Alcoholics Anonymous at 90: Still a powerful force in alcohol recovery?

Dr James Morris explores the role of Alcoholics Anonymous (AA) in modern-day society, including AA’s influence over the collective understanding of drinking problems, and the effectiveness of its ‘12 steps to recovery’ for people who identify as ‘alcoholics’.

Alcoholics Anonymous (AA) is a worldwide fellowship open to anyone with a desire to stop drinking. Whilst AA meetings come in many forms, all members are expected to self-identify as ‘alcoholics’ and accept the need for total abstinence. Members in turn commit to attending AA, typically ‘working’ the 12 steps as a journey of acceptance and personal transformation. Although not all meetings are step-based, they are guided by the principles of AA’s 12 traditions and texts such as the ‘Big Book’, which encourage members to develop self-awareness, spiritual growth, and connection with other members.

AA celebrated its 90th anniversary this year, having developed into a worldwide movement since its origins in Ohio (US) in 1935. AA is thought to have millions of active members. However, partly due to the fundamental principle of anonymity, it is not possible to quantify the number of people who recover, or otherwise, via AA.

‘Alcoholism’ versus ‘alcohol use disorder’

Central to AA’s approach is the idea that some people suffer from a life-long condition of ‘alcoholism’, and that attending regular meetings and following AA’s principles enable ‘alcoholics’ to maintain long-term sobriety. However, contemporary scientific explanations of alcohol problems are in many ways at odds with this way of understanding the nature of problem drinking. Whilst holding a firm place in public thinking, ‘alcoholism’ has largely been superseded by ‘alcohol dependence’ or ‘alcohol use disorder’ classifications.

Within AA, the notion of being an ‘alcoholic’ is generally considered as categorically different from other drinkers; as the Big Book states, “the delusion that we are like other people, or presently may be, has to be smashed”. In contrast, modern concepts of alcohol use disorders tend to recognise the continuum nature of alcohol problems in which there are no clear differences between groups, but categories are applied to assist appropriate targeting of treatment and interventions. For instance, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR), distinguishes between ‘mild’, ‘moderate’ and ‘severe’ alcohol use disorders. Other classification approaches include ‘hazardous’ (or ‘risky’) and ‘harmful’ drinking, defined as over 35 or 50 units a week for women and men, respectively, which would include many people who are far from the common stereotypes of an ‘alcoholic’.

Alcoholism-aligned models are embedded within ideas of alcohol problems as a ‘disease’ or an ‘illness’. Although some scientists do adopt disease model interpretations of alcohol use disorders, these tend to focus on brain disease models based on neurobiological features of addiction. These are different to the alcoholism-as-disease ideas within AA (1 2), whereby ‘alcoholics’ may be understood to have a physical allergy to alcohol, or to ‘alcoholism’ as a ‘mental’ and ‘spiritual malady’.

Defining features of AA

“We admitted we were powerless over alcohol — that our lives had become unmanageable.” Step one of the 12 Steps of Alcoholics Anonymous

AA places ‘powerlessness’ over drinking as a central feature of ‘alcoholism’, as indicated by step one. Although impaired control is also prominent in contemporary alcohol use disorder concepts, it is not essential to a diagnosis. For example, in DSM-5-TR, a diagnosis of alcohol use disorder can be met via other indicators such as social consequences or physiological markers such as tolerance. This relates to the complex but important subject within contemporary addiction science of ‘choice’, which, even if impaired in ‘addiction’, is still highly dependent on the context. Put simply, the degree to which a person experiencing ‘addiction’ may be able to exercise control over alcohol depends, at least to some extent, on where they are, who they are with, how they feel, and so on. This is evidently in contrast to the idea of total ‘powerlessness’ inherent to AA.

‘Denial’ is another concept that appears popular within AA and public discourse alike, but tends to be approached carefully, or avoided, in treatment or professional contexts. For instance, calls have been made to recognise the many complex reasons behind low problem recognition or reluctance to seek help, including stigma, or psychological and social challenges (3 4 5). Within addiction treatment, motivational interviewing remains a cornerstone of evidence-based care (6 7), and motivational interviewing regards ambivalence as a normal response to the challenges of addiction.

Arguably, the most significant tension between ‘alcoholism’ and alcohol use disorder concepts relates to the question of abstinence. Whilst seeking lifelong abstinence is essential within AA, evidence over many decades has shown that, for a significant proportion of people, ‘recovery’ can occur without total cessation of alcohol (8 9). This applies not only to hazardous or harmful drinkers, but even a proportion of ‘dependent’ drinkers (albeit such categorisations are in many ways also problematic). Questions remain about exactly for whom or under what conditions ‘controlled drinking’ may be achievable, although it is generally considered to be less suitable for people with more severe problems. However, despite the evidence for controlled drinking as a preferred and viable outcome for many, it has been argued that widespread scepticism towards it still exists due to the long-standing dominance of ‘alcoholism’ models.

Can the ‘alcoholic identity’ be useful?

People seen as ‘problem drinkers’ are highly stigmatised by society. Being labelled a problem drinker – especially via the term ‘alcoholic’ – can have serious implications. This includes via self-stigma; when people are aware of negative stereotypes, they are at risk of internalising and applying these beliefs to themselves. The pernicious effects of self-stigma include diminishing people’s self-worth and self-efficacy, which in turn can undermine their recovery.

Within AA, members can challenge or resolve self-stigma, and use this experience to bolster their recovery capital. For instance, one qualitative study explored how some AA members challenged the stigma by fostering an ‘alcoholic identity’ as a mark of their strength and dedication to recovery. Since ‘alcoholic’ self-labelling is required within AA, it signals commitment to the group, therefore enabling identification and bonding with others.

