Quart. J. Stud. Alc., Vol. 5, 267-278, 1944.

THE THERAPEUTIC ROLE OF ALCOHOLICS ANONYMOUS AS SEEN BY A SOCIOLOGIST

Robert Freed Bales, Ph.D.

What would a friend or member of Alcoholics Anonymous see if he were to step aside for a few minutes at an Alcoholics Anonymous meeting some night and put on the special pair of glasses worn by “the sociologist”? Many things would probably be out of focus, or would seem so at first. It might seem as if he were looking through the wrong end of a telescope, with everything at an unnatural distance in space and time. He might find himself wondering, “What kind of animal is this, anyway?” For he would see it as a sort of organism or, more exactly, as a social organization – a structured arrangement of individuals, thinking, feeling, and acting in certain more or less uniform ways with regard to one another and the outside world. He would notice it growing at a great rate, with many members coming into the group, and some dropping out, as if it mattered little just who thought the thoughts, felt the sentiments, and performed the functions characteristic of the structure, as long as somebody did. He might begin to wonder what the whole life cycle of this organism would look like, from birth to death – and of course the thought of “deathn might come as a slight shock. He might begin to look around for other social organisms with which he could compare this one, and so get some hints as to whether it might be stricken with some fatal disease, from within or without, or perhaps might grow to some fabulous size and live forever! If he were a real member of the group, however, he would probably check himself with the sudden thought, “Easy does it – that’s getting close to alcoholic thinking.” This would be a safe place to take off those peculiar glasses and get back to the comfortable room filled with friends, busy at the more familiar job of staying sober. In the long run, of course, the kind of social organization that Alcoholics Anonymous is, by reason of its origin, mode of

growth, and day-to-day life, has a great deal to do with the job of staying sober, both for the old and new members. Perhaps it would be useful to examine some of its principle structural features as a “going concern” and consider how these features affect the principal job of the members – staying sober. Alcoholics Anonymous is a group which was virtually started by one man – at least there is a strong tendency on the part of the members to look back to the “founderu for guidance and, in spite of his modesty, to regard him with an unusual degree of respect, even reverence. Many religious sects and popular movements start in this way, and it is likely to be a major crisis in their existence when the key figure is removed, as eventually he must be, by death if for no other reason. If he has been able to transfer his “magic,” or in other cases his “sacred” character, to a set of ideas, sentiments and procedures, perhaps expressed in a body of writings, or to some other impersonal source that can live after him, the organization has a chance to survive. His unique place as founder and father can never be filled by another, but his place in the functioning organization can be taken over by a more pedestrian executive; in fact, the more pedestrian the better for the preservation of the original tradition. This particular crisis is still to come for Alcoholics Anonymous. Steps have already been taken to meet it. The “magic” has been transferred to “The Book,” Alcoholics Anonymous, apparently with a considerable degree of success. One quite often hears of members who have become sober by the aid of The Book alone. The Book is the charter of the organization, and the “Twelve Stepsu are the core of its established procedure. The outlines laid down in The Book and in the Twelve Steps, however, are actually very broad, and require “filling in” according to local needs, resources, and types of members, before they become sufficiently concrete to function as stable guides for day-to-day activity. Thus far, Alcoholics Anonymous has gotten along with remarkably little articulation of what may be called “the minimum degree of structure necessary to the successful functioning of the group as a social organization.” To cite only one example of this lack of

articulation, the individual is encouraged to recognize the existence of a “Power greater than the self” and to transfer his worries and the direction of his will to that Power, as far as possible. The group does not attempt to go further than this in a theological way. From the point of view of those structural features which are necessary to the continued functioning of the organization as such, this is a distinct gap. Whether it is Itaccordingto plann or notr it can be confidently expected that there will be pressures to fill in such gaps in structure. At the present stage of development the gaps are held open by an active tolerance wisely exercised by the founder and by the leading members of certain of the local groups. In certain other local groups the process of filling in the gaps with a more definite content of ideas and procedures can already be recognized. This tendency toward crystallization, which might be called a “normal processu for all social organizations, whatever their purpose or type of membership may be, is particularly crucial to Alcoholics Anonymous because one of the great sources of strength in the group is the fact that it is largely residually defined. The very name of the group makes an initial appeal to the harassed compulsive drinker, since in it he will be “anonymoustWi.e., technically not known and not censured. He qualifies as a member of the group because for some undetermined reason he cannot drink like his friends who are social drinkers; and he is not required to determine what this reason is – at least, not immediately. He comes into a group which is unregimented, which is not specifically Protestant, Catholic, or Jewish, not Republican or Democratic, nor upper, middle or lower class, nor specifically anything else which can be placed neatly in the ordinary categories of social structure. The members are “a bunch of ex-drunks,I1 as some of them put it, and even this is a residual definition. As far as the job of staying sober is concerned, there are definite dangers in the inevitable pressures toward greater clarification, regularization and, finally, formalization and rigidity, to which Alcoholics Anonymous, like every living social organization is subjected. There is the constant danger that local

