The tenacity of error in the treatment of addiction.

It was a hot, humid July evening and I knew that the room wouldn't be air conditioned. I also knew that the atmosphere would be stuffy and repressive. It had been more than a decade since I'd been to an Al-Anon meeting but, strangely drawn to return, I walked in and was banded an information packet for newcomers. Then, as the group members went through the ritual of their readings, I went through the printed materials. And there it was: the very same pamphlet I'd found so offensive my first visit. I'd come back for one last look to see if anything had changed, but it was just as I'd remembered. The message was clear end essentially as before. The same, it turns out, can be said of the larger twelve-step movement and the addictions field in general: the message has developed riffle in the last six decades.

William Griffith Wilson, the founder of Alcoholics Anonymous, was born November 26, 1895, in East Dorset, Vermont. When he was nine, his parents divorced, apparently because of his father's drinking, and he was left in the care of his grandparents. In 1918, Wilson married Lois Burnham and began a career as a stockbroker; he also continued his father's career of drinking.

Later, after years of alcohol abuse and its associated miseries, Wilson began admitting himself to the Charles B. Towns Hospital in Manhattan. On December 11, 1934, he admitted himself for the fourth time and was treated by a neurologist named William Duncan Silkworth. Dr. Silkworth sedated Wilson and began administering treatment with belladonna. What happened next can best be described in Wilson's own words from his book Alcoholics Anonymous Comes of Age:

My depression deepened unbearably and finally it

seemed to me as though I were at the very bottom of

the pit. I still gagged badly on the notion of a Power

greater than myself, but finally, just for the moment, the

last vestige of my proud obstinacy was crushed. All at

once I found myself crying out, "If there is a God, let

Him show Himself! I am ready to do anything, anything"

Suddenly the room lit up with a great white light.

I was caught up into an ecstasy which there are no words

to describe. It seemed to me, in a mind's eye, that I was

on a mountain and that a wind not of air but of spirit

was blowing. And then it burst upon me that I was a

free man. Slowly the ecstasy subsided. I lay on the bed,

but for a time I was in another world, a new world of

consciousness. All about me and through me was a

wonderful feeling of Presence, and I thought to myself,

"So this is the God of the preachers!"

Wilson's psychic conversion was accomplished. On the surface, at least, he was a changed man.

This experience kept him sober for five months. Then, while on a business trip in Akron, Ohio, he was overcome by the fear of relapse and panicked. It was here that he came into contact with a doctor named Robert Smith, who was also a drinker, and the two men had what has been regarded as the first Alcoholics Anonymous meeting.

Nan Robertson, in her book Getting Better Inside Alcoholics Anonymous, suggests that Wilson's deep religious experience at Towns Hospital may have been the result of hallucinations during his withdrawal, induced or precipitated by his medication. Belladonna is an atropine powder derived from the leaves and roots of Atropa belladonna, a poisonous Eurasian plant popularly known as "deadly nightshade." In any event, Wilson was apparently never able to recapture his original high (which he in his later years would call his "hot flash") and continued to seek some form of spiritual bans formation. His pursuit of spirituality through seances and experiments with LSD, as well as megavitamin therapy, ultimately scandalized AA.

But AA was the result of more than just a hot flash and a chance meeting. Its basic philosophy was derived from the Oxford Group Movement, founded in 1921 by Frank N. D. Buchman, a spirited evangelist and self proclaimed "soul surgeon." Smith introduced Wilson to the Oxford Group Movement. Buchman's religious ideas of human powerlessness, redemption from above, the value of taking a moral inventory of oneself, and the value of making amends to others inspired Wilson to develop the "Twelve Steps of Recovery," which, referring to alcoholism only twice, reads:

We:

1. 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 ready 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 admired 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 awakening as the result of these steps, we tried to carry this message to alcoholics, and practice these principles in all our affairs.

Wilson started his recovery program in 1935 as part of the Oxford Group but broke from the movement to form Alcoholics Anonymous in 1936. Beyond his assimilation of many of Buchman's ideas, Wilson developed a formula that was remark ably egocentric. The basic concepts of AA embody the parochial singularities of his own recovery experience and are spelled out in his book Alcoholics Anonymous--nicknamed "The Big Book"--which is essentially the bible of AA.

