Alcoholics Anonymous

Alcoholics Anonymous (AA) is an informal society for recovering alcoholics. Members meet in local groups that vary in size from a handful to many hundreds of individuals. In 2001 there were perhaps 100,000 groups worldwide, with more than two million members.

The stated primary purpose of the society is "to stay sober and help other alcoholics to achieve sobriety." AA teaches that an alcoholic, in order to recover, should abstain completely from alcohol on a daily basis; the society in turn offers a community of recovering people who support each other by "sharing experience, strength and hope" and often by working the suggested Twelve Steps together.

Alcoholics Anonymous was the first twelve-step program and has been the model for similar recovery groups such as Al-Anon/Alateen, Gamblers Anonymous, Narcotics Anonymous, Overeaters Anonymous, Sexaholics Anonymous. Al-Anon and Alateen are companion programs designed to provide support for relatives and friends of alcoholics.

American understanding of alcoholism in the 1930s
Public opinion in post-Prohibition 1930s America saw alcoholism as a moral failing, and the medical profession saw it as a condition that in many cases was incurable and lethal. Those without financial resources found help through state hospitals, the Salvation Army, and other charitable and religious groups. Those who could afford psychiatrists or hospitals were often subjected to a treatment with barbiturate and belladonna known as "purge and puke" or were left in long-term asylum treatment. From the point of view of the alcoholic, there was simply no positive or helpful way of conceptualizing or responding to the condition.

A search for a spiritual cure
AA was founded by Bill Wilson, a Wall Street stockbroker and stock analyst, and Dr. Bob Smith, a proctologist from Akron, Ohio, both alcoholics. The chain of events that led to the meeting of these men began in Europe, where American business executive Rowland Hazard sought treatment for alcoholism with the famous Swiss psychiatrist Carl Jung. After a prolonged and unsuccessful period of therapy, Jung told Hazard that his case, like that of most alcoholics, was nearly hopeless—-the only possibility for a cure was through spiritual conversion.

Back in America, Rowland Hazard joined the Oxford Group, a Christian Evangelical association. The group advocated four spiritual principles: absolute honesty, absolute purity, absolute unselfishness, absolute love. Through the Oxford group, Hazard underwent a spiritual conversion and achieved his long hoped for sobriety.

The conversions of Thacher and Wilson
Rowland Hazard was introduced to a fellow by the name of Ebby Thacher by other members of the Oxford Group. Rowland Hazard brought Ebby Thacher to the Calvary Rescue Mission and Thacher, too, attained sobriety (although, in his case, it would not last his whole life ). The Calvary Rescue Mission, run by Dr. Sam Shoemaker, a leading figure in the Oxford Group, had over the years had been visited by over 200,000 needy people, in the process converting many of them to Christianity. Ebby then got in touch with his old drinking buddy Bill Wilson, who Thacher had heard was still having trouble with drink.

Wilson was an alcoholic who had seen a promising career on Wall Street ruined by his drinking. He had failed to graduate from law school because he was too drunk to pick up his diploma. He had blown partnerships and business deals, all but destroyed his marriage, been hospitalized for alcoholism under the care of Dr. William Silkworth, and still continued to drink. When Thacher visited him at his New Yord apartment, Wilson was astonished to find that his old drinking companion Thacher had become sober through spiritual means. But Wilson struggled with the existence of God. Then, he wrote, "My friend suggested what then seemed a novel idea. He said, 'Why don't you choose your own conception of God?' That statement hit me hard. It melted the icy intellectual mountain in whose shadow I had lived and shivered many years. I stood in the sunlight at last."

After attending his first meeting at the Calvary Mission, Wilson excitedly told his wife Lois about his spiritual progress, yet the very next day he drank again, and eventually found himself back in hospital under Silkworth's care. According to Wilson, while lying in bed depressed and despairing he cried out, "I'll do anything! Anything at all! If there be a God, let Him show Himself!". He then had the sensation of a bright light, a feeling of ecstasy, and a new serenity. Bill Wilson described his experience to Dr. Silkworth, who told him not to discount it. Ebby Thacher visited Bill Wilson at Townes hospital and introduced him to the basic tenets of the Oxford Group and the book Varieties of Religious Experience by American psychologist and philosopher William James, which described experiences similar to Wilson's. Upon his release from the hospital Dec. 18th 1934, Wilson, then joined the fellowship of the Oxford Group, Sam Shoemaker's Calvary Mission. To paraphrase his own words, admitted he was licked, got honest with himself, got honest with another, made amends, helped other alcoholics and prayed to whatever God he thought there was. (speech, 1952 convention.) Wilson never drank again for the remainder of his life.