groups will fall under the control of individuals who have not only imaginative and persuasive powers but also “ideas of their own” sufficiently unique to lead the group out of its loose and tentative structure into a rigidified form of organization and procedure which may destroy, or at least seriously hamper, the therapeutic effectiveness of the group, particularly where its appeal to new members is concerned. On the other hand, there are many organizational models which exercise a potential attractive influence on local groups – the model of some particular religious sect, perhaps, of some lodge, service club, charitable organization, crusading organization, or the leisure club of some particular social class, according to the composition of the membership. The discerning observer can see the struggle both toward and away from such a crystallization in many of the local groups. Projects, plans and opportunities are constantly presenting themselves which lead toward some more familiar and comfortable state of affairs. To a certain degree the development of overhead organization is unavoidable. Meetings have to be arranged and the rent has to be paid. Less obvious, perhaps, but just as important for the job of staying sober, is the fact that the method of reproduction of the group results in a intimate network of friendships and mutual obligations which constitutes a major structural feature in its own right. This structure also has its dangers – it contains within it the seeds of jealousy, just as the human family does. The sponsor obtains a protege. That man is “his baby.” When another “baby” comes, the first is likely to be somewhat neglected, and to resent it. He may even have a “slip” to regain his place as the center of attention. Another crisis appears when a protege begins to be attracted to other members of the group, to listen to their views and explanations, and is “weaned awayn from his original sponsor. This time the sponsor himself may “slip” from an excess of resentment or a need for attention. Still another crisis may be precipitated when the man who was a protege Ifcomesof age,” as it were, and becomes more productive and successful in obtaining followers than his sponsor. This is the time of Itold age” for the original sponsor. What he lacks in reproductive powers he may

compensate for in political direction of the group on a less intimate level than that of the sponsor-protege relationship. As long as he can command the veneration and respect which are likely to fall to an “old member” he may be safe, but when he begins to fall into the discard, as he may in a rapidly growing group, he is in danger of slipping again. There is a more or less definite limit to the number of old members who can retain top positions of veneration and direction in any one local group, and when this limit is approached the political conflicts may be expected to grow more acute. This is the time when the local group is subjected to the most severe strains toward splitting into rival factions or cliques. One possible solution to such a conflict, if it arises, is to make such a clique-formation the basis of a new group in a territorial setting somewhat removed-perhaps in a separate part of the city. If allowed to continue in one setting, these clique strains are a potential source of competition, irritation, jealousy and resentment – a whole series of emotional disturbances which may lead to slips. Against these potentially disturbing structural features, Alcoholics Anonymous has a very broad and sound basis of solidarity which can be positively defined. The things the members have in common which hold them together are their past drinking experiences, an intimate knowledge of the places and people the compulsive drinker inevitably gets to know, a bag of tricks, ruses, rationalizations and defenses which they have been forced to build up in the course of their compulsive drinking, an odyssey of adventures and misadventures too often ending in tragedy, and the sense of a common fate: they are all alcoholics to whom drinking has become so dangerous and unmanageable that they can only go on by living a life of complete abstinence. It is upon these things that their solidarity rests. Since the solidarity of the group depends upon past experiences which cannot form the basis for future action except in a negative way, that is, as an encouragement toward abstinence, the question as to what the group as such is to do in a positive way is one of the most obvious gaps in the structure. This gap is not actually filled

