May 21, 2013 by Dr. Bob Weathers
I just had opportunity to read two classic articles in addiction and recovery:
“How AA Works and Why It’s Important for Clinicians to Understand” by two Harvard psychiatrists and substance abuse experts, Edward Khantzian, M.D., and John Mack, M.D. (originally published in the “Journal of Substance Abuse Treatment” in 1994), and
“Twelve Reasons Why We Need to Find Alternatives to Alcoholics Anonymous” by correctional psychologist, Glenn Walters, Ph.D. (originally published in “Addictive Disorders & Their Treatment” in 2002).
Both articles receive frequent reference in the recovery literature, even now so many years after their initial publication.
Why did I pick two articles with seemingly diametrically opposed conclusions regarding Alcoholics Anonymous (A.A.)? It is simply a function of my wish to maintain as much balance and intellectual rigor as possible in reviewing A.A. I aim to explore both its strengths and potential areas for growth. You could say it is my best attempt at keeping myself honest in this ongoing inquiry.
What did I find? Well, I noticed myself quite naturally discussing the first article (Khantzian and Mack) throughout the weekend immediately following my having read it. The term which kept arising organically was “self-regulation.” The authors discuss this term first as regards the relative incapacity of the alcoholic or other drug abuser to self-regulate. What is it to self-regulate?
To be able to self-regulate includes our capacity to find relief from emotional pain, to experience pleasure (that is not ultimately self-destructive), to feel not too much or too little, to maintain sound judgment about planning our futures, and in general taking consistently good care of ourselves (e.g., avoiding hazardous situations).
For reasons upon which the authors elaborate (by means of several extended case studies), the above ability to self-regulate is most often impinged upon with the alcoholic or addict. Some combination of biology (right down to genetically inherited neurotransmitter function) and environment (e.g., one’s own developmental history, including psychological trauma and/or neglect) may be seen to predispose the alcoholic or addict to rely on chemicals to provide what is otherwise inaccessible.
A.A. works insofar as it seeks to redress the above lacks or imbalances. Utilizing key healing factors intrinsic to any therapeutic group, A.A. emphasizes such core values as honesty with oneself and others (instead of denial) and vulnerability/openness (as opposed to repression) to aid in repairing the alcoholic’s capacity for self-regulation.
While the Khantzian and Mack article underscores the power of A.A. as a recovery-directed intervention, the Walters article challenges the applicability or suitability of A.A. for any and all populations. Walters, in essence, argues against a “one-size-fits-all” approach, which he ascribes to A.A.
His critique of A.A. starts with evidence citing the high attrition rate in A.A. He next challenges the A.A. view that the alcoholic or addict must “hit rock bottom” to gain adequate motivation to change. He furthermore indicts A.A.’s Christian religious “atmosphere,” also drawing in its emphasis on an external locus of control (God as “outside me”) and personal powerlessness for the alcoholic.
Other components central to A.A. philosophy — all of them problematic for many recovering alcoholics and addicts, according to Walters — include: insistence on alcoholism as a disease, focus on one’s character defects needing to be removed by an outside forces (“higher power”), total abstinence as the only genuine way to overcoming alcoholic behavior, labeling oneself as “alcoholic” or “addict,” assuming that an alcoholic will necessarily and inevitably lose control in the presence of alcohol, potential dependence for a lifetime on attending daily A.A. meetings, and its commitment to complete anonymity (making empirical study extremely difficult).
My view of Walters’ critique? In fairness, I believe his argument for properly matching the recovering alcoholic or addict to a program which best mirrors his/her own belief system (see A.A.’s above philosophy) is critical. Feedback well-taken! Yet I must also confess that, as I read further into the Walters article, I developed a growing sense within that he somehow “missed” a deeper, insider’s view of the actual workings and benefits of A.A.
If we could combine the best of Khantzian and Mack’s examination of the profound healing dynamics intrinsic to A.A. with an openness to finding new, more cross-culturally sensitive expressions of those healing dynamics (a la Walters’ many practical suggestions), perhaps that would be the best…
Khantzian, E.J., & Mack, J.E. (1994). How AA works and why it’s important for clinicians to understand. Journal of Substance Abuse Treatment, 11(2), 77-92.
Walters, G.D. (2002). Twelve reasons why we need to find alternatives to Alcoholics Anonymous. Addictive Disorders & Their Treatment, 1(2), 53-59.