BASIC CONCEPTS OF ALCOHOLICS ANONYMOUS

N.Y. STATE JOURNAL OF MEDICINE Vol. 44, Aug.,1944.

William G. Wilson

Alcoholics Anonymous is an informal fellowship of about 12,000 formerly alcoholic men and women who are to be found banded together as groups in about three hundred and twenty-five American and Canadian communities, these groups ranging in size from half a dozen to many hundreds of individuals. Our oldest members have been sober for from eight to nearly ten years. Of those sincerely willing to stop drinking about 50 per cent have done so at once, 25 per cent after a few relapses, and most of the remainder have improved. It is probable that half of our members, had they not been drinkers, would have appeared in ordinary life to be normal people. The other half would have appeared as more or less pronounced neurotic.

Alcoholics Anonymous, or "AA," popularly so-called, has but one purpose - one objective only -"To help other alcoholics to recover from their illness."

Nothing is asked of the alcoholic approaching us save a desire on his part to get well. He subscribes to no membership requirements, no fees or dues, nor is belief in any particular view, medical or religious, demanded of him. As a group we take no position on any controversial question. Emphatically, we are not evangelists or reformers. Being alcoholics who have recovered, we aim to help only those who want to get well. We do this because we have found that working with other alcoholics plays such a vital part in keeping us all sober.

You may inquire "Just how does AA work?" I cannot fully answer that question. Many AA techniques have been adopted after a ten-year process of trial and error which has led to some interesting results. But, as laymen, we doubt our own ability to explain them. We can only tell you what we do, and what seems, from our point of view, to happen to us.

At the very outset we should like it made ever so clear that AA is a synthetic concept - a synthetic gadget, as it were, drawing upon the resources of medicine, psychiatry, religion, and our own experience of drinking and recovery. You will search in vain for a single new fundamental. We have merely streamlined old and proved principles of psychiatry and religion into such forms that the alcoholic will accept them. And then we have created a society of his own kind where he can enthusiastically put these very principles to work on himself and other sufferers.

Then too, we have tried hard to capitalize on our one great natural advantage. That advantage is, of course, our personal experience as drinkers who have recovered. How often the doctors and clergymen throw up their hands when, after exhaustive treatment or exhortation, the alcoholic still insists, "But you don't understand me. You never did any serious drinking yourself, so how can you? Neither can you show me many who have recovered."

Now, when one alcoholic who has got well talks to another who hasn't, such objections seldom arise, for the new man sees in a few minutes that he is talking to a kindred spirit, one who understands. Neither can the recovered AA member be deceived, for he knows every trick, every rationalization of the drinking game. So the usual barriers go down with a crash. Mutual confidence, that indispensable of all therapy, follows as surely as day does night. And if this absolutely necessary rapport is not forthcoming at once it is almost certain to develop when the new man has met other AA's. Someone will, as we say, "click with him."

As soon as that happens we have a good chance of selling our prospect those very essentials which you doctors have so long advocated, and the problem drinker finds our society a congenial place to work them out for himself and his fellow alcoholic. For the first time in years he thinks himself understood and he feels useful; uniquely useful, indeed, as he takes his own turn promoting the recovery of others. No matter what the outer world thinks of him, he now knows he can get well, for he stands in the midst of scores of cases worse than his own who have attained the goal. And there are other cases precisely like his own - a pressure of testimony which usually overwhelms him. If he doesn't succumb at once, he will almost surely do so later when Barleycorn builds a still hotter fire under him, thus blocking off all his other carefully planned exits from dilemma. The speaker recalls seventy-five failures during the first three years of AA - people we utterly gave up. During the past seven years sixty two of these people have returned to us, most of them now making good. They tell us they returned because they knew they would die or go mad if they didn't. Having tried everything else within their means and having exhausted their pet rationalizations, they came back and took their medicine. That is why we never need to evangelize alcoholics. If still in their right minds they come back, once they have been well exposed to AA

Now to recapitulate. Alcoholics Anonymous has made two major contributions to the program of psychiatry and religion. These are, it seems to us, the long missing links in the chain of recovery:

1. Our ability, as ex-drinkers, to secure the confidence of the new man - to "build a transmission line into him."

2. The provision of an understanding society of ex-drinkers in which the newcomer can successfully apply the principles of medicine and religion to himself and others.

