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The study concluded that patient-treatment matching is not necessary in alcoholism treatment because the three techniques are equal in effectiveness. Though AA itself was not studied but a 12 step approach was incorporated into the study, Tonigan and colleagues stated that "AA has rarely been investigated with the kind of rigorous methological attention it received in Project MATCH." <ref>J. Scott Tonigan, Gerard J. Connors, and William R. Miller. "Participation and involvement in Alcoholics Anonymous", in Thomas Babor, Frances K. Del Boca, eds, ''Treatment Matching in Alcoholism'', Cambridge University Press: 2003, p 184.</ref>
The study concluded that patient-treatment matching is not necessary in alcoholism treatment because the three techniques are equal in effectiveness. Though AA itself was not studied but a 12 step approach was incorporated into the study, Tonigan and colleagues stated that "AA has rarely been investigated with the kind of rigorous methological attention it received in Project MATCH." <ref>J. Scott Tonigan, Gerard J. Connors, and William R. Miller. "Participation and involvement in Alcoholics Anonymous", in Thomas Babor, Frances K. Del Boca, eds, ''Treatment Matching in Alcoholism'', Cambridge University Press: 2003, p 184.</ref>

==== Critics of Project Match====

Cutler and Fishbain July 14th, 2005, in a review of Project Match , stated that in out of more than 60 publications generated by Project MATCH , all have overlooked important results: first, the good outcomes of the zero treatment group, {those people who volunteered for treatment but dropped out} when compared to the full treatment group, and second, that improvement in all groups occurred ''immediately after enrollment'' in the study. " A median of only 3% of the drinking outcome at follow-up could be attributed to treatment. However this effect appeared to be present at week one before most of the treatment had been delivered. The zero treatment dropout group showed great improvement, achieving a mean of 72 percent days abstinent at follow-up... two-thirds to three-fourths of the improvement in the full treatment group was duplicated in the zero treatment group." They concluded that the success rate shown in project MATCH, had more to do with the population of people who volunteered for the study than with the treatments that were administered. Those who received zero treatment {people who dropped out of the study immediately} had better outcomes than those who received one session of treatment. Evidence is showing that extensive therapy may be no more effective than that of brief intervention, there is also literature that shows many of those with serious alcohol consumption problems are able to recover without any treatment.<ref> Culter, R. and Fishbain, D. (2005)Are alcoholism treatments effective? The Project MATCH data. BMC Public Health 2005, 5:75doi:10.1186/1471-2458-5-75 http://www.biomedcentral.com/1471-2458/5/75 </ref>

[[Stanton Peele|Dr. Stanton Peele]] criticized MATCH on the basis that there was no control group { a group selected specifically for non treatment} , to determine whether the treatments were more effective than the natural recovery process. Therapists in MATCH were more highly trained and monitored than addiction counselors usually available to the public. Effectiveness for all treatments was measured by reduction in frequency and intensity of drinking, whereas twelve-step and abstention-based programs, he argued, should claim no improvement without full abstention. Peele states the Project Match failure to confirm a matching hypothesis revealed more its oversights in their methods, as well as shows that American conceptions of alcoholism and treatment policy are fundamentally wrong. Non American research has shown that subjective matching does work and and other research shows that many with alcohol abuse problems heal on their own without treatment. <ref>Peele, Stanton. [http://www.peele.net/lib/niaaa.html "Ten Radical Things NIAAA Research Shows About Alcoholism."] ''The Addictions Newsletter'' (The American Psychological Association, Division 50), Spring, 1998 (Vol 5, No. 2), pp. 6; 17-19.</ref>


