Despite the widespread acceptance of the disease concept, the leading approach to overcoming alcoholism in the United States is, ironically, not a medical treatment but a self-help program based on principles of moral and spiritual renewal. Founded in 1935 by Bill Wilson, an alcoholic stockbroker, Alcoholics Anonymous (AA) borrowed many of its ideas from an evangelical Christian movement known as the Oxford Group. Though it embraces the disease concept as part of its holistic view of alcoholism as a threefold illness (physical, mental, and spiritual), AA's primary emphasis is on achieving sobriety through a process of moral-spiritual renewal as set forth in the Twelve Steps. Central to AA's approach is the alcoholic's decision to abstain from alcohol "one day at a time." Believing alcoholism to be a disease that may be arrested but never cured, AA views "recovery" as a lifelong process requiring constant vigilance and regular attendance at meetings where members "share their experience, strength, and hope." The Twelve Steps encourage AA's members to admit their faults, make amends to those they have hurt, and help other alcoholics achieve sobriety. Members are also encouraged to select sponsors, experienced AA members who are available for advice and support.
How effective is AA? AA's membership, estimated at 1.5 million worldwide (General Service Office), provides impressive evidence of its success in reaching problem drinkers. However, the overwhelming majority of alcoholics remain untreated. Of those who are exposed to AA, many drop out; those who remain may constitute a self-selected group receptive to its message and style. Moreover, because of the methodological difficulties of conducting research on a self-help group of anonymous individuals, few controlled studies exist on AA's effectiveness compared with other treatment approaches (Ogborne and Glaser). Nonetheless, AA has come to exercise a pervasive influence over both inpatient and outpatient treatment programs in the United States, where the primary goal is often to motivate the alcoholic to participate in AA.
Advocates of AA's approach to treatment have been accused of intolerance toward alternative approaches, especially behavior modification therapies that pursue the goal of controlled drinking rather than total abstinence. Despite evidence that not all problem drinking follows a progressive, deteriorating course and that some problem drinkers are able to return to more moderate patterns of consumption, controlled drinking advocates have been criticized as irresponsible for even suggesting an alternative to abstinence (Pendery et al.). AA's success presents a curious dilemma for researchers and clinicians: The very elements that may contribute to its effectiveness as a self-help group—simple beliefs, group loyalty and cohesiveness, and an emphasis on personal experience and testimony—leave it resistant to outside influence and to new information that appears to contradict its core assumptions (Galanter). The employment of large numbers of recovering alcoholics as counselors and administrators in alcohol treatment programs has further complicated the situation as personal loyalty to AA's "one disease, one treatment" approach has come into conflict with the more empirically based, eclectic approach of researchers and of clinicians trained in the mental-health professions. The difficulty of reconciling these two orientations finds expression in a growing trend toward dual diagnosis in which alcoholics are assigned an additional psychiatric diagnosis and treated with medication. Wary of all drugs as potentially addictive, many AA-based paraprofessionals have been uneasy with psychiatric diagnosis and medication; in turn, mental-health professionals have viewed alcoholism counselors as insufficiently aware of psychiatric disorders and treatments. Such tensions point to fundamental differences in the assumptive frameworks that each group brings to diagnosis and treatment.
The first of AA's Twelve Steps declares that the alcoholic is powerless over alcohol and must therefore surrender to a "higher power." Believing this to be a self-defeating prescription for helplessness and relapse in the face of a needlessly mystified "disease," Stanton Peele has argued for restoring an explicitly moral model of alcoholism and other addictions that emphasizes the alcoholic's ability rationally to choose sobriety and commit to new values (Peele, 1988). Advocates of AA's approach argue, however, that this is precisely what AA accomplishes: a daily commitment to abstinence and "a new way of life." That alcoholics may regain a sense of control by admitting powerlessness, they say, may simply reflect a spiritual paradox rather than a contradiction.
Medicalization of alcohol problems has yet to resolve the question ofwhat causes alcoholism or to provide satisfactory solutions to the moral problems posed by the use and misuse of alcohol. Motivated by the desire to destigmatize alcoholism in order to promote compassionate treatment, the disease model still has not adequately disposed of the issue of personal responsibility. The drinker makes choices, but these choices are significantly influenced by biological, psychological, and sociocultural forces beyond conscious control. An important element ofAA's success may be that it embraces both aspects of this duality: It holds that alcoholics do not choose their condition—they are subject to multiple systemic forces beyond their awareness—yet, with support, they can effectively assume responsibility for their problem and choose to abstain. Meaningful ethical inquiry must embrace both poles of this duality by recognizing the complex interplay of personal choice with the many factors that may influence or limit it.
RICHARD W. OSBORNE (1 995) BIBLIOGRAPHY REVISED
SEE ALSO: Alcohol and Other Drugs in a Public Health Context; Addiction and Dependence; Behavior Modification Therapies; Freedom and Free Will; Genetics and Human Behavior; Harmful Substances, Legal Control of; Impaired Professionals; Maternal-Fetal Relationship; Mental Health Services; Smoking
Was this article helpful?