Cycling in the South Bay

The book “US of AA,” a polemic by Joe Miller attacks the origins of Alcoholics Anonymous on three fronts. First, it argues convincingly that there is no science behind the AA theory of “alcoholism.” Second, it shows that AA’s claim to “attract, not promote” was never adhered to, and that the only reason AA and similar 12-step programs are the default treatment for alcohol use disorder is because of an orchestrated, funded, and indefatigable lobbying-media campaign that lasted decades. Third, Miller simply argues that for most people, AA does not work.

Miller’s first point, that AA treatment is not science based, is effectively but somewhat lazily argued. He focuses first on the fact that no one involved in the formation of AA had any scientific or medical training with regard to alcohol use disorder, and on the fact that the disease theory of alcoholism was accepted by the American Medical Association as the result of a coordinated but covert media campaign. These two points are thoroughly researched and proven in great detail. AA’s only medical researcher, Dr. Jellinek, had no medical credentials and was likely a fraud, and after concluding that alcoholism was a disease in an important treatise, he actually backed away from this conclusion in later years.

Unfortunately, Miller fails to focus on the modern scientific failures of AA, which are far more relevant, and which stem from the absence of a science based approach in AA from the very beginning. There’s hardly any mention of the Oxford Group and its bible-beating fundamentalism as the guiding approach for AA’s original six steps, and more importantly, there’s no discussion of what science based treatment should have looked like, even back in in 1939.

In short, the ammunition against AA in the 30’s for being whacky and wrong is weak; alcohol use disorder hadn’t been medically described and “alcoholism” was considered a moral failure. Few branches of medicine in the 1930’s operated according to theories and practices that would be accepted in a modern hospital. For example, rejected treatments for the “insane” included malarial therapy, deep sleep therapy, insulin shock therapy, cardiazol shock therapy, electroshock therapy, and lobotomy. The difference between real medicine and AA is that over time scientists discarded the use of the word “insane” in favor of more descriptive diagnoses, and they tested these various therapies against objective outcomes, eventually concluding that they didn’t work. AA has never tested, and will never test, its theories because they are religious and therefore not testable.

Miller fails to understand that AA isn’t to blame for being wrong in 1939, or even for being wrong-headed. He misses the cardinal point, that AA isn’t science based because nothing that AA promulgates is open to investigation, testing, and revision. AA’s principle that it will never engage in controversies is its statement of religious belief, that these truths according to AA are immutable. If anything, AA’s willingness to tackle a socially distasteful syndrome like alcohol abuse is worthy of great praise, and however misguided, AA’s insistence at least superficially that alcohol abuse deserves medical recognition not moral condemnation, was a giant leap forward. But as I’ve discussed elsewhere, acknowledging somatic processes and treating them with religion is a disappointing, and ultimately for most AA participants, an ineffective way to treat alcohol misuse.

Miller’s second attack is by far his best. AA goes to great length to claim that it is anonymous and that it succeeds due to “attraction” rather than “promotion.” Nothing could be more untrue. Through its tightly coordinated but organizationally distinct lobbying arm and the full time efforts of publicist-lobbyist Marty Mann, AA achieved public acceptance, public funding, and incorporation as a business model that it could never have gotten had it passively waited to “attract” new followers. This massive and massively coordinated chicanery explains why alcohol and drug misuse in the U.S. are treated with a 12-step religion rather than with science based therapies.

Much more than his weak critique of AA’s science, Miller’s presentation of prior research regarding the way that AA mobilized politicians and media to fund and install itself as the go-to treatment for alcohol use disorder explains why science will likely never prevail in the U.S. against this and similar syndromes. In short, the religious program of AA has been adopted by virtually every drug and alcohol treatment center in existence due to the low cost of start-up, the absence of any scientific or medical credentials to be a therapist/counselor, and the limitless funding provided by healthcare insurers who now include 12-step alcohol and drug treatment as covered therapies. Other writers have explained in detail the financial boondoggle of these centers, but Miller synthesizes why they exist and how AA’s model co-opted scientific treatment of alcohol use disorder before it ever fell under the rubric of serious scientific inquiry.

By far the most disappointing aspect of Miller’s book is his third critique, that AA simply doesn’t work for most people. From his bibliography and discussion, Miller shows himself to primarily be one who synthesizes and summarizes, which is important, but he’s also lazy because the single best critique of AA lies in a simple search on PubMed. There are significant reviews and numerous randomized, controlled studies that examine exactly the question of whether AA works, and all it would have taken was a bit of reading to marshal the strongest criticism of AA, namely, that it does not work.

Of course a few published studies do show that some people are helped by AA, and the most comprehensive review shows that compared to other treatment modalities AA can confer treatment benefits. However, even the most favorable research only shows that achieving abstinence through AA is limited to a few years. No study has ever confirmed, or even hinted, that AA delivers on its promise of lifelong sobriety when you “work the steps.”

In the most favorable study results, AA shows that it can have a slightly better outcome than other modalities but only as measured over a very short time span such as three or seven years. This is another huge knock on AA that Miller misses. AA cannot claim with any sincerity to have cured anyone because the organization is by definition anonymous and immune to study. When the Big Book throws out lines like “worse than average” in discussing its results, it’s GIGO. There are no numbers because AA membership and alcohol usage are not tracked.

This is most evident in the terrible selection bias of AA itself. In my short tenure there, so many people have come and gone, never to reappear. They could never be included in a study of AA’s effectiveness because there is no record of their existence, so all you’re left with are the people who have some measure of success. But eliminating all the failures has a much better phrase to explain its statistical worthlessness than “selection bias,” and the phrase is “cherry picking.”

Is AA better than doing nothing? Some studies say yes, but most say no. Has AA ever been shown to result in lifelong sobriety? No, never. Which isn’t to say that some people in AA haven’t become sober for life, it’s just to say that their sobriety can’t be shown to be a result of AA. This is exactly the point made in “This Naked Mind” by Annie Grace, which is that sobriety for many simply happens, and continued abuse simply continues: the causes and cures are, as of 2023, unknown.

As a treatment modality, the failure of AA to result in complete sobriety is damning because unlike other treatments, in AA you are not cured as long as you are drinking, even if it’s one drink per year. In fact, even after 30 years of complete sobriety, a single drink reverts you to the status of a newcomer. The burden of proof is on AA to show that its methods result not in moderate drinking, or healthier lifestyles, or other measures of success, but that AA attendance will result in complete abstinence. With no rolls, no records, and a religious approach, this is simply impossible. By its own standard, AA is a colossal failure.

Why would Miller have failed to account for these damning scientific results? It seems partly personal, because he begins and ends the book with his personal experiences. AA didn’t work for him, and he still struggles to control his drinking. There is obvious rage in his writing at being subjected to unscientific, religious mumbo-jumbo as a “cure” for a deadly and destructive disorder. At the same time, by failing to hit on the real problem with AA, which is the fact that it is a religion not a science, he misses the substantial benefit that AA has conferred to countless people. That’s the benefit of fellowship and a support network.

Whether AA helps you stop drinking, membership provides an instantaneous network of emotional, physical, financial, social, and medical resources. Members will drive you to the hospital, pick you up, give you a place to stay, give you money, feed you, give you a job, talk to you at all hours of the day or night, and for the most part will help you recover after a binge.

Like all functioning churches, AA has a human fabric that is strong and resilient in the face of great struggle, and the only requirement is that you have to believe, or at least go through the motions of belief.

For so many people on the knife-edge of death, despair, and disease, that’s a tradeoff well worth making.

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