http://radar.smh.com.au/archives/2005/01/now_that_the_pa.html

Now that the party's over...
Jack Marx

January 01, 2005

In November of 1999, the US Supreme Court ruled that atheist drink-driver Robert Warner had been “denied his constitutional rights” when he was forced, as a condition of his probation, to attend the “deeply religious” meetings of Alcoholics Anonymous. It was a bitter judgement for AA, a movement which, since its inception in the 1930s, has successfully battled the stigma of religion and thus enjoyed a level of legitimacy in the public mindset not usually afforded to churches.

The damage controllers had barely convened in April 2000 when Audrey Kishline, co-founder of “alternative to AA” therapy group Moderation Management, killed a man and his 12-year-old daughter while driving with a blood alcohol level three times the legal limit. The tragedy might have been a public-relations triumph for AA had it occurred a few months earlier - in January, after successfully moderating her drinking for nearly a decade, Kishline had shocked her peers and supporters by suddenly denouncing MM and converting to the AA program.

As Kishline took the witness stand, and the abstinence-verses-moderation debate found popular forum, unsavoury news arrived from across the Atlantic: an internal AA General Service memo containing information of an extremely delicate nature had been faxed to a wrong number. The receivers made good use of the document – July 5 was a slow news day at the Glasgow Herald.

"There appears to be a growing number of cases around the country of police (and other agency involvement) in allegations of unlawful sexual conduct by AA members," the memo revealed. “There is a small minority of men and women who operate with sick but hidden agendas, and…seek self-gratification, often at the expense of other members or potential members."

The memo concluded with startling candour: AA, it warned, had the "potential to become a breeding ground for predatory behaviour".
By the end of the year, American self-help bookshelves, once dominated by tomes spouting AA and 12-step therapy wisdom, became home for ideas that only months before had seemed like heresy: Marianne Gillian’s How Alcoholics Anonymous Failed Me, Ken Ragge’s The Real AA, Charles’s Bufe’s AA: Cult or Cure? and Stanton Peele’s The Diseasing of America, prodigiously sub-titled: How We Allowed Recovery Zealots and the Treatment Industry to Convince Us We Are Out of Control. Alcoholics Anonymous, the self-proclaimed “20th century miracle”, staggered into the new millennium under siege.

“It’s like any religion,” says Dr. Stanton Peele, a New York psychologist and undoubtedly AA‘s most vociferous medical critic. “If it works for you, then fine. Plenty of people go to church on Sundays, they’ve been doing it for years and I don’t have a problem with that. But in America, AA is institutionalised. We have a 12 step Government whose courts are sending people to AA as a form of policy. It’s medically wrong and ethically reprehensible and completely against our constitution. And I have a big problem with that.”

Jack Trimpey, the 60-year-old Californian founder of anti-12-step therapy group Rational Recovery, is even less diplomatic.
“It’s a dangerous…religious…cult,” he says, dumping the words like burdensome sacks he’s been carrying around for years, “and one that has become a potent political force because of its uncanny ability to present a pious exterior. The truth is, these people are hucksters with carney mentalities, and what they’re selling you is absolution from moral responsibility, which in turn absolves them of theirs.”

While Peele and Trimpey form the vanguard in the American rebellion against AA, they are by no means drinking buddies. They openly dislike each other (Trimpey regularly refers to Peele as “Dr Beast at Large”, Peele to “Jack’s inability to play with others”), and their respective agendas are so different as to be hostile.

For Peele, author of several scientifically applauded books on addiction, AA is flawed therapy whose hymnal supplication to the “disease” and “denial” concepts and ironclad edict of abstinence spell disaster not just for those who seek help, but those who seek to provide it. The solutions to addiction are mercurial as addiction itself, and Peele sees AA’s refusal to acknowledge this as tantamount to malpractice.

“If you go to a hospital and you say you’re sick,” he says, “they’ll give you penicillin or something. If it doesn’t work for you and you don’t get better, they won’t keep plying you with penicillin – they’ll try something else, then something else again until you’re well. In AA, if you say the treatment isn’t working for you they tell you that you’re the problem, not the treatment, and that your ‘denial’ of the treatment is a symptom of the ‘disease’ and you therefore need AA even more. It’s this crazy kind of all-or-nothing attitude with 12-step therapy that is actually setting us all back.”