The first such concept is that of "hitting bottom": reaching a state of total emotional collapse and depression. He viewed this as an essential component to the recovery process: emotionally, you have to feel as though you are "at the bottom of the pit"

The second concept is that of "deflation of ego in depth": essentially, the admission and acceptance of defeat. Desperation is viewed as an essential component, with Wilson saying that "proud obstinacy" has to be "crushed" Desperation is necessary for a "conversion experience"

The third concept is that of a "higher power": the turning of one's life and will over to an external entity that is more powerful and capable of managing one's life. In essence, this entails psychic surrender--turning one's life and will over to "the God of the preachers" or at least to the group pressure and collective belief system of AA.

Because AA came into being at a time when modern methods of medical therapy, clinical psychology, clinical sociology, and professional counseling were all but non existent in the field of addictions treatment, AA filled a vacuum. The medical and psychological communities had failed to provide appropriate and adequate care for those addicted to alcohol, and so AA got the franchise. This meant that, for decades after AA's founding, expensive and lengthy addictions treatment programs adopted and offered essentially the same basic philosophy and methodologies as AA.

In 1951, the organization known as Al-Anon was founded. It follows the same basic philosophy of AA, utilizing the twelve step approach, but provides a support network for the recovering alcoholic's family and friends. In 1953 came Narcotics Anonymous, a twelve step program and sup port network for recovering drug addicts. Then, through the 1970s and into the 1980s, there was an explosion of twelve step recovery programs. New organizations emerged until the self help domain had expanded to include just about every compulsive or self defeating behavior one could think of. It was like an evangelical movement: each program was a part of the larger AA religion, each one reframing reality to conform to the same monolithic culture and belief system. The growth was therefore lateral instead of vertical--a widening application of a single set of ideas rather than a progressive, research oriented development of new ideas and improvements. With its one size fits all approach, this larger AA movement was entirely formulaic; any self defeating or compulsive behavior called for the same prescription, the formation of yet another twelve step program.

A simple listing of existing groups is instructive: Adult Children of Alcoholics, Al-Anon, Alcoholics Anonymous, Alcoholics Victorious of the Institute for Christian Living, ARTS (Artists Recovering Through the Twelve Steps) Anonymous, Augustine Fellowship: Sex and Love Addicts Anonymous, Calix, Cocaine Anonymous, Codependents Anonymous, Co dependents of Sex Addicts, Debtors Anonymous, Drug-Anon Focus, Dual Disorders Anonymous, Emotional Health Anonymous, Emotions Anonymous, Ethics Anony mous, Gamblers Anonymous, Incest Survivors Anonymous, Naranon, Narcotics Anonymous, Nicotine Anonymous, Obsessive Compulsive Anonymous, Overcomers Outreach, Overeaters Anonymous, Pill Addicts Anonymous, Pills Anonymous, Prostitutes Anonymous, Sex Addicts Anonymous, Sexaholics Anonymous, Survivors of Incest Anonymous, and Workaholics Anonymous. Though some of these groups offer their own minor variations on the twelve steps, all have the same spiritual religious orientation.

The general nature of all these groups is best seen in the pamphlet Al-Anon Spoken Here, which I found so objectionable at my first Al-Anon meeting. In it, guidelines for the operation of the meetings are provided. The reader is told that, within meetings, only Al-Anon "conference approved" literature can be read and discussed; sources of information from outside the program are not to be used because they "dilute" the spiritual nature of the meetings. Therapy, therapists, and professional terminology are also taboo topics of discussion, as are other recovery or treatment programs.

Such limitations on freedom of inquiry and discussion are common throughout the wider movement. The twelve-step philosophy is essentially static and resistant to change. New ideas aren't readily embraced and new methodologies from out side any given program are viewed as a threat. The peculiar thing about this is an ironic relationship to the "denial" that is so often discussed within meetings. When AA-style programs discourage objective and critical thinking, as well as new information, they essentially embrace a blatant and collective denial system of their own.

Worse, if an individual in AA, for one reason or another, doesn't make adequate progress, the typical view is that he or she isn't adequately "working the program" The usual prescription, then, is to attend more meetings. This is another form of denial: the program can never be the problem.