A new program for recovery
In keeping with the practices of the Oxford Group, Wilson believed that his own sobriety seemed to grow stronger when he shared his personal alcoholic experience with other alcoholics. At one point Wilson was on a business trip in Akron, OH, and was tempted to relapse. In a hotel lobby, he decided to phone local ministers and ask if they knew of alcoholics he could talk to. He eventually reached Oxford Group member Henrietta Seiberling, whose group had been trying to help alcoholic Dr. Bob Smith. Wilson met with Smith for what was planned as 15 minutes, and the two men talked late into the night. They became friends, and for three months they studied the Bible, held long discussions, and reviewed Oxford Group ideas, eventually fashioning a pioneer recovery program. Smith's last drink is said to have been on June 10, 1935—a beer to steady his hand for surgery—and that is considered within AA to be the date of the founding of AA.

Wilson returned to New York, establishing a second group, he later revisited Akron and reviewed the movement with Smith. They estimated that by 1937, the two groups numbered forty recovered alcoholics with continuous sobriety, and decided with this success in mind, that they had a recovery program worth spreading. Discussion led to agreement that the essential communications tool would be in the form of a book. After great difficulties in raising the required funds for printing, a publishing company, Works Publishing Inc., was incorporated, and capital raised by selling shares to the groups’ members and friends. Wilson set to work writing the book. When he reached chapter five, he decided that a summary of their methods for treating alcoholism was needed to describe the Word of Mouth program. In these early days, the basic program had developed from the works of William James, Dr Silkworth and the Oxford Group (from which the AA groups separated in 1937 ), although several of the Oxford Group's ideas and attitudes were deliberately rejected, particularly any which would involve AA in theological controversy. The program involved an alcoholic: admitting that they were beaten by alcohol, making a moral inventory of their defects or sins, confessing their shortcomings with another person, making restitution to those harmed by the alcoholic's drinking, trying to help other alcoholics and praying to whatever God they believed in for the power to practice these precepts. Wilson, with contributions from others in the groups including several atheists who restrained the religious content, expanded these principles and the final version of the Twelve Steps was completed by the fall of 1938.

The "Big Book"
The book, Alcoholics Anonymous, was published in 1939 and while several titles for the book were proposed (including "The Way Out", which was already in use), Bill Wilson and Dr. Bob finally settled on "Alcoholics Anonymous", and the fellowship itself took its name from the book. The first edition had a "circus cover" of red and yellow, and it was printed in heavy paper and large size, which was thought to make it more saleable —hence the nickname "Big Book", a name that sticks today even though AA has published it in a more conventional size. Some critics of A.A. have suggested that the nickname "The Big Book" was meant to evoke the phrase "The Good Book", which is a term of affection for The Bible, and they argue that the newer editions of the "Big Book" are meant to resemble small, portable Bibles. Sales of the book—and the popularity of AA—increased rapidly after positive articles in Liberty magazine in 1939 and the Saturday Evening Post in 1941. The 4th edition was released in 2001. The first 164 pages of the first edition, plus the preface, the forewords, and the chapter called "The Doctor's Opinion" have been left largely intact, with minor statistical updates and edits. In each successive edition, the personal stories have been reviewed to represent the current population of AA, with the result that the stories of the original members of the 1930s have gradually been displaced. In 2003 the stories removed from the first three editions of Alcoholics Anonymous were gathered together in the book "Experience, Strength, and Hope."

International Expansion
In April 1945, Australia became the first country outside the U.S. to establish AA. This occurred through the efforts of two Sydney-based alcoholics - the medical superintendent of Rydalmere Mental Hospital, Dr Sylvester Minogue, a psychiatrist; and a Roman Catholic priest, Father Tom Dunlea.