Trimpey, something of a moral crusader by contrast, cares little for the adventures of medical science, which knows “exactly zero about addiction”. He cares even less for those who hand over responsibility for their addiction to AA and thus “deserve all the mistreatment and misguidance they will get”. For Trimpey, himself a former addict, it’s a simple matter of “taking control of one’s hands and feet” and not doing that which is “plainly stupid”.

“The founding principle of AA is: ‘we are powerless over the desire to get shitfaced drunk! We are exempt from the moral standards that apply to all others, because we are alcoholics.’ That’s just stupid, and there is no justification for calling stupidity a disease.”

One instinctively feels Trimpey’s explosive declarations should be treated with caution; they have that soapbox ring to them. At the same time, in an argument beleaguered with bickering doctors, fragile theories, flaky statistics, loose-limbed hypotheses and bubbling beakers of psychobabble, the vulcanised simplicity of a Trimpey analogy seems to sledge through confusion like the original blunt instrument.

“I always ask people to try to imagine that initial meeting between Bill Wilson and Bob Smith,” says Trimpey, referring to AA's founding fathers. “One says, ‘You know, just between you and me I can’t stop drinking.’ And then the other says, ‘Well, you know what? Neither can I.’ ‘Well, I tell you what: I’ll watch you if you watch me.’ ‘OK, because I sure can’t trust myself.’ So they look over each other’s shoulder, taking responsibility for each other’s behaviour rather than their own conduct, and they call the whole thing a disease. Now, whatever else was discussed in that meeting, whatever grew from that initial spark of an idea, is the product of a perverse mentality of moral irresponsibility taking place between a doctor and a stockbroker who are both, by their own definitions, constitutionally derelict.”

When New York stockbroker Bill Wilson and proctologist Bob Smith sat down in Akron, Ohio, in 1935 and promised each other they’d never drink again, they gave birth to the single most famous lay-treatment in the history of the world. Its doctrine, mapped in The Big Book of Alcoholics Anonymous (1939) was simple enough: stay sober “one day at a time”, attend meetings regularly, methodically ascend the “Twelve Steps of AA” and the house will not only stay dry, but be spiritually renovated.

And therein lay the catch: “recovery” could only be possible when one put one’s life “in God’s hands” and followed “the dictates of a higher power”. A “daily reprieve” was all that was promised (“we are never cured of alcoholism”), contingent on the daily prayer: "How can I best serve Thee, Thy will (not mine) be done." For the “spiritually sick” alcoholic, it was clear this would be no trivial conversion.

And where the spirit was weak, the flesh was ailing: alcoholism was “an illness” of “mind and body”, a “fatal malady” as unfathomable to medical science as it was to the individual unfortunate enough to fall prey to the “hopelessness of alcoholism”.
“Doctors are rightly loath to tell alcoholic patients the whole story,” said the Big Book, and thus “many are doomed who never realise their predicament”.

The “disease concept” was not new – Dr Benjamin Rush, a founder of the Temperance movement, had tabled it as early as 1784 in Inquiry into the Effects of Ardent Spirits on the Human Mind and Body – but it was far from accepted, with a 1943 poll by the Roper Center for Public Opinion Research showing only six per cent of Americans believing alcoholism to be anything other than lousy behaviour. The success of AA as both a treatment for the individual and a movement to be taken seriously would require a successful mutiny against accepted scientific and public opinion.

In 1944, Marty Mann, a professional publicist who became the “first woman to stay sober in AA”, organised the National Committee for Education on Alcoholism (now the National Council on Alcoholism and Drug Dependence), the public-relations arm of AA “resolved,” as Mann herself declared, “to let America know that alcoholism is a disease.”

According to the official NCADD history:
"She knew it would be an enormous undertaking that would need the support of an established academic institution so she turned to her friends at Yale University where E.M. Jellinek--father of the modern disease concept--and some of the most progressive minds in the country had been working to transform alcoholism from a moral problem into a public health issue."

It was a tidy quid pro quo: Mann offered Jellinek “the public relations skills she had developed while working at Macy's department store” in exchange for “the support of an established academic institution.”