Although many AA members effectively manage or resolve stigma, or experience benefits from aspects of self-labelling, this experience is not universal. The reasons any one person may or may not recover via AA are numerous and complex, but some report the expectations around self-labelling to be a barrier. Although there are limited studies into the experiences of people who engage with but do not benefit from AA, some research does point to the ways in which people may find AA’s approach either initially or later incompatible with or problematic to their recovery, beliefs, or identity (10 11). That is, even for those who do become members and adopt an ‘alcoholic’ identity, not all do so without difficulty, or maintain it permanently.

Another issue relates to the broader issue of how many people with alcohol problems are unlikely to ever consider themselves ‘alcoholics’ or attend AA (12 13). These concerns have been made particularly in view of the broad spectrum of alcohol use and problems, in which most people drinking at harmful or risky levels are far removed from common ideas about what ‘alcoholism’ looks like. Whilst approaches such as brief interventions or policy changes are aimed at ‘non-dependent’ groups, the widespread application of an ‘alcoholism’ model has been argued to undermine their implementation, as well as individuals’ likelihood of problem recognition. Indeed, it seems that many heavy drinkers specifically draw on ‘alcoholism’ stereotypes to contrast against their own ‘responsible’ drinking – a practice described as othering. Heavy drinkers may paradoxically increase the very stigma they seek to avoid by reifying ideas of ‘alcoholism’ as only existing amongst an extreme, severe, and separate other.

Is there evidence that AA works?

To date, the most comprehensive analysis of the effectiveness of AA was a 2020 Cochrane review, which compiled the results of 27 studies and 10,565 participants. The review compared both 12-step facilitation treatment, in which practitioners seek to involve people in AA during and following treatment, and AA engagement generally, versus other treatment approaches (e.g. cognitive behavioural therapy) or waitlist controls. The review found that AA/12-step facilitation “may be at least as effective as other treatments” for most outcomes. Furthermore, as widely reported and emphasised by the authors, 12-step facilitation was associated with higher rates of continuous abstinence (i.e. people engaged in 12-step facilitation experienced longer periods of uninterrupted abstinence) – perhaps unsurprising given AA’s focus on total sobriety and long-term participation.

The review attracted criticisms over both the limitations of the available evidence and the author’s interpretations, including by Stanton Peele and Professor Nick Heather (14 15). For example, although more continuous abstinence was found for AA/12-step facilitation, this did not appear to translate to more total days abstinent overall during 12-month follow-up (16 17). One explanation proffered by both Peele and Heather is that this may relate to the ‘abstinence violation effect’, whereby belief in the necessity of abstinence itself can trigger heavier drinking following a ‘lapse’ (18 19 20), although one of the Cochrane authors disagreed.

More broadly, however, it is the focus on abstinence itself as the main outcome measure of the review that was called into question (21 22). It is now largely accepted that ‘recovery’ is not synonymous with abstinence, and the focus on total abstinence can be a problem for some AA members. Many studies show significant improvements in quality of life or psychological wellbeing can be achieved with reduced alcohol use, even if people still have some heavy drinking occasions (23 24).

If AA works, how does it work?

The question of how AA works has been relatively well-researched, at least in a US context (25 26), and many of the identified mechanisms align with those found to underpin addiction recovery more broadly. Such common factors include various forms of recovery capital in which people’s social, personal, and cultural resources are developed, enhancing motivation and self-efficacy whilst forming new social groups and a recovery-focused social identity (27 28 29 30). Applied to AA, social network processes bring multiple benefits to people’s thoughts and wellbeing as they learn to live and value a life without alcohol.

Recovery peer groups, whether AA or otherwise, effectively help change a person’s social networks from ones that may have been facilitating their drinking to ones that are explicitly focused on changing their drinking. Research consistently finds that establishing good social networks, with meaning and purpose, is a critical factor in recovery, and AA membership is one way this can be achieved. AA can give members a sense of meaning that is conducive to their psychological well-being, and some members may also benefit specifically from its spirituality-based aspects.

Opinions and controversies

Ninety years on, AA remains a dominant part of the recovery landscape, and shapes the public understanding of alcohol problems via its well-known ‘alcoholism’ paradigm. Looking ahead, it seems likely that AA will continue to be an important route to recovery for many people with alcohol use disorders for years to come. Yet clearly its approach is not suitable for all, including those with less severe issues, those uninterested in abstinence, or those who may be uncomfortable with other aspects such as spirituality or self-labelling.

Does AA itself have responsibility to consider such implications? Such a question may be potentially moot considering AA’s tenth tradition, “Alcoholics Anonymous has no opinion on outside issues; hence the AA name ought never be drawn into public controversy”. It could be argued that the responsibility to consider the limitations of ‘alcoholism’ models is not on AA, but on professionals and wider stakeholders such as journalists to consider more broadly how alcohol issues are framed (31 32).

‘Alcoholism’ models highlight one route to recovery for a subset of people who experience harm from their drinking, but alternatives are also needed (33 34 35). Alcohol problems extend well beyond those who fit within the ‘alcoholism’ paradigm. To discuss this should not be considered an attack on AA, but to recognise that there are tensions inherent within how alcohol problems are understood, and in turn, addressed.

by James Morris

---

The opinions expressed in this post reflect the views of the author(s) and do not necessarily represent the opinions or official positions of the SSA.

The SSA does not endorse or guarantee the accuracy of the information in external sources or links and accepts no responsibility.

---