Tuesday, March 27, 2007

Alcoholics Anonymous: Cult or Cure

By Charles Bufe (2nd edition, 1997)

Reviewed by Marty N.

This book covers approximately the same ground as Ken Ragge’s The Real AA, reviewed here earlier, but is a much more competent and thoughtful work. Bufe refrains from expounding his own pet theory of addiction and wisely fills the pages instead with a more detailed and better documented exposition of AA’s matrix (the Buchman movement), early AA history, studies of AA’s efficacy, and contemporary currents in AA’s development. This is a more self-disciplined, better researched, less strident and ultimately more persuasive and useful critique of AA.

After a brief introduction to a stereotypical AA meeting – marked by dense cigarette smoke, drunkalogues and tributes to one’s Higher Power – Bufe asks where this came from, and launches into a study of Frank Buchman and his Oxford Group Movement (OGM), later known as Moral Rearmament.

Buchman was a Protestant evangelical who believed he had direct two-way communication with God. He was a social climber, a dandy, and an avowed admirer of Hitler in 1936. The movement he founded styled itself nondenominational and saw its mission as the integration of all religions and the establishment of a global theocracy. Buchman in the 1930s enjoyed the public support of such as Henry Ford, Russell Firestone, Cleveland Dodge, Admiral Byrd and a number of other ultraconservative patrons. Among the claims of the Buchmanite movement was that its "soul surgery" delivered its believers from sexual perversions and other sins, including the sin of drunkenness. Bufe’s account somewhat unnecessarily traces the complete history of the Buchman movement after the mid-30s through the death of its founder and its demise in the 70s, before introducing AA co-founder Bill Wilson.

Wilson was a union-hating, big-business-loving stock market promoter from a privileged background who became wealthy in the boom of the 1920s and lost it all in the crash of 1929. He began drinking self-destructively and his life fell apart.

Through a business friend who had joined Buchman’s group and stopped drinking there, Wilson was introduced to OGM principles, namely: "1) Admission of personal defeat; 2) Taking of personal inventory; 3) Confession of one’s defects to another person; 4) Making restitution to those one has harmed; 5) Helping others selflessly; 6) Praying to God for the power to put these precepts into practice."

During a stay in Towns’ hospital, the favored drying-out place for the elite, Wilson was given a cocktail of detoxification drugs including belladonna, and under that influence experienced a "great white light" and saw "the God of the Preachers." The next day he was given a copy of William James’ Varieties of Religious Experience, with its principal thesis that "the cure for dipsomania is religiomania."

He then became an active member of the Buchman group, focusing all his energy on efforts to convert other drunks to its principles. The Buchman group’s leadership was not thrilled with Wilson's single-minded concentration on drunks, however, especially drunks who had no money. And Wilson’s new Catholic recruits feared repercussions from their church, which vehemently denounced Buchman and his trend. In consequence, during 1937 the nascent and nameless "alcoholic squadron" around Wilson formally severed their OGM ties.

Bufe writes that the AA "Big Book" does not credit the OGM as source of the 12 Steps because Wilson did not want to offend the Catholic hierarchy. However, Bufe has little difficulty indeed in showing that "every single one of the steps is directly traceable to Buchman’s teachings." This is a piece of intellectual history known to relatively few who follow the 12-step philosophy.

While the "big book" was being written, the founders commenced fundraising. Through a religious connection, they obtained an initial grant of $5000 (which would be $57,000 in 1997 dollars, according to Bufe) from John D. Rockefeller in 1938. This was followed by a fundraising dinner in 1940 to which Rockefeller invited 400 of his social set. Although the immediate payoff from this event was slim, the event "made" AA in high society and led to a steady flow of donations from the power elite and, more importantly, to a stream of favorable publicity, which brought rapid expansion and thus eventually a great improvement in AA finances.

Bufe’s account of this early period unfortunately digresses at some length into a speculative and futile effort to demonstrate sixty years after the fact that Wilson and the early AA members commingled and diverted for their personal use a portion of the funds intended to finance production of the book. Who really cares?

Much more interesting and relevant is Bufe’s account of Bill W’s work to shape AA as an organization. Wilson was constantly on the road visiting members and groups, and in that process drafted the 12 traditions. While Wilson’s Steps added little new to Buchmanism, the Traditions showed Wilson at his most creative and paradoxical.

The Oxford Group Movement, Bufe writes, had been an example of the "’tyranny of structurelessness’; it was always under the informal but dictatorial control of its founder, Frank Buchman, and remained so until his death – thanks in part … to the fact that there was no organizational structure through which disaffected members could challenge him." In contrast to this, Wilson, the conservative Republican, created in AA an organizational structure that is both democratic and anarchistic.