This uneasy relationship, in which supply and demand seemed to travel like a secret code between the two parties, resulted in Jellinek’s papers, "Phases in the Drinking History of Alcoholics” (1946) and “Phases of Alcohol Addiction," carried in the Quarterly Journal of Studies on Alcohol in 1946 and 1952 respectively. Both were widely publicised (a 1957 Roper poll yielded a healthy 58 per cent in favour of the “disease concept”) and by the time he published his seminal work, The Disease Concept of Alcoholism in 1960, Jellinek had given Mann her rebellion, as well as a place for himself at the scientific table (alcohol science's most prestigious annual prize, the "Jellinek Memorial Award," commonly known as “The Bunky”, is presented each year in the U.S. for outstanding research in the alcohol field).

There had always been doubters within the medical community, but the first public criticism of AA to be widely distributed appeared in Harpers Magazine in January 1963. Under the headline “Alcoholics Can Be Cured – Despite AA”, Dr A. H. Cain, himself an ex-member of the Fellowship, claimed AA had become “a dogmatic cult” and urged “a thorough investigation of Alcoholics Anonymous in the interest of our public health”. A few months later, Bill Wilson, addressing the AA General Service Conference in New Jersey, coaxed titters of amusement when responding to the controversy:

“It is a mark of maturity on our part that members of the Fellowship seem to have been less disturbed by the critical article than our non-alcoholic friends have been."

With that comment, Alcoholics Anonymous turned a corner: there was something patronising in Wilson’s allusion, a self-satisfied purr in his reference to “our non-alcoholic friends” and their inability to stay cool under pressure. Suddenly, it seemed, AA members were being invited by the Fellowship’s founding father to view themselves not so much as damaged individuals forced to seek repair, but as Fellows of an enlightened elite – indeed, a “higher power”- that dwelled somewhere above the Pickwickian lumpenmasse.

But it was the unstoppable “self-help” phenomenon of the 70s and 80s that truly engaged AA with the Zeitgeist. This neurotic epoch, characterised by the logically burlesque notion of the “self-help group”, saw twelve-step therapy – a wisdom designed specifically for people with alcohol dependency – franchised from one notional asylum to the next, ‘assisting’ everyone from victims of rape to those with an unhealthy enthusiasm for community arts projects: Narcotics Anonymous, Over-Eaters Anonymous, Gamblers Anonymous, Sex and Love Addicts Anonymous, Shoplifters Anonymous, Suicide Anonymous, Emotions Anonymous, Parents Anonymous, Debtors Anonymous, Molesters Anonymous, Abortion Survivors Anonymous, Addicted Jews In Recovery Anonymous, Homosexuals Anonymous, Clutterers Anonymous, Dollars Anonymous, Fear of Success Anonymous, Media Anonymous, Shame Anonymous, Vulgarity Anonymous, Professional Artists Anonymous and, for those who may feel suffocated by so much anonymity, Fellowships Anonymous and Recoveries Anonymous. These groups – just a sample of hundreds - are neither inventions nor parodies, but actual twelve-step organisations (the addresses and phone numbers of which can be found on the Internet today).

If proof was required that AA and its doctrines had been warmly received by society at large, here it was at last, the ultimate evidence of embrace: AA and 20th century culture had reproduced, the names of their offspring fluttering from community noticeboards all over the world.

“It’s an evangelical movement about saving souls,” says Dr James Bell, a Sydney physician who specialises in addiction. “You can look at it as an intelligent, well thought-out approach to people with alcohol problems, but the underlying motif is still recovery through spiritual enlightenment.”

Bell, former director of Sydney’s Langton Centre, has seen many addicts come and go – and come again, for “none of the treatments we have today are terribly good.

“But AA is not a treatment and shouldn’t be regarded as anything to do with treatment,” he says. “It tends to be very confronting: ‘I can do it, therefore you can do it.’ In a lot of people that actually generates some antagonism and feelings of failure. It confirms their badness for them. The approach that most professionals would argue is more appropriate is a much more accepting, non-judgemental approach whereby one works with someone to try and find out what’s going on, rather than to set up two black and white alternatives.”

One of the most worrying examples of AA’s dogmatism can be heard in any one of the city’s remaindered halls every evening: the gateway to Chapter Five of The Big Book, read aloud at the opening of most AA meetings:

“Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average.”