in but simply blocked off by a program which aims only at the present “twenty-four hours,” by the caution that “easy does it,” and the warning against “screwy alcoholic thinking,” a type of thinking which, in part, consists of grandiose plans for the future. This simple blocking off of the future appears to be a sound feature, both for the individual who tends to be grandiose and for the continued successful functioning of the group. When plans for concerted action begin to be considered in detail, the pressures toward more specific and rigid organization increase, political jealousies and divisions are likely to appear, and the vital relationship between the sponsor and his protege, which is both the heart of the therapeutic process for the individual and the means of reproduction for the group, is likely to be endangered. One might say that as a result of its particular basis of solidarity the articulation of ideas and sentiments relevant to action, which is a necessary and natural product of group life, can take place only in the areas of orientation toward the past and the immediate present, rather than toward the future, if the solidarity of the group is not to be endangered. There is one positive course of action which would seem to offer a generalized protection against this whole series of potential dangers. This procedure is to emphasize above everything else, and to value above everything else, the activity of the individual member in bringing the Alcoholics Anonymous program to other a l ~ ~ h o l i ~ s and, to direct all common or collective efforts of the group to the creation of ways and means of expediting these individual active efforts. In the first place, this procedure brings into prominence the central purpose of Alcoholics Anonymous which distinguishes it from all other groups – devotion to the job of keeping sober and helping others to keep sober. The dangers of developing toward the pattern of some other more familiar type of organization, with therapeutically irrelevant purposes and features, are thus minimized. In the second place, the continued activity of every individual member in bringing the Alcoholics Anonymous program to other

alcoholics is the best generalized preventive measure against the overdevelopment and excessive prolongation of the individual attachments of sponsor to protege which are bound to arise if the therapy is effective. The advantage is similar to that which large families, generally speaking, have over families with only one or two children, in the minimization of excessive attachments, jealousies, and supressed conflicts. In the third place, this emphasis brings into prominence and utilizes to the fullest extent the one general basis of solidarity in an organization otherwise residually defined – the past common experiences and present common characteristics of the members as compulsive drinkers. The exploration, articulation and emphasis of this fund of past experience, as it applies to the present situation of the compulsive drinker, is the main resource of material for the meetings, and the central reason for their being. This resource can be utilized to the fullest extent without incurring any of the dangers of developing an irrelevant and therapeutically dangerous overhead organization which would follow from a more explicit articulation of future plans and features for the organization as a whole. Finally, in the activity of the individual as he attempts to help other alcoholics, this basis of solidarity comes into the sharpest focus and is, in general, the most effective and unique feature of the therapeutic process as it goes on between the Alcoholics Anonymous sponsor and his protege. In this fund of common experience, and in the particularly intimate friendship it fosters, every member has a resource for helping other alcoholics that can hardly be duplicated by any other type of therapist. In order to visualize more clearly the unique advantages of the Alcoholics Anonymous approach over other types of therapy, as well as its particular limitations, it seems helpful to consider very briefly the psychological state of the compulsive drinker which must be modified if he is to stay sober. At least two types of elements can be distinguished in the psychological state of the compulsive drinker just prior, let us say, to the time when he takes the first drink of a spree. The first type of element may be thought of as the

underlying needs for adjustment – a fund of resentment or hostility, perhaps, anxiety or guilt, a feeling of inferiority, sexual tension, or any combination of the thousand-and-one maladjustments that make life uncomfortable or even unbearable for the individual as an organized personality. The second type of element may be thought of as the fixation on or attachment to drinking as a means of dealing with these needs for adjustment – the obsessive impression, or nucleus of thoughts and feelings, that drinking and only drinking will effectively quiet the individual’s particular needs for adjustment. The conscious manifestation of these two types of elements, one blindly impelling to action of some kind, the other orienting these impulses in the specific direction of drinking, is the conscious craving. We have reason to believe that both of the elements mentioned may be actually below the level of consciousness, and that the individual may experience consciously only the fully developed craving for a drink. He may fight this craving with other conscious thoughts and feelings; but in the case of genuine addiction the conscious thoughts and feelings somehow do not have an effective grasp on impulse, and the practical effect is either a craving so strong that eventually it wins out, or a precipitous “slip” in which the impulse takes advantage of the offer of a drink without ever fully arousing the conscious inhibitions. Speaking very broadly, then, the job of staying sober, that is, of getting rid of the conscious craving and the tendency to “slip,” boils down to four approaches: (1) reducing the underlying needs for adjustment; (2) providing other means or activities for satisfying the needs; (3) breaking up or dissipating the obsessive thoughts and feelings which constitute the fixation on drinking as a means of adjustment; and (4) acquiring effective thoughts and feelings to combat the fixation. Types of psychotherapy for alcohol addiction can be characterized and evaluated roughly by the emphasis they place on one or more of these approaches. The effort of family, friends, and the church are often directed prematurely to the forth approach. They try, vainly, to reinforce the conscious inhibitions by