=== George Vaillant ===
=== George Vaillant ===

Revision as of 13:53, 25 February 2008

AA meeting sign

Alcoholics Anonymous (AA) is an informal meeting society for recovering alcoholics whose primary purpose is to stay sober and help other alcoholics achieve sobriety.[1] AA suggests that alcoholics follow its program and abstain from alcohol in order to recover from alcoholism, and share their experience, strength, and hope with each other that they may solve their common problem.[2][3][4] AA was the first twelve-step program and has been the model for similar recovery groups like Narcotics Anonymous. Al-Anon/Alateen are programs designed to provide support for relatives and friends of alcoholics. The organization was named after its primary guidebook Alcoholics Anonymous, also known as The Big Book. The issue of AA effectiveness is controversial. Although AA is not for everyone and attrition rates tend to be high,[5] there is growing evidence supporting the effectiveness of AA as a treatment for alcoholism.[6]

History

Main article: History of Alcoholics Anonymous

By 1934 alcoholic Bill Wilson had ruined a promising Wall Street career with his constant drunkenness. He was introduced to the idea of a spiritual cure by old drinking buddy Ebby Thacher who had become a member of a Christian movement called the Oxford Group. Wilson was treated by Dr. William Silkworth who promoted a disease concept of alcoholism. While in the hospital, Wilson underwent a spiritual experience which convinced him of the existence of a healing higher power and he was able to stop drinking. On a 1935 business trip to Akron, Ohio, Wilson felt the urge to drink again and in an effort to stay sober, he sought another alcoholic to help. Wilson was introduced to Dr. Bob Smith, and Smith also found sobriety through spiritual means.

Wilson and Smith co-founded AA with a word of mouth program to help alcoholics. By 1937 they determined that they had helped 40 alcoholics get sober, and two years later, with the first 100 members, Wilson expanded the program by writing a book entitled Alcoholics Anonymous which the organization also adopted as its name. The book described a twelve-step program involving admission of powerlessness, moral inventory, and asking for help from a higher power. In 1941 book sales and membership increased after radio interviews and favourable articles in national magazines, particularly by Jack Alexander in The Saturday Evening Post. By 1946, as membership grew, confusion and disputes within groups over practices, finances, and publicity led Wilson to write the guidelines for noncoercive group management that eventually became known as the Twelve Traditions. AA came of age at the 1955 St. Louis convention when Wilson turned over the stewardship of AA to the General Service Board.[7] In this era AA also began its international expansion, and by 2001 the number of members worldwide was estimated at two million.

Organization

See also: Twelve-step program: The Twelve Traditions

In 2006 there were a reported 1,867,212 AA members in 106,202 AA groups worldwide.[8] The Twelve Traditions informally guide how AA groups function, and the Twelve Concepts for World Service guide how AA is structured globally.[9]

A member who accepts a service position or an organizing role is a "trusted servant" with terms rotating and limited, typically lasting three months to one year and determined by group vote. Each group is a self-governing entity with AA World Services acting only in an advisory capacity. AA is served entirely by alcoholics, except for seven "nonalcoholic friends of the fellowship" out of twenty-one members of the AA Board of Trustees.[10]

AA groups are self-supporting and not charities, and they have no dues or membership fees. Groups rely on member donations, typically $1 collected per meeting in America, to pay for expenses like room rental, refreshments, and literature.[11] Visitors and new members are asked not to donate, and no one is turned away for lack of funds.[12]

AA undertakes no external restriction, screening, or vetting of its members, and the long-form version of Tradition Three states that any two or three alcoholics gathered together for sobriety may call themselves an AA group.[13]

AA receives proceeds from books and literature which constitute more than 50% of the income for the General Service Office (GSO),[14] which unlike individual groups is not self-supporting and maintains a small salaried staff. It also maintains service centers which coordinate activities like printing literature, responding to public inquiries, and organizing conferences. They are funded by local members and responsible to the AA groups they represent.