So far as we AA's are concerned, these principles, now used by us every day, seem to be in surprising agreement. Let's compare briefly what in a general way medicine and religion tell the alcoholic:

Medicine Says

1. The alcoholic needs a personality change.

2. The patient ought to be analyzed and should make a full and honest mental catharsis.

3. Serious personality defects must be cured through accurate self-knowledge and realistic adjustment to life.

4. The alcoholic neurotic retreats from life, is a picture of anxiety and abnormal self concern; he withdraws from the "herd."

5. The alcoholic must find, "a new compelling interest in life," must "get back into the herd," He should find an interesting occupation, should join clubs, social activities, political parties, or discover hobbies to take the place of alcohol.

Religion Says

1. The alcoholic needs a change of heart, a spiritual awakening.

2. The alcoholic should make an examination of the "conscience" - or a moral inventory and a frank discussion.

3. Character defects (sins) can be eliminated by acquiring more honesty, humility, unselfishness, tolerance, generosity, love, etc.

4. The alcoholic's basic trouble is self-centeredness. Filled with fear and self seeking he has forgotten the brotherhood of man.

5. The alcoholic should learn the "expulsive power of a new affection," love of serving man, of serving God. He must "lose his life to find it;" he should join the church and there find self forgetfulness in service. For "faith without works is dead."

Thus far religion and medicine are seen in hearty accord. But in one respect they do differ. When the doctor has shown the alcoholic his underlying difficulties and has prescribed a program of readjustment, he says to him, "Now that you understand what is required for recovery, you should no longer depend on me. You must depend on yourself. You go do it."

Clearly, then, the object of the doctor is to make the patient self-sufficient and largely, if not wholly, dependent upon himself.

Religion does not attempt this. It says that faith in self is not enough, even for a nonalcoholic. The clergyman says that we shall have to find and depend upon a higher power - God. He advises prayer and frankly recommends an attitude of unwavering reliance upon Him who presides over all. By this means we discover a strength much beyond our own resources.

So, the main difference seems to add up to this: Medicine says, know yourself, be strong and you will be able to face life. Religion says, know thyself, ask God for power, and you become truly free.

In Alcoholics Anonymous the new man may try either method. He sometimes eliminates "the spiritual angle" from the Twelve Steps to Recovery and wholly relies upon honesty, tolerance and working with others. But it is interesting to note that faith always comes to those who try this simple approach with an open mind - and in the meantime they stay sober.

If, however, the spiritual content of the Twelve Steps is actively denied, they can seldom remain dry. That is our AA experience everywhere. We stress the spiritual simply because thousands of us have found we can't do without it.

At this point I should like to state the Twelve Steps of the Alcoholics Anonymous Program of Recovery so that you physicians may accurately compare your methods with ours.

The Twelve Steps

1. We admitted we were powerless over alcohol - that our lives had become unmanageable.

2. Came to believe that a power greater than ourselves could restore us to sanity.

3. Made a decision to turn our will and our lives over to the care of God as we understood him.

4. Made a searching and fearless moral inventory of ourselves.

5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

6. Were entirely ready to have God remove all these defects of character.

7. Humbly asked Him to remove our shortcomings.

8. Made a list of all persons we had harmed, and became willing to make amends to them all.

9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

10. Continued to take personal inventory and when we were wrong promptly admitted it.

11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

12. Having had a spiritual experience as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs

Boiled down, these steps mean, simply (1) admission of alcoholism; (2) personality analysis and catharsis; (3) adjustment of personal relations; (4) dependence upon some higher power; and (5) working with other alcoholics.

