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1(1), Fall 1985
ANONYMOUS: Third Edition (1976). New York. Alcoholics Anonymous.
If there is a published review of Alcoholics Anonymous,
maybe better known as the Big Book, the editorial staff
of the Quarterly has not been able to locate it. To compensate
for its absence from the literature, we approached three
outstanding professionals in the field of addictive behaviours
and posed this task: review the Big Book. Addressing the
task are Albert Ellis, Ph. D., internationally renowned
psychologist and founder of Rational-Emotive Therapy; Alan
Marlatt, Ph.D, Director of Addictive Behaviours Research
Center at the University of Washington; and Abraham Twerski,
M.D., Medical Director of Gateway Rehabilitation Center
(near Pittsburgh) and author of "Kindness Can Be Dangerous
to the Alcoholic"
reviewer was asked to organize his review of the Big Book
around the following questions:
In light of current professional views of alcoholism, is
the Big Book still appropriate in understanding the nature
of the alcoholism and/or other addictive behaviours?
Does the Big Book provide an adequate explanation of alcoholism
Is the therapeutic approach to alcoholism, as depicted in
this text, consistent with contemporary efforts to treating
addictive behaviours like alcoholism?
Does this text adequately reflect how Alcoholics Anonymous
and other self-help groups currently practice?
In your opinion, does the Big Book represent an effective
therapeutic model for alcoholism and/or other addictive
Ellis' review, which was extrapolated from his other paper,
"Why Alcoholics Anonymous Is Probably Doing Itself
and Alcoholics More Harm Than Good By Its Insistence on
a Higher Power," chose only to address the last question
regarding the Big Book as an effective therapeutic model
for alcoholism/addictive behaviours. He did so in a rational
and logical manner. Dr. Marlatt, in his paper entitled "Is
Reliance Upon a Higher Power Incompatible With Learning
Skills?" arranged a general but scholarly response
to all of the questions. In an effort of resolution, he
drew parallels between social scientific and Alcoholics
Anonymous approaches to understanding alcoholism and recovery
Dr. Twerski complied with all the questions through his
prescription, "Go to the Patient, Not to a Book."
In his review he clarified the purpose of the Big Book;"
...it does not seek to treat nor teach by its contents...it
is a description of a program that is effective."
ALCOHOLICS ANONYMOUS IS PROBABLY DOING ITSELF AND ALCOHOLICS
HARM THAN GOOD BY ITS INSISTENCE ON A HIGHER POWER
Ellis, Ph.D., Executive Director
for Rational-Emotive Therapy
York, New York
Anonymous is a complex and profound book that has probably
helped millions of addicts. It includes so many good --
and so many questionable - points that I find it impossible
to review it in the 500 words I have been allowed. Nor can
I possibly answer the five important questions the Associate
Editor has asked of reviewers. Let me focus, therefore,
on the last of his questions: "In your opinion, does
the Big Book represent an effective therapeutic model for
alcoholism and/or other addictive behaviours?" As a
psychotherapist for more than 40 years and as the founder
of the most popular form of cognitive- behaviour therapy,
rational-emotive therapy (RET), I shall - all too briefly!
- review the 12 steps outlined in Chapter 5 of Alcoholics
Anonymous in regard to their therapeutic effectiveness.
seven therapeutic steps in A.A. that seem very useful to
many alcoholics are steps 1,4,5,8,9,10, and 12. These urge
them to admit their addictive and self-destructive ways,
make amends to those they have harmed, acquire a philosophic
awakening, and carry their message to other alcoholics.
The five A.A steps that are of dubious value and that may
easily do more harm than good in keeping people away from
Alcoholics Anonymous and in preventing their sobriety are
steps 2,3,6,7 and 11. These urge alcoholics to believe in,
rely on, and humbly pray to a Higher Power who will remove
their shortcomings and give them the will to stop drinking.
2,3,6,7 and ll are potentially unhelpful and dangerous for
many reasons -- which I expound in detail in an article
I am writing, "Why Alcoholics Anonymous Is Probably
Doing Itself and Alcoholics More Harm Than Good By Its Insistence
on a Higher Power." Let me (very briefly!) summarize
some of the points I am making in this article:
Obviously, not everyone needs a Higher Power to stop drinking,
since millions have done so while remaining agnostics and
Believing in a Higher Power is an indirect, and I would
say hypocritical, way of believing in your own power to
stop drinking. For you clearly choose to believe in this
power and you choose to assume that it exists and will help
There is no convincing evidence against the existence of
a Supreme Being who personally audits and obeys human supplication.