In 1983, therapist Janet Geringer Woititz published a book entitled Adult Children of Alcoholics, which describes the syndrome associated with individuals raised in an alcoholic family. This book became a best seller. After its success, a number of other authors began publishing on adult children of alchoholics, as well as on codependence in general. Within the framework of the twelve steps, both the ACoA and codependence movements grew rapidly, gaining considerable media attention.

Of course, true to form for any AA movement, acceptance of these new ideas was not easy or immediate. Within Al Anon, for example, a large proportion of the membership banded together to resist incorporating ACoA groups into their program. Though this incorporation eventually occurred, it was only after the twelve steps had been safely imposed upon the membership within the newly formed meetings.

The next development occurred in 1986 when therapist Anne Wilson Schaef, in her book Codependence Mistreated Misunderstood, expanded the concept of codependence from its original clinical application--involving the spouse of an alcoholic--to declare "that it includes the majority of the population of the United States" Along the same line, Herbert Gravitz and Julie Bowden prefaced their 1987 book Recovery: A Guide for Adult Children of Alcoholics with the statement, "Children of alcoholics are but a visible tip of a much larger social iceberg which casts an invisible shadow over as much as 96 percent of the population."

The next logical step was reported in an article entitled "Healing Ourselves and Our Planet" in the winter 1992 issue of Contemporary Drug Problems, in which Robin Room, vice president for research and development at the Addiction Research Foundation in Toronto, described the way in which many individuals within the growing twelve step movement--particularly in Northern California--moved between programs for a variety of life problems. He then warned of the potential emergence of "a generalized twelve step consciousness" with a "sociopolitical agenda." The message was clear: if a majority of the world's population could be described as essentially codependent or dysfunctional, the global solution was simple and obvious: therapy for everyone in conjunction with the twelve steps.

The first important challenge to this growing absurdity came from psychologist Stanton Peele in 1989. His book Diseasing of America questioned the efficacy of the proliferating twelve step programs and described the movement within the addictions field as "out of control" He in eluded an important quote from Donald Goodwin, pioneering researcher in the inheritance of alcoholism, who charged:

Therapists "invented" the concept that adult

children of alcoholics have special problems that

can be treated through therapy. They were able

to sell this concept to the public and now they

are eligible for reimbursement from insurance

companies. In short, it was a way for therapists

to tap into a new market and make money.

And so, in the fall of 1991, at the national conference of the American Association for Marriage and Family Therapy, psychiatrist Steven J. Wolin, a keynote speaker, publicly denounced the ACoA and codependence movements, declaring that "the recovery movement and its lopsided counsel of damage has become dangerous." After this statement, he received a standing ovation from the five thousand members in attendance. When a ranking member of the ACoA movement was later asked by a reporter from USA Today to respond, he answered, "They're just jealous of all the money we're making"

In 1992, Terence Gorski, a prominent spokesperson within the field of addictions, addressing a conference of the National Association of Alcoholism and Drug Abuse Counselors, stated:

If I were hired by the enemies of the chemical dependency 

field . . . I couldn't give them a better strategy [to

destroy the field] than the adult children of alcoholics

movement and the codependency movement. When we

as a field expanded addictions to include all compulsive

disorders we destroyed our constituency base . . .

destroyed our funding base . . . destroyed our economic

stability.

The paradox to all this is that one limited segment of the population to which these syndromes actually do apply has not been appropriately addressed or effectively handled. This population was identified by therapist Paul Curtin at both the 1986 and 1987 conferences of the National Association for Children of Alcoholics. Citing the work of Stephanie Brown--who had related the ACoA syndrome to the framework of eight stages of childhood development, as formulated by psychologist E. H. Erickson--Curtin applied the patterns of behavior encompassed within the syndromes to the actual professionals within the addictions field, saying:

Right now when we talk about an impaired professional

in the alcoholism field, we mean a counselor who is a

recovering alcoholic and who has relapsed. If her work

is true, would we not have to say that the impaired

professionals in the alcoholism field are also untreated adult

children of alcoholics and untreated codependents. The

implications of this are enormous.

