EMPLOYEE ASSISTANCE QUARTERLY
Vol. 1(1), Fall 1985
ALCOHOLICS 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"
Each 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 recovery?
- 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 behaviours?
Dr. 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."
WHY ALCOHOLICS ANONYMOUS IS PROBABLY DOING ITSELF AND ALCOHOLICS
MORE HARM THAN GOOD BY ITS INSISTENCE ON A HIGHER POWER
Albert Ellis, Ph.D., Executive Director
Institute for Rational-Emotive Therapy
New York, New York
Alcoholics 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.
The 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.
Steps 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:
1. Obviously, not everyone needs a Higher Power to stop drinking, since millions have done so while remaining agnostics and atheists.
2. 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 you.
3. There is no convincing evidence against the existence of a Supreme Being who personally audits and obeys human supplication.
4. 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.
5. 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.
6. 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.
7. 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!
8. 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."
In 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.
IS RELIANCE UPON A HIGHER POWER INCOMPATIBLE WITH LEARNING SELF-
G. Alan Marlatt, Ph. D., Director,
Addictive Behaviours Research Center,
University of Washington
Psychologists 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.
Despite 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 often does.
But 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 Press, 1985).
There 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 Things First"
GO TO THE PATIENT NOT THE BOOK
Abraham J. Twerski, M.D.
Gateway Rehabilitation Center
In 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.
Whereas 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.
The 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."
From 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."
The 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.
Many 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.
The 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.
Within 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.