For every person turned-on to A A. by its insistence on
belief in a Higher Power probably two or three are turned-off
and will not join or remain a member.
Belief in a Higher Power or God may easily lead to devout
belief in Absolute Truth and other forms of dogma that (a)
are often serious emotional disturbances in their own right
and that (b) leads to dictatorship, terrorism, war, and
enormous social harm.
By calling on God to remove your defects of character, you
falsely tell yourself that you do not have the ability to
do so yourself and you imply that you are basically an incompetent
who is unable to work on and correct your own low frustration
tolerance. Since God presumably only helps those who help
themselves, this is essentially a lie - and a lie that strongly
contradicts A.A.'s fine therapeutic stand for honesty.
To pray for knowledge of God's will is again hypocrisy.
For who decides that there is a God, that He or She has
a will, and that this deity will give you "Godly"
knowledge and power. Patently, you do. So "God's will"
is largely your choice and your invention. Which, if you
want to be truly honest, and fight the rationalizing that
often goes with addiction, you had better fully admit!
Although you may well have a philosophic awakening as a
result of taking A.A.'s 12 steps, calling this (in step
12) a "spiritual" awakening is unscientific and
antitherapeutic. "Spiritual" is a vague word that
means anything from intellectual and philosophical to incorporeal,
sacred, and ecclesiastical. Many people who have had a profound
philosophical and intellectual awakening and have thereby
quit drinking have been distinctly agnostic, atheistic,
and not at all "spiritual."
sum, Alcoholics Anonymous or the Big Book has some excellent
views and directions - and again, has unquestionably helped
millions of alcoholics to stop drinking. But for the above
reasons (and many more I could add) it also contains some
questionable and often iatrogenic ideas. I fervently (but
prayerfully and unspiritually!) hope that these will be
revised before the fourth edition appears. A.A. is too good
an organization to bow to the will of anyone - including
any hypothetical Higher Power.
RELIANCE UPON A HIGHER POWER INCOMPATIBLE WITH LEARNING
Alan Marlatt, Ph. D., Director,
Behaviours Research Center,
are often critical of A.A. as a psychologist trained in
the behavioral tradition, I was taught to view alcoholism
not as a physical disease but as an acquired behavioral
disorder, a vicious habit cycle, locked in by layers of
conditioning based on years of reinforcement, both positive
(the high of the buzz) and negative (the relief from withdrawal).
We were taught that alcoholics were made, not born, and
that anyone is susceptible to developing a drinking problem,
not just those with a genetic predisposition or "allergic
reaction" to alcohol. In short, we believed in science
and the experimental method of discovering the truth about
alcoholism. As budding scientists and research-oriented
clinicians, we rejected out of hand any approach that smacked
of religion or any other nonscientific values.
my scientific training, my intuition (perhaps based on early
experiences with several alcoholics in my own family) told
me that alcoholism was more of a psychological "dis-ease"
of the spirit than a physical disease of the body. I found
some statements in the Big Book that seem to echo this philosophy
e.g., "Therefore, the main problem of the alcoholic
centers in his mind, rather than his body" (p.23),
and Dr Bob's reputed claim that alcoholism "was more
of a moral or spiritual illness than it was a physical one"
(p.219). In addition, I cannot help but be impressed with
the amazing success of A A over the past 50 years of its
existence. If alcoholism is really a disease of the spirit
(for which alcohol is no real solution), then it makes sense
that the religious fellowship of A.A provides fulfilment
of the alcoholic's underlying craving for union with a Higher
Power. Especially if it keeps its members sober, which A.A
what about those who fail to maintain abstinence, those
who relapse? As the poet and writer John Berryman so aptly
points out in his alcoholic autobiography, Recovery (N.Y
, Farrar, Straus & Giroux, 1973), acceptance of the
first step in A.A. is not always an easy task. For those
fortunate individuals who experience a classical religious
conversion experience similar to those described in the
Big Book (e g., p.56 "In a few seconds he was overwhelmed
by a conviction of the presence of God. It poured over and
through him with the certainty and majesty of a great tide
at flood"), all is well and they seem to be protected
from further temptation by the protective umbrella of the
Higher Power. As the Big Book states, "The alcoholic
at certain times has no effective mental defense against
the first drink. Except in a few cases, neither he nor any
other human being can provide such a defense. His defense
must come from a Higher Power" (p.43). Does this mean
that those who return to drink have been abandoned by God?