Most strongly we point out that adherence to these principles is not a condition of AA membership. Any alcoholic who admits he has a problem is an A. A. member regardless of how much he disagrees with the program. Based upon our experience, the whole program is a suggestion only. The alcoholic, objecting at first to the spiritual factor, is urged to keep an open mind, meanwhile treating his own AA group as a "power greater than himself." Under these conditions the newcomer commences to undergo a personality change at such a rate and of such dimensions that he cannot fully account for it on the basis of self-realization and self-discipline. Not only does his alcoholic obsession disappear, but he finds himself progressively free of fear, resentment, and inferiority. These changes seem to have come about automatically. Hence he concludes that "A power greater than himself" must have indeed have been at work. Having come to this point, he begins to form his own concept of God. He then develops confidence in that concept, which grows as he gets proof in everyday life that his new faith actually works, really produces results.

This is what AA's are trying to say when they talk about a spiritual experience. They mean a certain quality of personality change which, in their belief, could not have occurred without the help and presence of the creative spirit of the universe.

With the average AA, many months, may lapse before he is aware of faith in the spiritual sense. Yet I know scarcely an AA member of more than a year's standing who still thinks his transformation wholly a psychologic phenomenon based entirely upon his own normal resources. Almost everyone of our members will tell you that, while he may not go along with a clergyman's concept of God, he has developed one of his own on which he can positively depend, one which works for him.

We AA's are quite indifferent to what people may call this spiritual experience of ours. But to us it looks very much like conversion, the very thing most alcoholics have sworn they never would have. In fact I am beginning to believe that we shall have to call it just that, for I know our good friend, Dr. Harry Tiebout, is sitting in this room. As you may know, he is the psychiatrist who recently told his own professional Society, The American Psychiatric Association, that what we AA's get is conversion - sure enough and no fooling! And if the spirit of that great psychologist, William James, could be consulted, he'd doubtless refer us to his famous book, varieties of Religious Experience, in which personality change through the "educational variety of spiritual experience, or conversion is so ably explored. Whatever this mysterious process is, it certainly seems to work, and with us who are on the way to the asylum or the undertaker anything that works looks very, very good indeed.

And I'm very happy to say that many other distinguished members of your profession have pronounced our Twelve Steps good medicine. Clergymen of all denominations say they are good religion, and of course we AA's like them because they do work. Most ardently we hope that every physician here today will find himself able to share this happy agreement. In the early years of AA, it seemed to us alcoholics that we wandered in a sort of no-man's-land, which appeared to divide science and religion. But all that has changed since AA has now become a common meeting ground for both concepts.

Yes, Alcoholics Anonymous is a cooperative venture. All cases requiring physical treatment are referred to you physicians. We frequently work with the psychiatrist and often find that he can do and say things to a patient, which we cannot. He, in turn, avails himself of the fact that as ex-alcoholics we can sometimes walk in where he fears to tread. Throughout the country we are in daily touch with hospitals and sanitariums, both public and private. The enthusiastic support given us by so many of your noted institutions is something for which we are deeply grateful. The opportunity to work with alcoholics means everything; to most of us it means life itself. Without the chance to forget our own troubles by helping others out of theirs, we would certainly perish. That is the heart of AA - it is our lifeblood.

We have torn still other pages from the Book of Medicine, putting them to practical use. It is from you gentlemen we learn that alcoholism is a complex malady; that abnormal drinking is but a symptom of personal maladjustment to life; that, as a class, we, alcoholics are apt to be sensitive, emotionally immature, grandiose in our demands upon ourselves and others; that we have usually "gone broke" on some dream ideal of perfection; that, failing to realize the dream, we sensitive folk escape cold reality by taking to the bottle; that this habit of escape finally turns into an obsession, or, as you gentlemen put it, a compulsion to drink so subtly powerful that no disaster, however great, even near death or insanity, can, in most cases, seem to break it; that we are the victims of the age-old alcoholic dilemma; our obsession guarantees that we shall go on drinking, but our increasing physical sensitivity guarantees that we shall go insane or die if we do.