How it works
Alcohol is described as “cunning powerful and baffling”, which without help from God who is all powerful, it is to much for the alcoholic to deal with. Alcoholics are described as selfish, self-centered , concerned mainly with their resentments and feelings of self pity. The attitudes and behavior that result in problems for the alcholic is described as “self will run riot”. Resentment is cited as the number one offender, and by holding onto old hurts, deep seated grudges and wrongs the Alcoholic returns to drinking. The spiritual awakening comes through contact with God {as the alcoholic understands him}. The alcoholic learns to come to trust and rely on God. God is described as the Director, The Principal, The Father and the Alcoholics are referred to as his agents and his children. God Can do for the alcoholic what he cannot do for himself. As God is considered all powerful he is capable of providing what the alcoholic needs and through him the alcoholic is reborn. Only God can judge a sexual situation.

The program
AA states its objective "to carry its message to the alcoholics who still suffer". AA members are encouraged to take the Steps, usually under the guidance of a voluntary sponsor—a member who has already completed the 12-step program. The Steps were designed with the intention of helping the alcoholic achieve a spiritual, emotional, and mental state conducive to lasting sobriety. Although the steps are based on seeking help from a higher power, atheists and agnostics are not excluded from achieved long-term sobriety in AA, since AA does not discriminate against any religion or lack of religion. Bill Wilson wrote a chapter in the "Big Book" entitled We Agnostics for recovering drunks who were struggling with the idea of a Higher Power as a means for them to accept the concept of a higher power.

"Working the program" might involve the following activities:
 * Above all, avoiding the first drink.
 * Regular attendance at meetings, and participation by talking or listening. AA meetings are frequent in large cities. Phone, internet, and mail are also methods used by members to attend AA. The organization urges new attendees to attempt 90 meetings in 90 days, which it believes will help to break the drinking habit and immerse them in a culture of sobriety.
 * Regular contact with a sponsor for support in staying and living sober and in working the program.
 * Service work, activities such as making coffee at meetings.
 * Taking the Twelve Steps.

AA recommends that longer-term members should:
 * Regularly attend to personal inventory (in accordance with Step Ten).
 * Daily prayer and meditation (in accordance with Step Eleven)
 * Communicating the AA method of recovery to other alcoholics (in accordance with Step Twelve).

The Twelve Steps

 * 1) We admitted we were powerless over alcohol – that our lives had become unmanageable.
 * 2) Came to believe that a Power greater than ourselves could restore us to sanity.
 * 3) Made a decision to turn our will and our lives over to the care of God as we understood Him.
 * 4) Made a searching and fearless moral inventory of ourselves.
 * 5) Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
 * 6) Were entirely ready to have God remove all these defects of character.
 * 7) Humbly asked Him to remove our shortcomings.
 * 8) Made a list of all persons we had harmed, and became willing to make amends to them all.
 * 9) Made direct amends to such people wherever possible, except when to do so would injure them or others.
 * 10) Continued to take personal inventory and when we were wrong promptly admitted it.
 * 11) Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
 * 12) Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

Organization
Alcoholics Anonymous has an informal control structure: there is no hierarchy of leaders. Guidelines for group conduct are outlined in the Twelve Traditions (below). A member who accepts a service position (an organizing role in a group) within the society is referred to as a trusted servant, a reference to Tradition 2. A member's commitment to service is held for a limited period, typically three months to one year, after which another member is chosen by a group vote. Individual members and groups cannot be compelled to do anything by higher AA authorities as each meeting, small or large, is considered a self-governing entity.

At the local and national level, AA groups are self-supporting and not a charity. The society has no membership fees and does not charge to attend meetings, but instead relies on whatever donations members choose to give to cover basic costs such as room rental and refreshments. Contributions from members are limited to a maximum annual amount of $3000 per year, though most donate only $1 to $2 per meeting.

Alcoholics Anonymous does receive proceeds from the sale of its book Alcoholics Anonymous, along with other published books and literature, which are periodically revised. Revenues from literature sales constitute more than 50% of the income for the General Service Office (GSO), which unlike individual groups is not self-supporting through contributions and does have a small number of salaried staff.

Additional to the GSO, Alcoholics Anonymous also maintains a few service centers, which have the task of coordinating activities such as printing literature, responding to public inquiries, and organizing state or national conferences. Funded by local members, the centers are directly responsible to the AA groups in the region or country they represent.