Program

See also: Twelve-step program: The Twelve Steps

The suggested AA recovery program for alcoholics includes not drinking alcohol one day at a time, following Twelve Steps,[15] helping with duties and service work in AA,[16] and regular AA meeting attendance[17] or contact with AA members.[15] Members are encouraged to ask their group for help in finding an experienced fellow alcoholic called a "sponsor" to help them follow the AA program, ideally one that has enjoyed sobriety for at least a year and is of the same sex as the sponsee, and who does not impose personal views on sponsees but only teaches the suggested AA program.[18]

Anyone is allowed to attend "open" AA meetings while "closed" meetings are for alcoholics, or those who feel they might be alcoholics, only.[19] There are groups for men only, groups for women only, groups angled at gay people, and groups for speakers of minority languages. Meeting formats vary between groups, and beginner meetings include a speech by the leader about how he or she came to AA and what was learned, then a group discussion on topics related to alcoholism and the AA program.[20]

AA Demographics

AA's 2004 survey of over 7500 members in Canada and the United States concluded that AA is composed of 89.1% white, 65% male, and 35% female members. Average member sobriety is eight years with 36% sober more than ten years, 14% sober from five to ten years, 24% sober from one to five years, and 26% sober less than one year. Before coming to AA, 64% of members received some type of treatment or counselling, such as medical, psychological, or spiritual. After coming to AA, 65% received outside treatment or counselling, and 84% of those members said that that outside help played an important part in their recovery.[21]

Influences on US Treatment Industry

Since 1949 when Hazelden treatment center was founded by members of alcoholics anonymous, some alcoholic rehabilitation clinics have frequently incorporated precepts of the AA program into their own treatment programs.[22] A reverse influence has also occurred with AA receiving 31% of its membership from treatment center referrals.[23]

Court Rulings

In the United States of America, Courts have ruled since 1996 that inmates, parolees, and probationers cannot be ordered to attend a religious based program such as AA or other recovery programs that have substantial religious components since such coercion is in violation of the Establishment Clause of the First Amendment of the Constitution.[24][25] AA receives 11% of its membership from court ordered attendance.[26]

The courts have found that communication between AA members is not covered under client patient or clergy privilege. AA members can be called upon to testify against other AA members in a court of law. Even though two people may promise not to disclose a shared confidence, the courts are not bound to honor that promise.[27][28]

Effectiveness

Limitations on research

The study of AA, like politics, tends to polarize observers into believers and non-believers,[29] and discussion of AA often creates argument rather than objective reflection.[30] Many researchers take a skeptical view of AA because some of AA's methods are spiritual, not scientific.[31] Membership is voluntary and determined by the individual, not by the group, with no requirements, dues or fees, or membership lists.[32] A randomized trial of AA is very difficult because members are self-selected, not randomly selected.[33] Two opposing types of self-selection bias are that drinkers may be motivated to stop drinking before they attend AA, and AA may attract the more severe and difficult cases.[34] Control groups with AA versus non-AA subjects are also difficult because AA is so easily accessible.[34] AA can work, but how well and for whom has not yet been adequately researched.[35]

Attrition

In a 1989 internal AA report based on an average of five surveys, it was estimated that of those who attended AA for the first time, 19% remained in AA after one month and 5% remained after twelve months. After the first year the rate of attrition continues at a slower rate. 40% of the Members sober for less than a year will remain another year and 90 % of members sober for five years will remain another year however, this does not predict the number that will remain sober, also those that remain sober but do not remain in the fellowship cannot be determined. There is no accurate way to determine why people leave, but the high attrition rate was significant in revealing that more needed to be done to help newcomers remain in AA.[5]

Project MATCH

Project MATCH began in 1989 and was sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The project was an 8-year, multi site, $27-million investigation that studied which types of alcoholics respond best to which forms of treatment. MATCH studied whether treatment should be uniform or assigned to patients based on specific needs and characteristics. The programs were administered by psychotherapists and, although twelve-step methods were incorporated into the therapy, actual AA meetings were not included.[36][37] Three types of treatment were investigated:

  • Cognitive Behavioral Coping Skills Therapy, focusing on correcting poor self-esteem and distorted, negative, and self-defeating thinking.[38][39]
  • Motivational Enhancement Therapy, which helps clients to become aware of and build on personal strengths that can help improve readiness to quit.[40]
  • Twelve-Step Facilitation Therapy administered as an independent treatment designed to familiarize patients with the AA philosophy and to encourage participation.[36]