When these facts, coming from the mouths of you gentlemen of science, are poured by an AA member into the person of another alcoholic they strike deep - the effect is shattering. That inflated ego, those elaborate rationalizations by which our neurotic friend has been trying to erect self-sufficiency on a foundation of inferiority, begin to ooze out of him. Sometimes his deflation is like the collapse of a toy balloon at the approach of a hot poker. But deflation is just what we AA's are looking for. It is our universal experience that unless we can start deflation, as so self-realization, we get nowhere at all. The more utterly we can smash the delusion that the alcoholic can get over alcoholism "on his own," or that someday he may be able to drink like a gentleman, the more successful we are bound to be.

In fact, we aim to produce a crisis, to cause him to "hit bottom," as AA's say. Of course you will understand that this is all done by indirection. We never pronounce sentences, nor do we tell any alcoholic what he must do. We don't even tell him he is an alcoholic. Relating the seriousness of our own cases, we leave him to draw his own conclusions. But once he has accepted the fact that he is an alcoholic and the further fact that he is powerless to recover unaided, the battle is half won. As the AA's have it, "he is hooked." He is caught as if in a psychologic vise.

If the jaws of it do not grip him tightly enough at first, more drinking will almost invariably turn up the screw to the point where he will cry "Enough!" Then, as we say, he is softened up. This reduces him to a state of complete dependence on whatever or whoever can stop his drinking. He is in exactly the same mental fix as the cancer patient who becomes dependent, abjectly dependent, if you will, on what you men of science can do for cancer. Better still, he becomes "sweetly reasonable," truly open-minded, as only the dying can.

Under these conditions, accepting the spiritual implications of the AA program presents no difficulty even to the sophisticate. About half of the AA members were once agnostics or atheists. This dispels the notion that we are only effective with the religiously susceptible. You remember now the famous remark, "There are no atheists in the foxholes." So it is with most alcoholics. Bring them within range of the AA and "blockbusters" will soon land near enough to start radical changes in outlook, attitude, and personality.

These are some of the basic factors which perhaps partly account for such success as we have had. I wish time permitted me to give you an intimate glimpse of our life together, of our meetings, of our social side, of those fast friendships unlike any we had known before, of our participation by thousands in the war effort and the armed services, where so many AA's are discovering that they can face up to reality - no longer institutionalized, even within an AA Group. We have all found that God can be relied upon both in Alaska and India, that strength can come out of weakness, that perhaps only those who have tasted the fruits of reliance upon a higher power can fully understand the true meaning of personal liberty, freedom of the human spirit.

Surely, you who are here this morning must realize how much we A.A.'s are beholden to you, how much we have borrowed from you, how much we still depend on you. For you have supplied us with ammunition which we have used as your lay assistants - gun pointers for your artillery. I have put out for inspection our version of the factors which bring about personality change, our method of analysis, catharsis, and adjustment. I have tried to show you a little of our great new compelling interest in life - this society where men and women understand each other, where the clamors of self are lost in our great common objective, where we can learn enough of patience, tolerance, honesty, humility, and service to subdue our former masters - insecurity, resentment, and unsatisfied dreams of power.

But I must not close without paying tribute to our partner, Religion. Like Medicine, it is indispensable. At this temple of science I hope none will take it amiss if I give Religion the last word:

"God grant us the serenity to accept the things we cannot change, courage to change the things we can, and wisdom to know the difference."

Please address inquiries and requests for AA literature to The Alcoholic Foundation, Box 459, Grand Central Annex, New York 17, New York.

DISCUSSION

Dr. C. Kirby Collier, Rochester. Realizing how ineffectual our efforts in the treatment of the chronic alcoholic through the usually accepted psychiatric procedures were was my reason for investigating Alcoholics Anonymous. With one of their members I was privileged to attend a meeting in New York and had the opportunity to discuss their philosophy with Mr. Wilson. First, I was impressed with the honesty and sincerity of those members I met, and second, with the broad socio-religious background and its psychiatric implications - chiefly man's recognition of self, his abilities as well as his inefficiencies, and that intangible power which all mankind recognizes, whether he acknowledges it or not. Upon my return home, I asked three chronic alcoholics, all of twenty to twenty five years duration, to organize a group, after going over the situation with them as I understood it. These three contacted others and held their first meeting in the small apartment of one. Growing, they approached me as to a place for meeting. We eliminated the YMCA, Public Library, church halls, or parish homes for obvious reasons, and at last advised a room in one of our large centrally located hotels. This has worked out nicely and meetings are held each Sunday afternoon and Wednesday evening. From the original group of three, contacts have been made with over 500, of whom 60 per cent are active members, having been free from indulgence in alcohol for one to two years.