About that time, other researchers were coming to the same conclusion. Addictions professional Susan Nobleman, conducting a survey on how addictions counselors enter the field, learned that 71 percent of the professionals she surveyed had entered as a result of a personal need for addictions treatment. "The vast majority of the sample simply did not plan in the sense of any schooling or special training for this job," she reported. They had simply entered into a treatment program and were later re cruised into the profession by other recovering professionals within the field.

Joseph C. Kern, director of Alcoholism Treatment Services in Nassau County, New York, surveyed his own staff and discovered that at least 80 to 85 percent were raised in alcoholic homes. Within the agency structure, most of his staff replicated in their behavior patterns the life style of their dysfunctional families of origin. Kern also noticed that many of the professionals within the addictions field were as psychologically unhealthy as their clients.

In this context, it was no surprise that the response of most of Kern's staff to those staff members who didn't conform to the norms of the twelve step belief system, or who attempted to expose and correct obvious flaws, was to engage in a variety of passive aggressive behaviors, avoiding direct confrontation, until the nonconformers were "frozen out" and induced to resign. Criticism of the belief system wasn't tolerated; maintenance of the status quo was more important than efficacy.

Emil Chiauzzi and Steven Liljegren, in a 1993 article ap peering in the journal Substance Abuse Treatment, took note of this problem, calling the treatment of addictions within the health care field an "anomaly." They named several topics of inquiry considered taboo among health care providers, one of the most predominant being to question either the effficacy or necessity of AA and the twelve steps.

This is the nature of the "anomaly." The addictions field is one of the few areas of professional endeavor where the counselors and the patients are drawn from the same constituency, hence the twelve step bias. It's not just what these individuals embrace in terms of a belief system that's important; it's how they believe it. Their faith in the twelve step approach is quite literally as if their lives depended on it. True believers recruit other true believers, and the belief system perpetuates itself. This creates an obvious resistance to any other treatment possibilities that might be proposed.

Not surprisingly, because so many addictions professionals are as dependent upon the twelve steps as their clients, it is not at all uncommon at professional addictions conferences, workshops, and seminars for twelve step support groups to be made available for the benefit of the professionals in attendance. This is almost always done to the exclusion of any other type of support group with a differing philosophy.

All this calls into question the health of the addictions field. With the majority of its professionals having had a personal and intimate relationship with addiction, either through their own or through parental addiction within their families of origin, they often lack the emotional and psychological detachment necessary to maintain objectivity when providing treatment and open-mindedness when assessing new scientific data.

Is such therapeutic distance and new scientific data actually needed? After all, one could argue that just because the AA movement has a religious origin and nature, the features of which are significantly tied to the singularities of the founder's recovery experience; just because it is a one size fits all dogma that is offered as a panacea for so broad a range of problems that nearly everyone in the world is thought to need it; and just because most of the people who administer its treatments are also among the treated, that doesn't logically prove that there's anything wrong with it. The AA method could be wonderfully effective nonetheless.

But it is not. It suffers from two central problems: it scarcely works, and its cure is almost as bad as the malady.

George E. Vaillant, in his 1983 landmark book The Natural History of Alcoholism, describes the natural healing process associated with individuals addicted to alcohol. Without AA, therapy, or any other outside intervention, a certain percentage of the population addicted to alcohol will reach a point when they will, of their own volition, choose to abstain from the drug. Vaillant's question was: does the AA modality improve on this percentage? Compiling forty years of clinical studies, including an eight year longitudinal study of his own, he was able to determine that this treatment approach produces results no better than the natural history of the malady.

Initially such programs do produce dramatic results, as the testimonials attest. However, over the long run, the "cured" population, through relapse, like water seeking its own level, asymptotically approaches the low water mark. With or without the AA approach, approximately S percent of the alcoholic population Vaillant surveyed managed to achieve sustained abstinence. Subsequent studies have produced similar results. Therefore, to the extent that AA and other twelve step programs work, they do so for only a tiny percentage of the addicted population.