The study concluded that patient-treatment matching is not necessary in alcoholism treatment because the three techniques are equal in effectiveness. Though AA itself was not studied but a 12 step approach was incorporated into the study, Tonigan and colleagues stated that "AA has rarely been investigated with the kind of rigorous methological attention it received in Project MATCH." [41]

George Vaillant

In The Natural History of Alcoholism Revisited[42] Harvard professor of psychiatry George E. Vaillant, a member of the Board of Trustees of Alcoholics Anonymous World Services, described his investigations into the effectiveness of AA.[43] In the sample of 100 severe alcoholics from his clinic, 48% of the 29 alcoholics who eventually achieved sobriety attended 300 or more AA meetings,[44] and AA attendance was associated with good outcomes in patients who otherwise would have been predicted not to remit.[45] In the sample of 465 men who grew up in Boston's inner city, the more severe alcoholics attended AA, possibly because all other avenues had failed[46] Vaillant's research and literature surveys revealed growing indirect evidence that AA is an effective treatment for alcohol abuse,[31] partly because it is a cheap, community-based fellowship with easy access.[47] Although AA is not a magic bullet for every alcoholic, in that there were a few men who attended AA for scores of meetings without improvement, good clinical outcomes correlated with frequency of AA attendance, having a sponsor, engaging in a Twelve-Step work, and leading meetings. Vaillant concluded that AA appears equal or superior to conventional treatments for alcoholism and that skepticism of some professionals regarding AA as an effective treatment for alcoholism is unwarranted.[47]Vaillant sees AA as a moral and religious system that works like many religions in that it indoctrinates its members into a new belief system. Members learn to see their former 'friend' alcohol as an enemy.[48]

Stanton Peele criticized the Vaillant study on the basis that Peele's review of Vaillant's data showed that people who quit drinking without help were less likely to relapse than people who quit drinking with the help of Alcoholics Anonymous [49].

Brandsma, Welsh, Maultsby

Research made possible by the National Institute on Alcohol Abuse and Alcoholism

A study of 260 individuals, 184 referred by the courts and 76 self referred or referred by other agencies for 210 days. Participants in the study had been screened to eliminate those who were retarded,psychotic, organically imparied, or not alcoholic. Paticipants were assigned randomly to one of the five groups listed below.

1. A Control Group: no treatment provided

2. AA Meetings: run by a man with a B.S. and a woman with high school education who had 14 and 10 years experience in Alcoholics Anonymous.

3. RBT Nonprofessional: {Rational Behavior Therapy} administered by an individual with no formal training but self taught skills.

4. RBT Professional : {Rational Behavior Therapy} led by one Phd, one M.D., three M.S.s and two M.S.W.

5. Insight Therapy: conducted by three Phd's and one M.S.W


After treatment was completed a three month follow up showed that the AA group did five times more binge drinking {drinks taken after the first one or two} than the control group and nine times the binge drinking of the Non Professional RBT group. Nonprofessional RBT was deemed the superior treatment in a comparison between the two. The study concluded coerced AA attendance did not work well.

Other finding showed AA had the worst drop out rate in spite of follow up calls by social workers suggesting they re-enter the group. Insight and the Professional RBT group showed the best in drinking indexes for the most dry days over the 3 and 9 month follow up.[50]

Other studies

  • 1967, Ditman et Al study: a court judge randomly assigned offenders to either clinical treatment, AA treatment, or to a no treatment group {control group}, and after one year 68% in the clinic group were rearrested, 69% in the AA group were rearrested, and 56% were rearrested in the group receiving no treatment. No statistically significant differences between the three groups were discovered in recidivism rate, in number of subsequent rearrests or in time elapsed prior to rearrest.[51].