Alcoholics Anonymous is exclusively served by people who identify themselves as alcoholics with the exception that seven of the 21 members of the AA Board of trustees are listed as “nonalcoholic friends of the fellowship”.

The Twelve Traditions
The affairs of Alcoholics Anonymous are governed broadly by AA's Twelve Traditions, suggested rules for organizing how the members and groups of the society interact with each other and with AA as a whole (see the book Twelve Steps and Twelve Traditions for more information ). These traditions were developed from experiences of the early groups during their first 13 years with the purpose of answering the questions "How can AA best function?" and "How can AA best stay whole and so survive?"


 * 1) Our common welfare should come first; personal recovery depends upon A.A. unity.
 * 2) For our group purpose there is but one ultimate authority – a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants; they do not govern.
 * 3) The only requirement for A.A. membership is a desire to stop drinking.
 * 4) Each group should be autonomous except in matters affecting other groups or A.A. as a whole.
 * 5) Each group has but one primary purpose to carry its message to the alcoholic who still suffers.
 * 6) An A.A. group ought never endorse, finance, or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose.
 * 7) Every A.A. group ought to be fully self-supporting, declining outside contributions.
 * 8) Alcoholics Anonymous should remain forever non-professional, but our service centers may employ special workers.
 * 9) A.A., as such, ought never be organized; but we may create service boards or committees directly responsible to those they serve.
 * 10) Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy.
 * 11) Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, and films.
 * 12) Anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities.

Definition of alcoholism
Although AA lacks an official, singular definition of alcoholism, Dr Silkworth contributed the chapter in the AA basic text of Alcoholics Anonymous entitled "The Doctor's Opinion". That chapter would become one of the more influential pieces in AA thought. He wrote they "have one symptom in common: they cannot start drinking without developing the phenomenon of craving. This phenomenon, as we have suggested, may be the manifestation of an allergy which differentiates these people, and sets them apart as a distinct entity." That allergy takes the form of a craving which is explained earlier in the chapter when he states "the phenomenon of craving is limited to this class [alcoholics] and never occurs in the average temperate drinker. These allergic types can never safely use alcohol in any form at all; and once having formed the habit ... they cannot break it..." Alcoholics Anonymous offers a solution that will create a "spiritual experience" or complete change in the person's outlook on life and alcoholism.

On page 44 of the Big Book, it states, "If, when you honestly want to, you find you cannot quit entirely, or if when drinking, you have little control over the amount you take, you are probably alcoholic."

In the article Alcoholics Anonymous and the Disease Concept of Alcoholism, AA historian Ernest Kurtz wrote, "The closest the book Alcoholics Anonymous comes to a definition of alcoholism appears on p. 44, at the conclusion of the first paragraph of the 'We Agnostics' chapter, where we are told that alcoholism 'is an illness which only a spiritual experience will conquer'." In 1960, Bill Wilson gave a speech to the National Catholic Clergy Conference on Alcoholism. During the ensuing question and answer discussion, Wilson was asked why he did not use the term disease when he spoke of alcoholism in that speech. He replied, "We AA's have never called alcoholism a disease because, technically speaking it is not a disease entity. For example there is no such thing as heart disease. Instead there are many separate heart ailments, or combinations of them. It is something like that with alcoholism. Therefore we do not wish to get in wrong with the medical profession by pronouncing alcoholism a disease entity. Therefore we always call it an illness, or a malady, -- a far safer term for us to use."

Limitations of research
One reason that many researchers take a skeptical view of AA is that AA is so unscientific because of its spiritual basis. "Membership is voluntary and is determined by the individual, not by the group. There are no membership requirements, no dues or fees, no membership lists. AA is notoriously difficult to pin down as an organization," writes Maria Gabrielle Swora. In his book Alcohol: The World's Favorite Drug, addiction specialist Griffith Edwards argues that a randomized trial of AA is not possible because members are self-selected, not randomly selected. Keith Humphreys points out two opposing types of self-selection bias: that some drinkers may be motivated to stop drinking before they attend AA, and that AA may attract the more severe and difficult cases. Humphreys also argues that control groups with AA vs. non-AA subjects are impossible, because AA is so accessible that it is not feasible to prevent subjects from attending. Edgar P. Nace concludes that "AA, like all other therapies for alcoholism, is limited. ...AA works. How well and for whom remain unsatisfactorily researched." Edwards conjectures, on the basis of available research, that "AA probably works, in some way or other, for not less than 50% of the troubled drinkers that make contact with it." The studies below have attempted to examine the effectiveness of Alcoholics Anonymous.