“Terribly judgemental!” says Bell. “That’s like saying, ‘If you’re a loser, it won’t work for you’. Despite the overtly non-judgemental design of AA – the belief that alcoholism is a disease, that it’s not a matter of guilt – there remains this spectre of, ‘You’re getting this one chance and, if you don’t take it, then you’re basically a very flawed person with some serious character defects.’
“Like many evangelical movements, AA has become a victim of its own excesses in terms of fundamentalism. And fundamentalism is a narrow church, a church of blacks and whites. Of course, life is full of greys and soft edges and tolerance and forbearance and humour, all of which are conspicuously lacking in a world of fundamentalist zeal.”

That AA is a religious movement is a truth so self-evident it’s a wonder debate still exists. References to “God” – a proper noun always – appear in The Big Book 136 times, with a further 348 references to “Him”. Prayers ride on language more suited to the King James Bible than a manuscript from post-Volstead New York:
"God, I offer myself to Thee - to build with me and to do with me as Thou wilt. Relieve me of the bondage of self, that I may better do Thy will…Thy Power, Thy Love, and Thy Way of life. May I do Thy will always!"

Chapter Four, entitled "We Agnostics", goes to pains to reassure the “anti-religious” that the higher power need only be “God as you understand him”, then very clearly refers to agnosticism as “prejudice”, experienced pre-recovery by the authors who “often found ourselves handicapped by obstinacy” before “casting aside such feelings” to become “open-minded on spiritual matters”.

“We hope,” says The Big Book, “no one else will be prejudiced for as long as some of us were.”

It’s a persistent theme in AA, the notion that any feeling or thought that may arise within the mind of a newcomer – no matter how complex or wrought by individual experience – is already notorious to the Fellowship. The new AA member is thus a thoroughly predictable unit, whose doubts or reservations about any aspect of the Fellowship can be dismissed as products of a monstrous symptom of early recovery – a psychological bogeyman made famous in the 1960s by Elizabeth Kubler-Ross: “denial”.

“There is no such thing as denial,” declares Jack Trimpey. “Problem drinkers always know they’re problem drinkers, which is why they go, often quite trustingly, to AA in the first place. Denial is a semantic ratchet with which to wrench people into AA and keep them there. And let’s not forget it’s also a tool with which they forgive themselves. They say, ‘For the 29 years that I drank outrageously, spending my family’s money on alcohol to the tune of $300 a week while my kids didn’t have any shoes, I was unaware!’ Their ‘denial’, which is a ‘symptom’ of the ‘disease’, becomes the medical absolution of moral culpability.”

An example, no less typical for being asinine, can be found in the Rutgers University doctoral dissertation of Dr Janet Woititz, author of the bestselling Adult Children of Alcoholics (1990). Attempting to show that children of alcoholics benefited from 12-step programs, Woititz in fact found that those who attended Alateen had significantly lower self-esteem than those who did not. Finding her own evidence somewhat burdensome, Woititz concluded that "the non-Alateen children are still in the process of denial."

The dangers of this type of thinking should be palpable to anyone familiar with the controversy surrounding “Repressed Memory Syndrome” in the 80s and 90s.

But such criticisms of AA and 12-step therapy are primarily cosmetic. One might just as well cite the maddeningly infinite list of slogans with their cheap, meaningless magic (“Live simply so that others can simply live!”), or the inherently tedious biographical tales of inebriated excess (every bit as engaging in a scout hall as they are in a pub) as reason enough to stay away.

The crucial questions about AA that beg to be answered are “does AA work?” and “does AA do harm?” Another must precede both of these questions: “Can we trust our information?” Unfortunately, while the answer to that question might not be a definitive “no”, it certainly isn’t “yes”.

“The whole notion of AA belongs to a different realm of discourse to the realm of empirical science,” says Bell. “It’s not about evidence, as in controlled trials or statistical analyses. It’s about testimony.”

After over a century of attempted identification, the disease known as alcoholism remains quite the phantom. While almost all human ailments, from cancer to constipation, can be accurately diagnosed using blood tests, biopsies, scans or any number of invasive physical examinations, alcoholism – by any other name – exists only in the testimony of the sufferer. And verbal testimony constitutes wayward science at the best of times, let alone when the witness may be little more than a ventriloquist dummy for the types of psychopathology commonly associated with alcoholism: paranoia, self-loathing, delusion, or, indeed, “denial”.