  • 1997, A study assessed subjects during treatment, and at one and six-month follow-ups. Increased affiliation with AA produced better outcomes, greater motivation, and improved coping skills.[52]


  • 1999, Belief in the disease theory of alcoholism and high commitment to total abstinence were found to be factors correlated with increased likelihood that an alcoholic would have a full-blown relapse (substantial continued use) following an initial lapse (single use).[53]


  • 2001, A study was undertaken to evaluate the relationship of Sponsorship and sustained abstinence in NA/AA. The 500 participants were injection drug users that came from the inner city of Baltimore , from the community at large and were independent of treatment center affilation. The study found that over the 1 year period that there was little difference in the abstitent rate for those people who had a sponsor in NA/AA and those who did not have a sponsor. The study concluded that those people who sponsored others by giving guidance and direction to other addicts had improved abstinent rates however it did little to improve the short term success rates of those being sponsored. [54]


  • 2001, In a study of 1,774 low-income, substance-dependent men who had been enrolled in inpatient substance abuse treatment programs at ten Department of Veteran Affairs medical centers around the United States, five of the programs were based on twelve-step principles, but run by professional therapists, and five used cognitive-behavioral therapy. Over 45% of the men in twelve-step programs were abstinent one year after discharge, compared to 36% of those treated by cognitive-behavioral therapy. Moos stated that the benefits of participation in AA may not necessarily accrue to all types of individuals and it is important to specify the characteristics of individuals who may not need to join AA in order to overcome their alcoholic-related problems. [55]
  • 2001, The largest benefit associated with AA attendance was increased abstinence, followed by reductions in alcohol-related consequences. A slight positive association was also found between AA attendance and increased purpose in life – the study found that AA attendance was associated with psychosocial improvement.[56]


  • 2004, Clients who had 27 weeks or more of treatment in the first year had better outcomes 16 years later. After the first year, continued clinical treatment had little effect on the 16-year outcomes, whereas continued involvement in AA did help. Associations between treatment and long-term alcohol-related outcomes appeared to be due to participation in AA.[57][58][59]


  • 2006- No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems. One large study focused on the prognostic factors associated with interventions that were assumed to be successful rather than on the effectiveness of interventions themselves, so more efficacy studies are needed.[60]


  • 2007, A national survery of mutual aid support groups for addiction was conducted to identify key differences between people participating in recovery groups. Survey data indicated that active involvement in support groups improves one's chances of remaining clean and sober, regardless of the group. Respondents whose beliefs matched that of the support group had more group involvement and more days sober. Religious respondents were more likely to participate in 12 step programs and Women for Sobriety. Non religious respondents were less likely to participate in 12-step groups. Religiousity had little impact on Smart Recovery but decreased participation in Secular Organizations for Sobriety. The results have important implications for treatment planning and matching individuals to appropriate support groups. [61]


  • 2007, A two year study of 556 University students. Students were assigned to one of three groups: a brief skills-training {BSTP}, alcohol-intervention program; a 12-step-influenced alcohol intervention program {TSI}; or a control group that received no intervention. The Brief skills-training program included interactive lectures and discussions and was derived from the University of Washington's Brief Alcohol Screening and Intervention for College Students program. The 12-step program provided lectures by therapists trained in the 12-step approach. All groups reduced their alcohol consumption. The Twelve step approach showed no significant difference from the No Treatment Control Group in terms of reducing consumption within the group of students that had high-risk alcohol consumption audit scores. Students with high-risk alcohol consumption scores that were assigned to the Brief Skills training showed significant differences in reduction when compared to the Control Group and had a tendency to show better results than the Twelve Step intervention. This study suggests that a BSTP is effective as an intervention in students with high-risk alcohol consumption[62]