moralizing, and by persuading and coercing the compulsive drinker. The courts and jails take over where their resources give out. This approach, used alone, almost invariably fails, because it leaves the underlying disorder untouched or even aggravates it, because it fails to uncover and modify the compulsive thoughts and feelings which lead the distressd individual specifically toward drinking, and, finally, because the necessary inhibitory thoughts and feelings cannot be internalized and made effective in the intimate aspects of the personality when there is hostility and resentment toward the source. The psychiatrist is most likely, by training and by inclination, to attack the underlying disorder directly, through analysis and catharsis. He may be aided by the social worker, who may attempt to reduce the needs by manipulation of the situation, and by the “practical psychologist” and occupational therapist, who may be able to provide other means of adjustment – a more suitable job, a day-to-day schedule, and the like. The psychiatrist, however, and professional workers generally, are severely handicapped by mistrust and hostility on the part of the a l ~ o h ~ l i c , which may have been precipitated or increased by earlier therapeutic attempts that failed. The psychiatrist may be able to gain a good insight into the underlying disorder and still be able to obtain insight or catharsis on the part of the patient, to say nothing of breaking the fixation or rebuilding inhibitions, because of this hostility and mistrust. The psychosocial isolation of the confirmed alcohol addict the feeling that nobody really understands or cares about him, that he is “bucking a hostile world,” that he cannot trust anybody or be of any worth to anybody, even to himself; in brief, the lack of real, vital, emotional contact of a positive sort with any single human being or group – is perhaps the greatest barrier to the success of any type of treatment. As long as the individual is cut off from any positive emotional attachment to a solidary primary group of some kind, he is at the mercy of the compulsive thoughts and feelings which urge him constantly towards drinking as a means of dealing with his problems. He has “nothing to tie to,” no point of reference except his own immediate needs and impulses. He has

nothing effective within himself with which to fight his obsession. To put it in still another way, there is no reason for not drinking which deep down and involuntarily, makes “emotional sensetrto him. The undesirable effects in the ultimate future may make “intellectual sense,Ir but the immediate effect is relief, and this makes compelling emotional sense because his strongest emotions are bound up with himself and his immediate needs for adjustment, not with anything or anybody outside himself. Continued drinking, in turn, weakens the inhibitions, accentuates the isolation of the individual from the group and group controls, increases the needs for adjustment and strengthens the compulsive thoughts and feelings which urge toward still further drinking. The individual finds it impossible to break this vicious circle. A member of Alcoholics Anonymous has the peculiar advantage of being able to break through this sense of isolation, hostility and mistrust by drawing on the fund of experience which he has in common with the drinker who has not yet found a way out. In his own person he offers a concrete and convincing hope that something can be done – that there is a way out. The group meetings increase the sense of kinship between the compulsive drinker and a group which is essentially like him, which cannot reject him, and which he finds hard to reject or deceive because the members know him so much more intimately and sympathetically than the public does. He finds that that they actually are sincere, and that they will make sacrifices to help him if he, too, is sincere and will come half way. Thus the basis for a genuine modification of his psychological state is laid, especially for a recognition and modification of the compulsive thoughts and feelings which constitute his fixation on drinking. The whole process of relating past experiences and comparing notes with his new-found friends is, in one sense, a laying-bare of those techniques, ruses, evasions, rationalizations and defenses which have heretofore protected the obsessive, half-unconscious conviction that drinking and only drinking will bring him relief. Those techniques and evasions which have been individual “guilty secretsn and “private sins” are transformed into something more like

“trade secrets,” part of a common nalcoholic culture,” in the process of half-humorous confession which goes on constantly in the group. The alcoholic who has been to a few Alcoholics Anonymous meetings finds it much harder to “fool himself” about the nature and significance of his drinking than he has in the past. He finds it easier to expose these defenses, which have been only half-conscious, and not in any simple sense deliberate, because by doing so he “qualifies himselfu as a real, bona fide member of the group, and feels himself more irrevocably a part of it. He finds that his inner defenses against a rational and even a moral attack on his drinking are fading out. Thus the basis is laid for the replacement of compulsive thoughts and feelings, which constitute the fixation on drinking, with effective counterthoughts and feelings capable of inhibiting and controlling the impulse to take a drink before it is fully formed. There is a certain type of control within the individual personality which can have its source only “outside the selfw – for practical purposes, in the moral principles advocated by a closely knit solidary group – and can only be internalized and made effective against self-centered, satisfaction-directed impulses by an involuntary feeling of belongingness and allegiance to such a group, i.e., a “moral community.” This feeling of allegiance, in turn, must be constantly refreshed and renewed by voluntary acts of self-searching and self-subjection closely similar to or identical with “prayeru in the familiar religious sense. Each time a member of Alcoholics Anonymous, at the cost of inconvenience and self-denial, answers the call to help another alcoholic, he is performing an act of religious devotion in the most basic sense, an act that binds him ever tighter to the group and makes the moral principles for which it stands just so much the more effective in his own personality. There is no substitute for this active discipline in the building of a dynamic moral agency in the personality which stands firm and unyielding at the time of crisis, as every great religious leader has known. This is not a principle used for religious purposes alone, however, nor is it any vague sort of llpreaching.ll Military men, too, who have an exceptional regard for brute facts, know this