Project MATCH
Project MATCH was initiated in 1989 and was sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The project was an 8-year, multisite, $27-million investigation that asked whether certain types of alcoholics respond best to specific forms of treatment. MATCH notes "No single treatment approach is effective for all persons with alcohol problems. A more promising strategy involves assigning patients to alternative treatments based on specific needs and characteristics of patients." Three types of treatment were investigated:
 * Cognitive Behavioral Coping Skills Therapy, which focuses on correcting poor self esteem and distorted, negative, and self-defeating thinking.
 * Motivational Enhancement Therapy, which helps clients to become aware of and build on personal strengths that can help improve readiness to quit.
 * 12-Step Facilitation Therapy administered as an independent treatment designed to familiarize patients with the AA philosophy and to encourage participation

All the programs were administered by trained psychotherapists, which in the case of 12-step meant that it was the method and not AA itself that was studied.

The conclusion of the research was that patient-treatment matching is not necessary in alcoholism treatment, because the three techniques were approximately equal in effectiveness. In a December 1996 press release, NIAAA Director Enoch Gordis, M.D. said "These findings are good news for treatment providers and for patients who can have confidence that any one of these treatments, if well-delivered, represents the state of the art in behavioral treatments."

However overall success rates for all treatments were, and continue to be, less than spectacular. Based on information from Dr. Mark Willenbring of the NIAAA, Newsweek reported in their February 2007 issue that "A year after completing a rehab program, about a third of alcoholics are sober, an additional 40 percent are substantially improved but still drink heavily on occasion, and a quarter have completely relapsed."

Project MATCH has been criticised by a psychologist, Dr Stanton Peele, on the grounds that there was no untreated study group to determine whether the treatments were more effective than the natural recovery process. Peele argued that the therapists in MATCH were much more highly trained and monitored than the addiction counselors usually available to the public. Peele also objected that effectiveness for all treatments was measured by reduction in frequency and intensity of drinking, whereas abstention-based programs such as 12-step should claim no improvement without full abstention.

George Vaillant
In his book The Natural History of Alcoholism Revisited, Harvard psychiatric professor George E. Vaillant, who is a member of the Board of Trustees of Alcoholics Anonymous World Services, posed seven key questions, the seventh of which was "How helpful is Alcoholics Anonymous in the Treatment of Alcoholism?" Vaillant's book was partly based on his experience with a 60-year study of 600 alcoholic men. Aware of the difficulties of obtaining direct evidence by statistical methods, he nevertheless states in his summary of literature and personal experience that "... research during the last 15 years has revealed growing indirect evidence that AA is an effective treatment for alcohol abuse." Vaillant argued that AA shows an advantage over other treatments in the long term because, as a cheap, community-based fellowship it is easy for people to keep coming back. He argues that "AA is the most effective means of long-term relapse prevention in the physician’s armamentarium."

In 2005, Vaillant produced an extensive study of the efficacy and safety of AA in the treatment of alcoholism, reviewing the published works from 1940 until the present day. In this paper he acknowledges that, 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." , his overall observation is that "multiple studies that collectively involved a thousand or more individuals, suggest that good clinical outcomes are significantly correlated with frequency of AA attendance, with having a sponsor, with engaging in a Twelve-Step work and with chairing meetings." Dr. Vaillant's overall conclusion is that "Alcoholics Anonymous appears equal to or superior to conventional treatments for alcoholism, and the skepticism of some professionals regarding AA as a first rank treatment for alcoholism would appear to be unwarranted."

Vaillant in his long study on alcoholism noted that 60% of those with a drinking problem quit on their own without a treatment program.

Moos and Moos
In a 16-year follow-up study, Rudolf and Bernice Moos examined the effectiveness of clinical treatment and participation in AA. They reported that 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. A conclusion was that "Some of the association between treatment and long-term alcohol-related outcomes appears to be due to participation in AA."