  • 2008, A study was undertaken to determine factors affecting adherence to Alcoholics Anonymous (AA) groups. It involved 300 alcoholics committed to three hospitals in Porto Alegre, Brazil. They were interviewed in their homes six months later, a questionnaire focusing on patient relationship with AA groups were used and the responses were evaluated by two independent researchers. AA adherence was below 20%. Factors that contributed for non-adherence to AA were relapse, lack of identification with the method, lack of need, and lack of credibility. The factors reported by patients as reasons for adherence were identification with the method and a way to avoid relapse. The identification of these nonadherence factors could help health professionals in referring certain alcoholic patients to therapeutic interventions other than AA.[63]

Criticism and controversy

See also: Twelve-step program: Criticism

Moderation vs. abstinence

The debate about moderation versus total abstinence is one of the most hotly contested issues in alcohol treatment.[64] AA acknowledges that not all drinkers are alcoholics, but advocates total abstinence for those who are.[65] Critics believe more options should be available to problem drinkers who can manage their drinking with the right treatment.[64]

Disease of alcoholism

Main article: Disease theory of alcoholism

The concept of alcoholism and addiction as a disease is controversial.[66] Dr. William Silkworth introduced to Wilson and AA the idea that alcoholism is a disease consisting of an obsession to drink alcohol, and an allergy, which was the compulsion to continue drinking once the first drink had been taken.[67] Alcoholics, he argued, can never safely use alcohol in any form at all, since once forming the habit, they cannot break it.[68]

AA regards alcoholism as a disease[69][70] (though Bill Wilson once stated that it was not and more comparable to an illness or malady)[71] and uses the concept to challenge the belief of chronic, compulsive drinkers that they can stay sober by willpower alone.[72] AA has been criticized by opponents of the disease model, especially those who argue that AA groups apply the disease model to all problem drinkers, whether or not they are full-blown alcoholics.[73]Others state bona fide medical researchers do not view alcoholism as disease. The AA disease theory is influenced by the beliefs of the Temperance movement. [74]Others suggest that all addictions stem from faulty parenting.[75]

Thirteenth-stepping

"Thirteenth-stepping" is a euphemistic term describing the practice of targeting new and vulnerable AA members for dates or sex. Fifty-five female AA members, selected through convenience and snowball sampling, were surveyed on the thirteenth-stepping behavior they witnessed or experienced in AA, such as: feeling seduced, or feeling intimidated and uncomfortable with sexual comments; receiving unwanted hugs and flirting; observing men flirting with, pressuring, and seducing of other women; and observing men who seemed more interested in sex than in recovery. At least 50% of the survey participants experienced seven or more of these behaviors, two volunteered that they were raped by men they met in AA. Chemical dependency treatment providers should be aware of this trend, and vulnerable women like those with histories of sexual abuse should be referred to female-only groups or be trained to avoid sexual exploitation in coed meetings.[76]

A leaked internal AA memorandum stated that the UK AA service board was considering how to deal with a small minority of members being investigated by police for taking advantage of vulnerable new AA members.[77] Former members of a Washington DC Midtown AA group alleged that females were manipulated into sexual relationships with older male group members, older male sponsors were assigned to young women, members were told to cut off ties with family and friends, and others told to stop taking their medications. Several churches banned the group from meeting in their facilities, and members complaining to AA General Service Office in New York found that AA has no firm hierarchy and exercises no oversight of individual groups.[78][79][80]

Cult-like behavior

The rhetoric and emotional language of AA leads some journalists and social scientists to fear AA is a religion or cult: that the term "sobriety" has taken on a religious flavor and AA members over-rely on dogmatic slogans and are slaves to the group.[81] Critics of twelve-step programs warn of detrimental iatrogenic effects of twelve-step philosophy, and label the organizations as cults. Alexander and Rollins measured AA against criteria developed by Robert Jay Lifton, in his work on Thought Reform and concluded “AA uses all the methods of brain washing, which are also the methods employed by cults,” “It is our contention that AA is a cult.”[82][83]

Vaillant in a review of Nace 1992: "AA certainly functions as a cult and systemically indoctrinates its members in ways common to cults the world over " though its negative effects are benign in comparison with other cults he has known.[84] Vaillant argues that AA's encouragement of dependence is healthy in the way that dependence on exercise is healthy,[47][85] and it does not try to isolate its members from society and take over their lives by creating an unusual and total dependence on the organization for basic human needs like friends, food, and shelter, as is typical with other cult practices.[86]