In our city we have had a Council on Alcohol for about three years. The group consists of psychiatrists, social workers, and others, who meet each month for discussion. At two of these meetings members of AA have spoken, and, as a result, two members of AA are now members of this Council. Members of AA are frequently called upon to address various groups, and it is most interesting to hear of men who have never spoken in public before being willing to get up and talk before any group. In Rochester they have become especially interested in meeting with youth groups. I might say that I have attended but few meetings of the Rochester group and these only at their invitation. I have felt that AA is a group unto themselves and their best results can be had under their own guidance, as a result of their philosophy. Any therapeutic or philosophic procedure which can prove a recovery rate of 50 to 60 per cent must merit our consideration. As stated by Tiebout in a paper read at Detroit, Michigan, before the American Psychiatric Association in May 1943, "It is highly imperative for us, as presumably open minded scientists, to view wisely and long the efforts of others in our field of work. We may be wearing bigger blinders than we know.

Dr. Foster Kennedy, New York City, We have heard a truly moving and eloquent address, moving in its form and in its facts.

I have no doubt that a man who has cured himself of the lust for alcohol has a far greater power for curing alcoholism than a doctor who has never been afflicted by the same curse. No matter how sympathetic and patient the doctor may be in the approach to his patient, the patient is sure either to feel, or to imagine, condescension to himself, or to the notion that he is being hectored by one of the minor prophets.

This organization of Alcoholics Anonymous calls on two of the greatest reservoirs of power known to man - religion and that instinct for association with one's fellows which Trotter has called the "herd instinct." Religious faith has been described by Matthew Arnold as a convinced belief in a power greater than ourselves that makes for righteousness, and a sense of helpfulness from this can be acquired through a kind of spiritual conversion which might well be called a variety of religious experience.

The sick man's association with those who, having been sick, have become or are becoming well, is a therapeutic suggestion of cure and an obliteration of his feelings of being, in society, a pariah; and this tapping of deep internal forces is shown by the great growth of this sturdy and beneficent movement. Furthermore this movement furnishes an objective of high emotional driving power in making every cured drunkard a missionary to the sick.

We physicians, I think, have always had difficulty in finding an occupation for our convalescent patients of sufficient emotional driving power to replace the psychic results of the alcohol that has been withdrawn. These men grow filled with a holy zeal, and the very zealousness keeps the missionary steady while the next man is being cured.

I think our profession must take appreciative cognizance of this great therapeutic weapon. If we do not do so, we shall stand convicted of emotional sterility and of having lost the faith that moves mountains, without which medicine can do little.

Dr. Harry M. Tiebout, Greenwich, Connecticut. My first contact with AA began five years ago when a patient with whom I had been working for well over a year came under the influence of AA and within a relatively short time dried up and for at least four years has remained completely dry. At that time I was puzzled and a little indignant that my best efforts had failed but AA had worked; but I kept sending patients, and now the situation has reversed. I get puzzled and a little indignant when AA doesn't work.

As a psychiatrist, I have to think about the relationship of my specialty to AA and I have come to the conclusion that our particular function can very often lie in preparing the way for the patient to accept any sort of treatment or outside help. I now conceive the psychiatrist's job to be the task of breaking down the inner resistance so that which is inside will flower, as under the activity of the AA program.

In this respect I should like to point out that the same flowering can take place with patients who are not alcoholics, and I should like at this time to record my indebtedness to Mr. Wilson and AA for the understanding which has made my own therapeutic practice a more intelligent and meaningful process in so far as my own attitudes is concerned. I now have more faith in the patient's own inner resources.