The Veterans Study
Moos, Moos, and Humphreys carried out a study of 1,774 low-income, substance-dependent men who had been enrolled in inpatient substance abuse treatment programs at 10 Department of Veteran Affairs medical centers around the U.S. Five of the programs were 12-step based, and five used cognitive-behavioral therapy. The 12-step programs were found to be effective in terms of cost and recovery: over 45% of the men in 12-step programs were abstinent one year after discharge, compared to 36% of those treated by cognitive-behavioral therapy. In answer to the often-posed question as to which comes first, AA participation or reduced drinking, the study concluded that the answer is AA. Moos said, however, that the benefits of participation in AA may not necessarily accrue to all types of individuals: "It is important to specify the characteristics of individuals who may not need to join AA in order to overcome their alcoholic-related problems."

Brandsma, Ditman and Bower
A study from 1979 found a correlation between AA and an increased rate of binge drinking. After several months of participating in AA, the alcoholics in AA were doing five times as much binge drinking as a control group that got no treatment at all, and nine times as much binge drinking as another group that got Rational Emotive Behavior Therapy. Brandsma argues that teaching people that they are alcoholics who are powerless over alcohol becomes a self-fulfilling prophecy.

Ditman et al. (1967) found a correlation between participation in AA and an increase in the alcoholics' rate of multiple arrests for public drunkenness.

Bruce Bower. Research has indicated that alcoholics reporting a lack of motivation reverted to their drinking levels soon after leaving clinical treatment.

J. Scott Tonigan
Tonigan's study found the largest benefit associated with AA attendance was increased abstinence, followed by reductions in alcohol-related consequences. "The magnitude of these benefits did not differ between sites." 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.

After treatment
A 1997 study of affiliation with Alcoholics Anonymous after treatment for alcoholism, assessed during treatment and at one and six-month follow-ups. Results indicated that increased affiliation with AA predicted better outcomes and maintenance of motivation as well as to increased active coping efforts.

Moderation vs. abstinence
The debate on cutting back versus total abstinence is "one of the most hotly contested issues in alcohol treatment." Treatment in America, particularly, tends to lean towards total abstinence, even though not all problem drinkers are actually alcohol dependent. The AA "Big Book" acknowledges that not all drinkers are alcoholics. However AA advocates total abstinence as an essential aim towards overcoming alcoholism, and is often criticized for this policy.

Disease concept of alcoholism
The concept of alcoholism (and addiction) as a disease is controversial. AA regards alcoholism as a disease, and uses the concept to challenge the belief of some chronic, compulsive drinkers that they can stay sober by willpower alone. AA has been criticized by opponents of the disease model, especially those who argue that some AA groups apply the disease model to all problem drinkers, whether or not they are full-blown alcoholics.

Court mandated attendance
Judges and probation officers have required individuals to attend twelve-step programs as conditions of their parole and sentences. This has resulted in a number of court cases, starting in 1996. September 7, 2007, The Ninth Circuit Court of Appeals in San Francisco ruling on the case of Inouye vs. Kemna stated, "the constitutional dividing line between church and state in such cases is so clear that a parole officer can be sued for damages for ordering a parolee to go through rehabilitation at Alcoholics Anonymous or an affiliated program for drug addicts." The ruling continued, "adherence to the AA fellowship entails engagement in religious activity and religious proselytism." The Ninth Circuit Court of Appeals pointed to cases decided before 2001 by the federal courts of appeal for the Seventh Circuit and the Second Circuit, in addition to a number of cases in lower federal courts and in state courts, all with the same result. The unanimous conclusion of these courts was that the coercion of a person into AA/NA or into AA/NA based treatment programs was unconstitutional because of their religious nature.

"Open" AA meetings are open to anyone who wishes to attend, including those mandated by a court. Court ordered attendees have to answer to the judge, not to anyone in AA. Such forced attendance may not satisfy AA's Tradition 3, which says, "The only requirement for A.A. membership is a desire to stop drinking." AA takes the position that the organization cannot discriminate against any prospective member, even if he or she attends under pressure from a court, an employer, or any other agency. The distinction between coercion or pressure as represented by legal authorities, one's own conscience or pressure from friends and family is taken to be immaterial. Some groups provide proof of attendance that may be required by a court or probation office, whereas other groups choose not to sign court slips."

Occasions of abuse at meetings
Mutual support and abuse have both been observed in AA groups. AA undertakes no external restriction or screening of its members, and the long-form version of Tradition 3 (the basis of AA policy) states that "Any two or three alcoholics gathered together for sobriety may call themselves an AA group..."