Confidentiality

Twelve-step program members are not legally bound to keep confidentiality agreements like therapists or clergy.[87]

See also: Alcoholics Anonymous program: Court Rulings

Literature

  • Alcoholics Anonymous (1976-06-01). Alcoholics Anonymous. Alcoholics Anonymous World Services. ISBN 0916856593. OCLC 32014950.
  • Alcoholics Anonymous (2002-02-10). Twelve Steps and Twelve Traditions. Alcoholics Anonymous World Services. ISBN 0916856011. OCLC 13572433.
  • Alcoholics Anonymous (1984). Pass It On. Alcoholics Anonymous World Services. ISBN 0916856011.

See also

References

  1. ^ "What is AA? Defining "Alcoholics Anonymous"". The General Service Board of Alcoholics Anonymous (Great Britain). Retrieved 2006-11-27.
  2. ^ AA Preamble
  3. ^ AA Fact File, 'The Recovery Program'
  4. ^ Alcoholics Anonymous : the story of how many thousands of men and women have recovered from alcoholism. 4th ed. New York : Alcoholics Anonymous World Services, 2001. ISBN 1893007162. Available online at www.AA.org
  5. ^ a b "Comments On A.A. Triennial Surveys" (PDF, 2 MB), Dec. 1990, Alcoholics Anonymous World Services.
  6. ^ Practice Guideline for the Treatment of Patients With Substance Use Disorders, 2nd ed. American Psychiatric Association, August 2006. (PDF 2.2 MB.} P 98.
  7. ^ Pass It On p 359
  8. ^ AA Fact File
  9. ^ The AA Service Manual/Twelve Concepts for World Service (BM-31).
  10. ^ The AA Fact File, 'The Structure of AA'
  11. ^ Once Upon A Time... Mitchel K. 04/08/98
  12. ^ [1]AA Fact File p 17
  13. ^ The A.A. Tradition
  14. ^ GSO 2005 Operating Results, 'Gross Profit from Literature ~$6.7M (55%), Contributions ~$5.4M (45%)'
  15. ^ a b http://www.alcoholics-anonymous.org/en_pdfs/p-1_thisisAA.pdf This is AA pamphlet
  16. ^ http://www.alcoholics-anonymous.org/en_services_for_members.cfm?PageID=98&SubPage=119 Sponsorship-A Vital Stepping Stone to Service & Sobriety
  17. ^ http://www.alcoholics-anonymous.org/en_is_aa_for_you.cfm?PageID=14 A Newcomer Asks pamphlet
  18. ^ http://www.alcoholics-anonymous.org/en_pdfs/p-15_Q&AonSpon.pdf Questions and Answers on Sponsorship pamphlet
  19. ^ http://www.alcoholics-anonymous.org/en_information_aa.cfm?PageID=10 AA at a Glance pamphlet
  20. ^ [2] Suggestions for Leading Beginners Meetings pamphlet
  21. ^ http://www.alcoholics-anonymous.org/en_pdfs/p-48_04survey.pdf AA 2004 Membership Survey
  22. ^ N. Roberson, Getting Better:Inside Alcoholics Anonymous (London: Macmillan, 1988), p 220
  23. ^ http://www.alcoholics-anonymous.org/en_pdfs/p-48_04survey.pdf AA 2004 Membership Survey
  24. ^ name="EGELKO2007">Egelko, Bob (2007-09-08). "Appeals court says requirement to attend AA unconstitutional". San Francisco Chronicle. Retrieved 2007-10-08.
  25. ^ Inouye vs. Kemna page 11889
  26. ^ http://www.alcoholics-anonymous.org/en_pdfs/p-48_04survey.pdf AA 2004 Membership Survey
  27. ^ New York Times, Jan Hoffman June 15, 1994 ["Faith in Confidentiality of Therapy Is Shaken" http://query.nytimes.com/gst/fullpage.html?res=9F0CE4D81F3AF936A25755C0A962958260&sec=&spon=&pagewanted=all]