Ironically enough, the futility of this situation is no more strikingly evident than in the Michigan Alcoholism Screening Test (MAST), a diagnostic questionnaire developed by Melvin Selzer, M.D. in 1971 and still widely used today. Question #8 of the test, for which an affirmative answer rates extremely high marks, is: “Have you ever attended a meeting of Alcoholics Anonymous?” Which is surely akin to ascertaining whether someone is dead by asking them if they have ever attended their own funeral.

So what of Jellinek’s famous “disease” papers? How did one man do in the 1940s that which nobody has seemed capable of doing since? Ron Roizen PhD, a doctor of sociology from the Berkeley University of California, has spent the better part of 30 years studying the social history of post-repeal America.

“Jellinek's data came from a survey he did not design,” he says. “It was generated by Marty Mann and distributed to AA members through its newsletter, The Grapevine.” Not being of scientific stock, Mann approached Jellinek and asked that he process the data into scientifically acceptable form. Jellinek did his best – of the 158 questionnaires returned, many, he discovered, had been answered by groups of Fellowship members who had pooled and averaged their responses, and no questionnaires from women were used at all.

“In the paper itself,” says Roizen, “there is a fascinating introduction in which you see the apologetic nature of Jellinek – not apologetic towards Mann, but towards his scientific audience - for the fact that he’s dealing with such crappy data.”

Before his death in 1963, Jellinek would state that "…Alcoholics Anonymous have naturally created the picture of alcoholism in their own image."

In 1996, Roizen noticed that one of the Jellinek’s early papers was signed "E.M. Jellinek, Sc.D. (Hon.)", the parenthetical "Hon." indicating that his doctorate was honorary rather than earned – “a specification which magically disappeared from later papers”.

Curious, Roizen obtained a copy of Jellinek’s curriculum vitae from the Historical Register of Yale University, as well as a later-in-life c.v. Jellinek had given to Stanford University. The two documents did not match, with Jellinek completing degrees and doctorates almost simultaneously at an assortment of universities from Europe to Central America.

“Let’s just say,” says Roizen, “that if Jellinek’s c.v. was a piece of evidence in a court of law, if someone had prodded it, it wouldn’t have stood up.”

Further investigation of the student transcripts from University Registrars at Berlin and Liepzig Universities – the two solid entries on both c.v.s - reveals that Elvin Morton Jellinek did not even complete a degree, but had, in fact, been dropped from University rolls for failure to attend lectures or take classes. His subject preferences displayed a taste for linguistics.
The “father of the disease model of alcoholism” was, in anyone’s language, a fraud.

"It is now clear,” wrote Nick Heather and Ian Robertson in Problem Drinking, “that the disease perspective was not based on any sound scientific knowledge but on the folk wisdom of alcoholics and their helpers, on hearsay, myth, tradition, rumour and ex cathedra pronouncements of prominent alcoholics and alchologists.”

One of the the world's most respectable studies regarding the value of AA is that detailed in The Natural History of Alcoholism (1993) by Dr George E. Vaillant, professor of psychiatry at Harvard Medical School. The book is based on a 40-year study of about 600 men from two “social groups” – a college group and an “inner-city” group - along with 100 men and women from Vaillant’s own Cambridge Mass. Clinic. Vaillant’s extraordinary efforts produced a dense and baffling forest of data, but two important results stand out: more than half of the alcoholics in the inner city group “naturally evolved” out of their drinking problems without the assistance of treatment, while 95 per cent of the patients treated at Vaillant’s own clinic, where AA attendance was compulsory, had relapsed in the eight-year period following treatment, showing no greater progress than comparable groups of untreated alcoholics.

Vaillant’s findings – all the more credible for the fact they present evidence that counters Vaillant’s own interests - seemed to support the gloomy statistics revealed at the 1989 Triennial Alcoholics Anonymous Membership Survey, which stated that only five per cent of newcomers continued with the Fellowship past the first year, with a 50 per cent dropout within 30 days.