It is democratic in that the policy-making power rests in the hands of a national council of delegates (the General Service Conference) elected from below by their meetings. It is anarchistic in the sense that the board of directors (the General Service Board) has no powers of coercion over the meetings, which remain completely autonomous. Bufe credits Wilson with a sincere intent to create a structure that no individual could dominate, not even himself.

Wilson also championed the later move to make alcoholics the majority on the AA Board. Initially the majority were non-alcoholics, to reassure donors that their funds were in reliable hands. Unfortunately Bufe’s account of AA’s unique organizational structure remains schematic; there do not seem to be sources that describe from the inside how the structure really works at its highest levels.

Much like Ragge’s work, Bufe’s book then takes the reader through the 12 steps. This is the one section where Ragge’s treatment is more thorough and more insightful than Bufe’s. Ragge is more keenly attuned to issues of psychic trauma, and he sees a potential for positive injury in the Steps, where Bufe sees mainly placebo. In Bufe’s view, the steps have little intrinsic content and little relevance to recovery from alcoholism, but a great deal of relevance to creating dependency on the AA organization with its de facto compulsory religiosity. Bufe concludes the chapter with a challenge that, I think, many of us in SOS have taken up some time ago, each in our own way. He says "Virtually anyone with any real knowledge of alcohol abuse should be able to construct a sturdier set of steps to recovery."

Bufe’s next chapter takes up the 12 traditions (which Ragge’s book practically ignored). Bufe generally likes the traditions. Their decentralization and their rule that leaders serve rather than govern, and the limitations on outside funding, are, he writes, a safeguard against emergence of a ruling elite and an expression of "one of AA’s prime goals … to keep control of the organization in the hands of its membership."

However, Bufe also notes that the 12th tradition, anonymity, besides its incidental function of protecting the organization from embarrassment should an identified member relapse, has the more strategic function of permitting AA members to penetrate the media, the treatment industry, politics and many other spheres, doing AA’s work while keeping their AA affiliation a secret.

Bufe’s too-brief discussion of AA’s published finances is also illuminating. His estimate is that nearly half of AA’s groups contribute not a dime to the financial upkeep of the General Services Office. The GSO spends more than $1 million annually over and above what the meetings contribute. The deficit is made up by profits from the sale of AA literature, principally to treatment facilities. Bufe does not discuss whether AA has a policy toward the profits made by treatment entrepreneurs purveying what is basically the AA program; there is no tithe.

Perhaps Bufe’s most thoughtful and useful chapter is No. 7, "How Effective is AA." He reviews here the significantly paltry body of literature that applies any scientific yardstick to AA’s work. AA steadfastly resists having its effectiveness measured by outsiders. However, even "friendly" studies and AA’s own figures show unimpressive results. Bufe shows, for example:

Although at least half and perhaps as many as nine out of ten alcoholics in the US have been to an AA meeting once in their lives, only about 5 to 8 percent of alcoholics return often enough for AA to count them as members.
Taking at face value AA’s own claim that 45 % of its members in 1996 had at least five years sobriety, this means that only about 2 to 4 per cent of alcoholics in the US achieved five years’ sobriety in AA.
Of every 100 persons who begin AA in any given year, only 5 are still in AA and still sober a year later – according to AA’s own 1989 surveys.
The only two studies attempting to measure the impact of AA participation against control groups (one in San Diego in 1960, another in Kentucky in the mid-70s) both concluded that AA participation was less effective than either nothing or participation in secular treatment.
A sympathetic long-term comparative study of AA-based treatment, by Harvard professor George Vaillant, found that the rate of relapse for those who had participated in the AA-based treatment was no different than for the untreated control group.
On the basis of this and a good deal of other data, most of it circumstantial but in the aggregate quite suggestive, Bufe concludes that there is no good evidence that participation in AA has any measurable effect in improving rates of recovery from alcoholism.

Like Ragge’s work, Bufe’s study leaves unanswered the question why AA does work for the people for whom it works. Bufe at least sees the issue, unlike Ragge, and suggests that AA answers some people’s needs for structure and for authority, and that it relieves loneliness, and that its essential ingredient may be the placebo effect. These are of course intuitions and speculations only. A more penetrating book about AA would expose not only why and when AA appears to fail, but also why and when AA appears to be effective. It is not enough to array numbers showing that the proportion of alcoholics who are sober in AA is a minuscule proportion of all alcoholics. This minuscule proportion makes up a cluster of about three quarters of a million sober alcoholics (>5 years), a phenomenon quite unprecedented and unparalleled, and certainly deserving of explication. One will not find the answers, or really even the question, in Bufe’s work, any more than in Ragge’s.