  28. ^ Associated Press ["Federal Appals Court backs Use of AA confessions to convict man" http://www.freedomforum.org/templates/document.asp?documentID=16575&printerfriendly=1]
  29. ^ Vaillant, 1995, p 255.
  30. ^ Vaillant, 1995, p 265.
  31. ^ a b Vaillant, George Eman (1995). "Chapter 4: Paths into Abstinence". The Natural History of Alcoholism Revisited (2nd edition ed.). Harvard University Press. pp. 231–277. ISBN 0674603788. OCLC 31605790. {{cite book}}: |edition= has extra text (help); Unknown parameter |month= ignored (help)
  32. ^ Maria Gabrielle Swora. "The rhetoric of transformation in the healing of alcoholism: The twelve steps of alcoholics anonymous." Mental Health, Religion & Culture, Sep2004, Vol. 7 Issue 3, p187-209.
  33. ^ Edwards, Griffith (2002). "Chapter 8: Alcoholics Anonymous". Alcohol: The World's Favorite Drug (1st edition ed.). Thomas Dunne Books. pp. 103–117. ISBN 0312283873. OCLC 48176740. {{cite book}}: |edition= has extra text (help); Unknown parameter |month= ignored (help)
  34. ^ a b Humphreys, Keith (2002). "Alcoholics Anonymous and 12-Step Alcoholism Treatment Programs". Recent Developments in Alcoholism. Vol. 16. Springer US. pp. 149–164. doi:10.1007/b100495. ISBN 978-0-306-47258-9. PMID 12638636.
  35. ^ Nace, Edgar P. "Alcoholics Anonymous" in Substance abuse: a comprehensive textbook. Ed. Joyce H. Lowinson et al. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2005, p 597 & 598.
  36. ^ a b NIAAA Reports Project MATCH Main Findings, Press release from National Institute on Alcohol Abuse and Alcoholism, Dec 1996. Retrieved 2007-05-25.
  37. ^ Project Match Research Group. (1997). "Matching alcoholism treatments to client heterogeneity: Project MATCH Posttreatment drinking outcomes." Journal of Studies on Alcohol, 58(1), 7-29.
  38. ^ Treatment of alcoholism: New results. Harvard Mental Health Letter, Aug2006, Vol. 23 Issue 2, p6-7, 2p
  39. ^ Adler, Jerry; Underwood, Anne; Kelley, Raina; Springen, Karen; Breslau, Karen. "Rehab Reality Check" Newsweek, 2/19/2007, Vol. 149 Issue 8, p44-46, 3p, 4c
  40. ^ Bruce Bower. Alcoholics synonymous: heavy drinkers of all stripes may get comparable help from a variety of therapies. Science News v151.n4 (Jan 25, 1997): pp62(2).
  41. ^ J. Scott Tonigan, Gerard J. Connors, and William R. Miller. "Participation and involvement in Alcoholics Anonymous", in Thomas Babor, Frances K. Del Boca, eds, Treatment Matching in Alcoholism, Cambridge University Press: 2003, p 184.
  42. ^ Vaillant, George Eman (1995). "Acknowledgments". The Natural History of Alcoholism Revisited (2nd edition ed.). Harvard University Press. pp. vii–xi. ISBN 0674603788. OCLC 31605790. {{cite book}}: |edition= has extra text (help); Unknown parameter |month= ignored (help)
  43. ^ Vaillant, George Eman (1995). "Introduction: The Problem". The Natural History of Alcoholism Revisited (2nd edition ed.). Harvard University Press. pp. 1–11. ISBN 0674603788. OCLC 31605790. {{cite book}}: |edition= has extra text (help); Unknown parameter |month= ignored (help)
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