very well – “morale**cannot be built without drilling. This is at least part of the procedure by means of which the active member of Alcoholics Anonymous is able to tap “a Power greater than the self” and obtain a release from his craving. The job of attacking the fixation on drinking and replacing it by a set of effective inhibitions, through social and religious means is the job which Alcoholics Anonymous is naturally fitted to do, and this is the job it does best. This is the job it can concentrate on with the least danger of disturbing complications in its own structure and function. It is not too much to say that Alcoholics Anonymous does this particular job more effectively, economically and dependably than any other therapeutic agency in operation at the present time. So far as the underlying disorder or needs for adjustment are concerned, Alcoholics Anonymous is not equipped to do an equally effective job. A certain number of these needs for adjustment, of course, are more or less direct results of the disorder which compulsive drinking has introduced into the physical, psychological and social life of the individual. Some of them stem quite directly from the psychosocial isolation which has gradually cut him off from a satisfying relationship of acceptance and participation in the group. As far as the needs for adjustment involved in the drinking are of this sort, membership in a solitary group standing for constructive moral principles, which restores the individual’s feelings of worth and puts his original resources back to work, plays a real part in the reduction of these needs. There are some cases of addiction, apparently, in which the fixation itself, and these secondary or resulting needs feeding back into itr are the most prominent features. In cases of this sort Alcoholics Anonymous can often do a very adequate job single-handed. The individual’s troubles largely disappear if he once manages to attain sobriety for a reasonable period of time and maintains an active membership. There are many other compulsive drinkers, however, who appear in the total hospital or court intake, for example, in whom the underlying disorders are so severe and persistent, or the personality resources are so limited, that the Alcoholics Anonymous

program can hardly be expected to make much difference. The feeble-minded drinkers, and those with borderline intelligence, are a part of this group. The lack of mental ability plays into the needs for adjustment, and at the same time makes it almost impossible to arouse any effective motivation to stop drinking or build in any effective inhibitions. The fixation, which Alcoholics Anonymous attacks most directly, is the least prominent part of the picture. The same may be said of the psychotic and prepsychotic drinkers and of the senile deteriorated derelict type. For these the only abvailable disposition is adequate custodial care, with the exception of certain of the psychotic or prepsychotic types for whom special treatments have been developed. In many ways the most discouraging type of all, from the point of view of alleviating the problem either for the individual or for society, but at the same time the most challenging, is the so-called psychopathic personality with a strong addiction. There is no existing public institution which will hold such individuals for custodial care; according to existing legal definitions they are not sick enough. Alcoholics Anonymous is unable to hold them for any length of time because their underlying disorder is too severe they are too sick. Their neurotic difficulties are such as to block off or dissipate any effective motivation to stop drinking, and they feel themselves lltoosmartu to be helped by any program with a religious aspect like that of Alcoholics Anonymous. They never really feel a part of the group. The psychiatrist is unable to do anything for such a drinker because the patient is not able really to cooperate, is unable to stay sober long enough for any effective therapy to be done; and the difficulty is of such severity that even under the best conditions the prognosis would be poor. The social worker is not able to accomplish anything by working with the situation because all too often the wife or other family members are involved in an interlocking neurotic relationship such that no stable situational change can be induced or maintained. There are many encouraging things, however, about the way in which the problem of alcohol addiction is being attacked at the present time: There is a clearer recognition than ever before that

compulsive drinkers do not all fall into the same class, that compulsive drinking is an external symptom of underlying disorders and disturbances of many different kinds, and that the treatment of alcohol addiction must thus necessarily be a many-sided cooperative affair. Facilities are gradually being deleloped for a simultaneous attack from these different angles. In this cooperative many-sided attack Alcoholics Anonymous plays a virtually indispensable part, a part which promises to grow even clearer and more effective as experience produces a better basis for recognizing and treating in a different fashion those compulsive drinkers who are not able to profit by the Alcoholics Anonymous program, or for whom that program in itself is not sufficient.