In a succeeding chapter, Bufe (like Ragge and others) traces some indicia of the penetration of AA into the mass media, the treatment industry, the courts and the penal system, and thus its impact on society generally. I have the feeling in reading this material that Bufe and others working in this area have only begun to scratch the surface. I share these authors’ conviction that what AA has done in these areas is frequently dishonest and overreaching. The stated goals of AA’s covert activities in many cases are worthy ones: to define alcoholism as a medical rather than a penal problem, to channel the alcoholic toward doctors and other health care providers rather than toward jails and prisons. In the name of those laudable goals, billions in public and private funds have been committed. What the public has not been told is that the gatekeepers of these funds, in 98 cases out of 100, have been secret members of a religious organization whose claim to effectiveness in treating alcoholism is threadbare at best. There has been a tremendous waste of public and private money for the surreptitious benefit of a semi-secret religious society.

A significant lacuna in Bufe's work is that not a word is said about the ties between AA and the alcoholic beverage industry. As on a number of other points, the work of William L. White, who is not at all a critic of AA, is more revealing than that of the avowed critics Ragge and Bufe.

In two succeeding chapters, Bufe examines the issue whether AA is a "cult." Contrary to Ragge’s view that AA clearly is a cult, Bufe comes to the conclusion that AA as a visible organization is in some respects a cult, in other respects not; but that the invisible part of AA operating in the treatment and other industries has so many cult-like qualities that the word fits. I found these chapters not so interesting inasmuch as there are many definitions of "cult" and the argument quickly becomes academic.

Much better is Bufe’s summing-up chapter on the current status of AA. Bufe, unlike Ragge, has locked his jaws onto a very significant fact, one which all observers of contemporary AA ought to always keep foremost in mind. This is that thanks to the power of the invisible AA in the court system and in the treatment industry, at least one third of the persons attending AA meetings today were coerced into attending. This proportion is a very conservative one, and may be substantially higher as a national average; it is very much higher at some times in some local areas.

As Bufe rightly points out, AA’s real motto today is "coercion rather than attraction." These people did not volunteer, they were drafted; they did not go into those rooms of their own free will but as prisoners. (And those who are inmates of correctional institutions compelled to attend AA are doubly prisoners.) The presence of this sizeable mass of conscripts drains AA of funds and energy, because the coerced members put little in the basket and perform little service.

More importantly, their presence drains AA of its greatest asset, its moral authority to speak for the suffering alcoholic. AA is no longer a place where you want to go to relieve your suffering, but where you have to go to take punishment. The presence of these sullen, unwilling, counter-motivated and sometimes openly rebellious masses fatally corrupts the guiding vision that once, despite its overt religiosity, gave AA its historical greatness. The core image of that vision was of AA as a society of peers holding hands. Today, it is a society where some alcoholics hold other alcoholics in a headlock.

Bufe deserves credit for a book that examines AA with very little stridency, with a judicious eye for many of AA’s contributions and strong points, and with an earnest effort to dig up the facts and to treat the evidence fairly.

There is, however, one strategic mistake in Bufe’s analysis, in my opinion, one that he shares with Ragge and with Stanton Peele (who wrote the foreword) and Jack Trimpey (the afterword). That is to equate AA with the "disease theory" of alcoholism.

To be sure, it would probably be hard to find an AA meeting today where "disease" cliches are not heard. Still, one misses one of the central contradictions within AA, and overlooks a key point for applying leverage, if one throws the "disease" baby out with the Oxford Group bathwater.

The disease theory (or group of theories) originated more than 150 years before the birth of AA; William L. White has shown in his Slaying the Dragon that treatment facilities based on the disease model were widespread before the turn of the century (100 years ago) and, indeed, it was in a medical-model facility, Towns’ Hospital, that Bill Wilson got sober.

It seems to me that AA’s attachment to the disease theory is skin-deep and purely opportunistic. The disease theory serves as a psychological hammer with which to crack the tough egos of certain types of alcoholics and open them up for religious indoctrination. It serves as respectable, scientific windowdressing for AA’s evangelical religious program, much like the "Science" in "Scientology" and in "Christian Science," which AA most resembles. It serves as political camouflage for the maneuvers of the invisible AA to channel public funds into AA pockets. It is the sheep’s cloak on the Buchmanite wolf.

Instead of peremptorily dismissing the disease theory, as Bufe does, it would be sounder strategy to hold AA to its claims and to demand from it the same accountability that is applied to other medical and quasi-medical efforts. Since alcoholism is a disease, those who purport to dispense advice about it to sufferers, e.g. AA sponsors, should be examined for basic medical competency and either licensed and bonded or prosecuted. Since alcoholism is a disease, accurate epidemiological and outcome statistics should be required of all entities that benefit from public funds related to its treatment. Refusal of an entity to submit to controlled double-blind efficacy studies using standard sociometric techniques should be immediate ground for termination of funding. Since alcoholism is a disease, there should be no less openness toward alternative treatment modalities than in treatment of other diseases. Since alcoholism is a disease, an approach that relies primarily on religious conversion should get the same short shrift as such methods receive in the medical treatment of diabetes, allergies, and other diseases with which alcoholism is often compared. The disease theory, if really taken seriously and applied consistently, is the burial shroud for the whole legacy of Buchmanite "soul surgery" in AA.

