phoce or call. Help is given with pleasure when requested and offered spontaneously when not. A significant part of A . A . is that it makes both needing help and helping ordinary everyday things. It is clear that A . A . requires a high degree of active involvement from its members, not just passive participation in a helping process; A . A . membership is not simply a xatter of doing. It is a matter of being; of being in the group, and of being in A . A . outside of the group, in ordinary everyday life. This is what is meant when people say that self-help is a way of life, and this is why A . A . requires its members to change into almost completely different people, if they are to emerge from alcoholism the A . A . way. REFERENCES 1. Maxwell, M.A. in Alcoholics Anonymous: An Interpretation in Alcoholism. edited by D. Pittman; p211, New York, 1967. 2. Robinson, D. From Drinking to Alcoholism: A Sociological Commentary; p101, London, 1976. 3. Cartwright, A.K.J., Shaw, S.J., Spratley, T.A., Designing a Comprehensive Community Response to Problems of Alcohol Abuse: Report to the D.H.S.S. by the Maudsley Alcohol Pilot Project. Mimeo, London, 1975. 4. Cartwright, A.K.J., ibid, p.86. 5. Robinson, D., From Drinking to Alcoholism: A Sociological Commentary; p.100. London, 1976. 6. Robinson, D., Henry, S., Br. J. Alcohol and Alcoholism (in the press). 7. Leach, B. et al. Int. J. Addict. 1969,4,507. 8. Henry, S., Robinson, D., Talking Out Alcoholism: Results from a Survey of Alcoholics Anonymous in England and Wales. Mimeo. London. 1977. 9. Alcoholics Anonymous. Twelve Steps and Twelve Traditions. New York, 1352. 10. Bean, M. Psychiat. Ann. 1975, 5, 20. 11. Robinson, D., Henry, S., Self-Help and Health: Mutual Aid for Modern Problems; p.104, London, 1977.

12. Trice, H.M., Ann. Am. Acad. Polit. Soc. Sci. 1958, 315, 105.

13. Robinson, D., Henry, S., Self-Help and Health: Mutual Aid for Modern Problems p.119, London, 1977.