“There is compelling evidence,” writes Vaillant, “that the results of our treatment were no better than the natural history of the disease.” Sensationally, Vaillant goes on to warn the recovery community "not to interfere with the recovery process," for “it may be easier for improper treatment to retard recovery than for proper treatment to hasten it."

“Anything that has the power to do good also has the power, one must assume, to do harm,” says Dr Bell. “For me, one of the serious concerns about AA is the notion that sobriety is absolute – that you’re either recovering or you’re a drunk, even when you’re not drinking. This has a tendency to become a self-fulfilling prophesy for many people, who may have been sober for a while and then one day – perhaps because they’re simply finding things a bit stressful or whatever – they have a drink. In the support of the movement they’ve accepted the all-or-nothing notion that you’re either saved or you’re lost, and so they say, ‘Oh, hell, I’ve relapsed, I’m on the outer again.’ In that situation the acceptance of AA and all of its slogans can make the catastrophe of the relapse greater for the individual.”

In their 1990 study, The Quantification of Drug Caused Morbidity and Mortality in Australia, Holman and Armstrong found that 21 per cent of all alcohol-related deaths were the result of suicide. While we can only speculate on how many of those lives ended themselves because of alcohol, Stephen Jurd, director of the Herbert Street Clinic in North Sydney for Alcohol and Drug Abuse and a staunch supporter of AA, hints at an area where the answer may be found:
“The one thing that’s actually wrong with AA, particularly in Australia, is that you can go to meetings every day for six months, be a hard worker, get to know everybody, stack the chairs up at the end of the meetings, stop going and nobody calls you. The follow-up is inadequate.”

Which is not to say that AA should be hauled in for questioning; simply that it has a responsibility that extends beyond the warmth of the Fellowship. Having successfully sold itself to the world, it should now be willing to participate in, rather than blithely dismiss, any investigation into the impact it has on the community. Testimonials from satisfied customers tell us – according to AAs own figures – only five per cent of the story.

“There is a tremendous cost from the many downsides of 12-step groups,” says Stanton Peele. “And if a treatment not only doesn’t treat the problem but gives you a whole new set of problems again, then hey, buddy, it’s a bad treatment.”

Jack Trimpey, in his own way, concurs.

“You put thirty people in a room called Sex Addicts Anonymous, thirty people, men and women, standing up one by one and saying, ‘You know what? I just can’t say no!’ then I’ll tell you what; somebody’s going to leave with an erection.”

Australia was quick to jump on the AA wagon (the first AA meeting in Australia was held in Rydalmere in 1945) and while the movement here is strong, it is only a shadow of the institution it remains in the US. Australia does not have the same evangelical tradition as America, a legacy, perhaps, of being founded by convicts rather than by pilgrim fathers.

However, Australia’s resistance to evangelical fundamentalism is likely to change.

In 1998, John Howard responded to community anxiety over the rise of heroin addiction by launching the Australian National Council on Drugs, installing as Chairman Major Brian Watters of the Salvation Army. His second in charge was a policeman.

When in July 2000, Howard announced the establishment of the Alcohol Education and Rehabilitation foundation, $115 million over 4 years was directed towards “community-based education and rehabilitation projects”, on “advice from the Australian National Council on Drugs”. Much of this funding has gone towards faith-based treatment approaches, almost all incorporating a 12-step approach. With the rise of Drug Courts, young people on drug charges are regularly sentenced to rehabilitation in faith-based treatment programs.

Unlike the situation in America, where there are constitutional restraints on public funding for evangelical groups, Australians are unlikely to win the support of the High Court if they object to being forced to engage in evangelical treatment.

Our hunger for conspicuous heroes, combined with a growing frontline of “fundamentalist zeal”, is bound to provide more ‘solutions’ to ‘problems’ than much-needed answers to questions.

And there’s no point in waiting for answers to come from America.
Languishing in her prison cell in the United States, Audrey Kishline released a contrite statement that ended with a startling admission:

“When I failed at moderation, and then failed at abstinence, I was too full of embarrassment and shame to seek help.”

Stacia Murphy, president of the NCADD, responded:

“It’s a pity this terrible tragedy could not have been avoided by Audrey realising this much sooner.

“Unfortunately, the disease of alcoholism, which is characterised by denial, prevented this from occurring.”

Jack Marx