The Washington Post and Newsweek reported on allegations of cult-like and abusive behavior in the Washington DC "Midtown" AA group. Former members, teenage girls and women said that they had been manipulated into sexual relationships with much older group members, that older men had been assigned to young women as sponsors, that others were told to cut off all ties with family and friends, and still others told to stop taking their medications.

In the UK in 2000, the Guardian newspaper reported that a leaked internal AA memorandum stated that "volunteer members are increasingly being investigated by police forces examining allegations of sexual abuse." According to the memo, a "small minority" of members were taking advantage of vulnerable new members who were seeking help by phone or looking for a sponsor. At that time the AA service board in the UK was considering how to deal with the issue on a national level.

Thirteenth-stepping
Thirteenth-stepping is a euphemistic term describing the practice of targeting new and vulnerable AA members for dates or sex. AA has suggested guidelines that discourages the  beginning any new relationships in early sobriety. A survey of fifty-five female AA members, selected through convenience and snowball sampling, rated their experience of 13th-stepping in AA on a thirteen question four level Likert scale instrument. Each question was associated with 13th-stepping experiences, such as: feeling intimidated, feeling uncomfortable due to sex-related comments, receiving unwanted hugs, flirting, observing men flirting with other women, feeling seduced, observing other women being seduced, observing men who seemed more interested in getting a date than in personal growth and observing other women being pressured to have sex. At least 50% of the survey participants experienced seven or more of these behaviors, two of the participants volunteered that they met men in AA who raped them. The conclusion was that chemical dependency treatment providers should be aware of 13th-stepping in AA, particularly when treating women, and that vulnerable women, such as those with histories of sexual abuse, should be referred to female-only groups when possible, and be ready to protect themselves from possible sexual exploitation in coed meetings.

Is AA cult-like?
Merriam-Webster defines a health cult as "a system for the cure of disease based on dogma set forth by its promulgator." As early as 1963, Alcoholics Anonymous has come under scrutiny as a possible cult. Dr Arthur H. Cain talked of the "religious flavor" the word sobriety had taken in AA, the "slavery" to the group and an over reliance on dogmatic slogans. AA's need for submission to a higher power leaves potential for abuse, and that that submission can become the basis for cult like cohesion.

Researcher George Vaillant argues that that "the rhetoric and the emotional language of the spirituality of AA leads journalists and social scientists to understandably fear that AA is a religion or cult." It is a widely accepted fact that many people find help in AA while others find no help or experience AA as cult-like. One addiction professional stated that "some AA groups become cultist and some members are convinced that AA is the only way to recover from alcoholism." Vaillant holds that "Individual alcoholics attending incompatible AA groups or allying themselves with unfortunate sponsors sometimes tell horror stories about the fellowship." Vaillant summarized a review of AA by E.P. Nace that listed some negative aspects of AA:
 * AA members are not encouraged to take a dispassionate or scientific view of their organization.
 * "Individual members, like members of any partisan group, can be extremely and erroneously opinionated."
 * "AA certainly functions as a cult and systematically indoctrinates its members in ways common to cults the world over."

Vaillant also quotes Nace as clarifying the helpful aspects of AA: tolerance, a non-threatening personal style, and acceptance of self and others. Vaillant himself argues that AA's encouragement of dependence is healthy in the sense that dependence on vitamins and exercise is healthy, and that the rigidity of AA is similar to the discipline of post-coronary exercise programs. Vaillant holds that AA generally has characteristics that distinguish it from cults:
 * the program is based on suggestion only;
 * religious conviction does not prevent AA membership and minority opinions are respected;
 * there is no prescribed concept of "higher power";
 * unlike many cults, AA has no charismatic leaders; government is based on the principle of rotation of leadership.

Confidentiality
The Twelve Traditions ask members to respect each others confidentiality, but there are no legal consequences to prevent others from revealing statements he or she made during a twelve-step meeting. Statutes on group therapy do not encompass those associations that lack a professional therapist or clergyman to whom confidentiality and privilege might apply. Physicians who refer patients to these groups, to avoid both civil liability and licensure problems, should alert their patients that, under exceptional circumstances, their statements made in working through the Twelve Steps might be disclosed.