Overall, the best hard research evidence available indicates that the most commonly employed addiction treatment modalities in the United States and Canada have questionable effficacy and consistently produce negative treatment outcomes. Extensive research in a comparative analysis of treatment outcomes, conducted and compiled by Reid K. Hester and William R. Miller at the Center on Alcoholism, Substance Abuse, and Addictions--places Alcoholics Anonymous, educational lectures and films, general alcoholism counseling, and psychotherapy at the very bottom of the list in terms of effectiveness. On the other hand, modalities which include brief intervention, coping and social skills training, motivational enhancement, community reinforcement, relapse prevention, and cognitive therapy--when employed within the context of a client to program matching system typically found in Europe--consistently produce positive treatment outcomes. A statement by Miller in the September/October 1994 issue of Psychology Today puts it best: "The drug treatment community has been curiously resistant to using what works."

In fact, it has been curiously attached to that which is harmful. Twelve step groups offer what is, in reality, the antithesis of therapy. There is no cure; the solution provided by such programs entails an endless attendance at meetings. An old slogan says it best: "You never graduate from Al-Anon." And you don't; you become addicted to it, desperately hanging on to the program like a spiritual lifeline in a sea of sin and death.

Somewhere within the quagmire of the AA movement and all of the twelve-step programs associated within it, the meaning of recovery was lost. By definition, recovery is a retrieval and reclamation process, not a surrender and abdication. The process of recovery or emotional balance and psychological well being entails independence from addictive chemicals, compulsive behaviors, therapists, and recovery groups. To transfer dependence on chemically addictive substances to emotional or psychological dependence on a group or recovery program is not recovery in the true sense of the word.

Looking back to William Wilson, we might do well to describe him as an untreated adult child of an alcoholic and an untreated codependent. Given the patterns of his behavior and his life-long spiritual quest for an external solution to an internal problem, he effectively institutionalized both syndromes into his twelve step program.

This can be readily seen by returning to the original definition of the term codependence. Prior to having been expanded, convoluted, and rendered empty, the term had meaning in a limited clinical setting for a specific population. In her book Choice-making, Sharon Wegscheider-Cruse quotes Robert Subby, director of Family Systems, Inc., of Minneapolis, who defined codependency as "an emotional, psychological, and behavioral condition that develops as a result of an individual's prolonged exposure to, and practice of, a set of oppressive rules--rules which prevent the open expression of feelings, as well as the direct discussion of personal and interpersonal problems." Using this as a base, Wegscheider-Cruse expands her own definition: "Codependency is a specific condition that is characterized by preoccupation and extreme dependence (emotionally, socially, and sometimes physically) on a person or object. Eventually, this dependence on another person becomes a pathological condition that affects the codependent in all other relationships" These definitions are significant in that they describe so well both the nature of twelve step programs and the relationship of the participants in these programs to their groups.

And if the problem of AA addiction isn't bad enough on its own, there's an economic incentive to keep it going. Since twelve step recovery programs admittedly offer no cure--only a lifetime of participation in a recovery group--the advantage to the professionals is obvious. Each new client can be viewed as offering the potential financial equivalent of an annuity. People looking to break a dependency on alcohol may find greater success as a participant in one of the many nonspirituality based treatment programs which, although not as widely publicized, are available as alternatives to AA-style programs.

RELATED ARTICLE: Alternative Recovery Programs

* Drinkwise 527 East Liberty, Suite 209, Ann Arbor, MI 48104-2242 1-313-747-9473 1-800-222-5145

* Moderation Management P.O. Box 6005, Ann Arbor, MI 48106-6005 1-810-788-8040 [e-mail] http://comnet.org/mm/

* Rational Recovery Systems, Inc. P.O. Box 800, Lotus, CA 95651 1-916-621-2667 [e-mail] http://www.rational.org/recovery

* Secular Organizations for Sobriety 5521 Grosvenor Boulevard, Los Angeles, CA 90066 1-310-821-8430 [e-mail] http://www.codesh.org/sos

* Self-Management and Recovery Training [SMART] 24000 Merchantile Road, Suite 11, Beachwood, OH 44122 1-216-292-0220 [e-mail] http://home.sprynet.com/sprynet/mike888/

* Women for Sobriety/Men for Sobriety P.O. Box 618, Quakertown, PA 18951-0618 1-215-536-8026 [e-mail] http://www.mediapulse.com/wfs/

Michael J. Lemanski is a member of the National Association for Children of Alcoholics and has been active in the ACoA movement since its inception in the early 1980s. He currently serves as coordinator for Self Management and Recovery Training (SMART) in Massachusetts.