Is Alcoholics Anonymous (AA) a cult? Or the most successful cure for alcoholism yet devised?

Using the same methods employed in experimental medicine to test new drugs—that is, comparing AA with placebo and other standard treatments, and assessing its side effects—the verdict appears to be in.

"AA isn’t the only path to recovery, but it does allow desperate survivors to come together in one place to share experience, strength, and hope," said George Vaillant, M.D., at APA’s 2003 Institute on Psychiatric Services in Boston. "The places we as health professionals inhabit—clinics and emergency rooms—are filled with unrecovered alcoholics. But in AA you can find the greatest concentration of recovering alcoholics in the world."

Vaillant is a professor of psychiatry at Harvard Medical School and director of research for the department of psychiatry at Brigham and Women’s Hospital in Boston.

In his lecture, Vaillant reviewed literature on recovery from alcoholism, including his renowned longitudinal studies following "recovering" and "unrecovered" alcoholics more than 60 years.

Those studies tend to support the view that abstinence, as espoused by AA, is almost always a requirement for recovery from alcoholism, and that a return to socially controlled drinking is rare, he said. Frequency of AA attendance, having a sponsor, and engaging in 12-step work appear to contribute to the chances for successful, stable abstinence.

Vaillant said AA does not have a monopoly on treatment for alcoholism and noted that in his long-term studies many of the people who achieved stable sobriety did so without AA.

"It isn’t that professional treatment is unimportant, any more than medical and hospital treatment for diabetes is unimportant," Vaillant said.

Nonetheless, he said that some kind of disciplined regimen to sustain sobriety over a long period—such as AA offers in its 12-step program—appears to be essential.

"It isn’t that AA is a magic bullet, and a few visits create a cure," Vaillant said. "It’s something like teeth flossing or exercising—it’s something you have to keep on doing."

He acknowledged that controlling for all possible treatment effects that contribute to sobriety is exceedingly difficult, if not impossible. "You can’t control all the different ways there are of getting your alcoholism treated, so it’s very hard to do well-controlled studies and terribly hard to separate out what is the actual effect of AA and what is simply motivation and compliance."

Vaillant’s work has centered on a longitudinal comparison of Harvard graduates and inner-city men, a cohort that has now been studied for a wide range of attributes since the 1940s.

Among this group, Vaillant has also compared the long-term course of alcoholism among men in both groups who met criteria for alcohol abuse (55 of the college men; 150 of the city men).

Vaillant reported in the March 1996 Archives of General Psychiatry that by 60 years of age, 18 percent of the college alcohol abusers had died, 11 percent were abstinent, 11 percent were controlled drinkers, and 59 percent were known to be still abusing alcohol. By 60 years of age, 28 percent of the city alcohol abusers had died, 30 percent were abstinent, 11 percent were controlled drinkers, and 28 percent were known to be still abusing alcohol.

"After abstinence had been maintained for five years, relapse was rare," Vaillant concluded in the article. "In contrast, return to controlled drinking without eventual relapse was unlikely. Alcohol abuse could continue for decades without remission or progression of symptoms. The samples differed in that the core city men began to abuse alcohol when younger and, although they were more likely than the college men to become alcohol dependent, the core city men were twice as likely to achieve stable abstinence."

In his lecture at the institute, Vaillant said that among the men who had achieved five or more years of stable sobriety, the number of AA visits was significantly greater than among those who did not. He linked the motivation to attend AA, and hence the chances for recovery, to the severity of alcoholism.

"No one is going to sit on those hard church seats and inhale passive cigarette smoke if they just have a light case of alcoholism, any more than you are going to submit to a hip transplant if you just have the hip arthritis that spoils your golf and tennis game, but still lets you climb the stairs."

Vaillant emphasized that psychotherapy, SSRIs, detoxification, and Antabuse are ineffective against alcoholism in the long term. "None of the treatments lasts long enough," Vaillant said. "The advantage of AA isn’t that it is so effective at any given dose, but that it keeps on giving after you leave the clinic."

He added that the most successful psychiatric treatments affect the more advanced parts of the brain, while addiction is controlled by primitive, "reptilian" areas of the brain.

"Once you get into the reptile brain, you have as much luck [with standard treatments] as you do getting a crocodile to come when it’s called," he said.

Vaillant outlined four factors that appear to be part of any successful recovery:

• External supervision

• A competing dependency

• New love relationships

• Increased spirituality

"AA knows what all behavioralists know—that you can’t stop a bad habit by prohibiting it," he said. "You have to stop it by offering some kind of gratifying competing behavior. AA provides gratifying social events that occur during prime drinking time, positive regard, and an unlimited supply of not-so-good coffee and quite good hugs."

He suggested that the competing dependency on new relationships within the AA fellowship responds to the same neuroanatomical demand that is met—with disastrous consequences—by alcohol and drugs.

"Since it is very doubtful that our primate ancestors shot dope, the opiate receptors in our brains must have been put there for some kind of addiction," he said. "Most likely it is the underpinnings of attachment."

Finally, Vaillant refuted claims that appear from time to time in the popular press that AA operates as a cult. He noted that AA is notably nonexclusive in its acceptance of divergent religious beliefs, and he pointed to the freedom it allows members to rely on God "as we understand him."

"It is important to note that in the last 20 years, AA membership has increased 10-fold in Buddhist Japan and Catholic Spain," Vaillant said.

Moreover, AA is distinguished from cults by its style of leadership and governance. "Cults are characterized by strong charismatic leaders at the top," he said. In contrast, AA leaders—as stated in AA’s traditions—are "but trusted servants."

No cult leader wants to remain anonymous for long, Vaillant said. "Anonymity is a very good cure for cultic narcissism," he said.

An abstract of "A Long-Term Follow-up of Male Alcohol Abuse" is posted on the Web at http://archpsyc.ama-assn.org/cgi/content/abstract/53/3/243. ▪

Arch Gen Psychiatry  199653243