By throwing the "disease" baby out with the Buchman bathwater, Bufe also paints himself into a political corner. Bufe’s heart is in the right place, he hates the "social meat grinder" that systematically mutilates people’s psyches and then stigmatizes their resulting symptoms as sinful or criminal, and throws them in jail. Yet, by dumping the disease theory, Bufe abandons the one and only social and political platform to emerge within the past 200 years which has sought to humanize addicts and to win public sympathy for our situation. Public opinion has vacillated in broad swings between viewing us as bad people who should be jailed or sick people who should be helped. No third alternative has emerged, or is likely to. As a political sophisticate and apparently a progressive who is capable of seeing the big picture, Bufe should be aware that he who dumps the medical model ends up in bed with political reaction.

By dumping the disease theory, Bufe also discredits himself as a serious student of alcoholism and the addictions. To be sure, it is easy to pick holes in some of the aspects of the AA version or versions of the disease theory, e.g. the inevitably-progressive-and-fatal-theory (some people just stop on their own), the one-drink-one-drunk theory (it’s not that simple), and others. But to pick holes in a theory and to refute its foundation are not the same thing.

When the Journal of the American Medical Association reviewed the Big Book on its first appearance in 1939, Bufe reports, the reviewer commented scathingly and accurately on the book’s Buchmanite roots: "The book contains instructions as to how to intrigue the alcoholic addict into the acceptance of divine guidance in place of alcohol in terms strongly reminiscent of Dale Carnegie and the adherents of the Buchman ("Oxford") movement." The reviewer found only one thing of merit in the book: "The one valid thing in the book is the recognition of the seriousness of addiction to alcohol. Other than this, the book has no scientific merit or interest."

This "one valid thing" goes out the window in Bufe’s analysis. Bufe’s facile syllogism that "alcoholism is a behavior not a disease" – as if there were no diseases that had a behavioral component – closes its eyes to the monstrous fact that millions of individuals have behaviored themselves to death, or very near there, with alcohol and other addictive drugs, and continue to do so. What is the cause of this behavior? Either there exists a mysterious Jonestown cult 20 times larger than AA that secretly recruits millions of perfectly healthy and normal people and programs them to seek out a slow and terrible death by engaging in the behavior of repeatedly imbibing excessive quantities of ethanol. Or alcoholism is a disease.

Perhaps AA’s propagandists will eventually be proved wrong about ten out of ten specific characteristics of that disease as they see it, but the disease model in some form is the only thing that has emerged with sufficient power to explain the sheer massiveness and seriousness of the alcoholism problem.

One probably has to understand Bufe’s flippant rejection of the medical model and his trendy flirtation with moderation as an overreaction to the claims and practices of AA. Quite a few people are so turned off by contact with AA that they reject everything they ever heard there, even if it happens to be true. Fortunately these points form a minor part of Bufe’s work; he has the good sense not to dilate on these issues.

Bufe concludes his work with the prediction that AA has reached the peak of its influence and will probably wane substantially in the next decade. He cites six factors that are worth watching: the shrinkage of the treatment industry (due to the conservative ascendancy in government and due to Managed Care); the court decisions that mandate secular alternatives to AA in the penal system; the gradual penetration of the truth about AA’s ineffectiveness; the loosening of AA’s stranglehold on the media; the appearance and persistence of the alternative groups such as WFS, SOS and others; and AA’s own ideological fossilization. He could probably add: the dilution and corruption of AA’s vision due to the growing proportion of coerced members; and the mounting impatience with AA among real treatment professionals – people who have studied something, anything, beyond the closed world of AA’s dogma. Of course, in predicting AA’s demise, Bufe goes out on a limb. But then, those who 20 years ago predicted the collapse of the Soviet Union were also out on a limb. It has been a time of almost unimaginably rapid changes in the world, and the riskiest prophecy of all is to assume that things will remain the same.


fox said...

I went into AA on my own accord
almost 40 years ago a hopless drunk
and never had a drink since AA works if we really want sobriety
I have had a wonderful life thanks to AA

Anonymous said...

AA does live by mandates. That is, attendance by court order. if that were eliminated, the drop in attendance would be very significant.
The nexus of SAT centers and AA is important.

Anonymous said...

Exactly correct on the negative influence of the convicted. Expect to see more of them in LSR meetings as the general tolerance of them in AA has long been running thin. Shifting the convicted, the medicated, and the non-alcoholic druggies to Lifering will benefit all concerned.