Does a slip mean a fall from grace or a moral sin in the
eyes of God or the alcoholic? What factors precipitate a
relapse? Here the Big Book and scientific data seem to agree.
According to the Big Book, "The greatest enemy of us
alcoholics are resentment, jealousy, envy, frustration,
and fear" (p.145). Anger and resentment are frequently
described throughout the Big Book as psychological precipitants
of the first drink. In our own research on determinants
of relapse, we found that the negative emotions such as
frustration and anger, along with interpersonal conflict
and social pressure, represent highrisk situations that
are associated with 75% of the initial relapse episodes
reported by alcoholics. Frequently, these initial steps
are preceded by certain psychological "early warning
signals" such as rationalization excuses and unrealistic
expectancies about the effects of alcohol as a means of
coping with stress or transforming unpleasant mood states.
To the extent that people can be trained to recognize and
act upon these warning signals and learn to cope more effectively
with high-risk situations for relapse, they may be able
to prevent or minimize the severity of their relapses. Forewarned
is forearmed, as the saying goes. These methods, along with
research supporting the effectiveness of these procedures
in the treatment of alcoholism, are described in a forthcoming
book by Marlatt and Gordon (Relapse Prevention, N.Y.: Guilford
may be a way of resolving the apparent dilenma between relinquishing
personal control to a Higher Power vs learning self-management
skills in the prevention of relapse. For those who experience
a profound religious conversion experience, no coping skills
other than a relianceon a Higher Power may be necessary.
In Appendix II of the Big Book it is stated, however, that
such religious "transformations, though frequent, are
by no means the rule." Most of our experiences are
what the psychologist William James calls the 'educational
variety' because they develop slowly over a period of time"
(p.569). It is for these latter individuals that coping
skills for relapse prevention are particularly helpful.
I would encourage A.A. members to share their "survival
skills" with new members or with those who are experiencing
setbacks.In this way, the "higher power" of group
support and shared coping experiences can be made available
to all members. As it says in the Big Book (p.135), "First
TO THE PATIENT NOT THE BOOK
J. Twerski, M.D.
1527, Paracelsus assembled his medical students at the University
of Basel, gathered the authoritative medical textbooks,
and threw them into a huge bonfire. "You wish to learn
medicine? Go see your patients," he said.
one cannot totally dismiss the written word, there is truth
in Paracelsus' directive. Furthermore, advances in modern
medicine occur at so rapid a pace that most texts are partially
obsolete by the time they are published.
continuing relevance of the Big Book to today's alcoholic
is precisely due to the fact that it does not seek to treat
nor teach by its contents. Rather, it is a description of
a program that is effective, and provides testimonials of
people whom the program has helped. In other words, this
is a book that says "Go to the patients, both the suffering
and the recovering. They will help you, not a book; not
even this book."
the vantage point of a psychiatrist with 20 years of experience
and involvement with 32,000 patients afflicted by alcohol
and/or chemical dependence, I have found this to be true.
The Big Book works because it advocates the program, and
it is the program that works. Searching for the secret of
A.A.'s effectiveness is akin to saying "it works in
practice, but how does it hold up in theory." The famous
5th chapter is appropriately titled "How It Works,"
not "Why It Works."
Big Book approaches alcoholism phenomenologically, and thus
remains valid, genetic and neurophysiologic findings not
withstanding. The quasirational insanity of alcoholic thinking
described in the personal accounts is as applicable today
as a half-century ago, as are the endless manipulations
with which the modern alcoholic can identify.
psychiatrists and psychologists consider all cases of alcoholism
to be symptomatic of an underlying disorder. The Big Book
seems to consider all alcoholism as primary. Given the consensus
in the field that the ratio of primary to secondary alcoholism
is 4:1, the Big Book's approach has greater likelihood of
success in an unselected population.
effectiveness of the 12-step program in other addictions,
especially narcotics, gambling, and food, indicates that
the Big Book's value extends far beyond ethanol. This is
because the 12-steps are a protocol for personality, for
growth, and for self-realization, a process of value to
even the non-alcoholic or non-addicted individual. Thus,
even if science will someday discover a physiologic solution
to the destructive effects of alcohol, the personality enhancing
value of the Big Book will continue.
the firm guidelines of its 12 traditions, Alcoholics Anonymous
has evolved and adapted to cultural changes. Nor does the
Big Book advocate a rigidity that would stultify recovery.
The Big Book and A.A. remain as effective today as the day
they came into being, and are likely to remain unfettered
by the continuing passage of time.