Dr. Nace is clinical professor of psychiatry in the Department of Psychiatry at the University of Texas Southwestern Medical Center in Dallas.
Disclosure: The author reports no financial, academic, or other support of this work.
Disclaimer: The 12 steps, 12 traditions, and 12 promises are reprinted with permission of Alcoholics Anonymous (AA) World Services, Inc. Permission to reprint this material does not mean that AA has reviewed or approved the contents of this publication, nor that AA agrees with the views expressed herein. AA is a program of recovery from alcoholism. Use of the 12 steps and 12 traditions in connection with programs and activities which are patterned after AA but which address other problems does not imply otherwise.
Please direct all correspondence to: Edgar P. Nace, MD, 7777 Forest Lane, #B413, Dallas, TX 75230; Tel: 972-566-6282; Fax: 972-566-3857; E-mail: EPNace@aol.com.
• Alcoholics Anonymous (AA) is a fellowship that utilizes a 12-step program to assist individuals in achieving abstinence from alcohol.
• Participation in AA, in addition to addressing alcohol use, promotes psychological maturity and spiritual growth.
• Physicians who understand the benefits of AA will be able to assist patients in joining the AA program.
Alcoholics Anonymous (AA) is a major community resource with which physicians should be familiar. Knowledge and understanding of AA will enable primary care physicians to effectively motivate their problem-drinking patients to participate in AA. It is prudent to recommend AA to any patient with alcohol abuse or dependence. There are no consistent data to suggest who may or may not respond to AA, and, therefore, anyone with a desire to stop drinking is a reasonable candidate for AA membership. Facts about AA, its structure, and process, are briefly described.
Primary care physicians commonly encounter health-impairing behaviors in their patients. Alcoholism is one such behavior and is often a challenge for the practitioner. Physician acceptance of this challenge can lead to improved helath of patients.1 Behavior change is typically incremental and a physician’s attention to the desired change can accelerate the patient’s movement through the following well-recognized stages2:
• Precontemplation. This is the stage in which the patient is not considering changes in behavior or is unaware of a need for change.
• Contemplation. This is the stage wherein the patient realizes a change is desirable but is ambivalent or uncommitted to making the change.
• Determination. During this stage, the patient makes a decision to change behavior.
• Action. This stage promotes a particular strategy for producing the change, eg, disulfiram is used to prevent alcohol use, bupropion is taken to help eliminate smoking, exercise is begun as part of weight reduction.
• Maintenance. This is the stage during which the patient continues the strategies which effect change. The stage usually requires at least 6 months of the continued behavior change.
• Relapse. The adverse behavior is re-initiated in this stage. At this point the individual is counseled to resume the action and maintenance stages.
In order to be successful in guiding the patient in this process of behavior change, the physician will need to have available “tools.” These tools may be pharmacologic treatment, knowledge of specific effective strategies (eg, throw away cigarettes and any smoking-related paraphernalia; remove all alcohol from the house), or, the capacity to direct the patient to community resources.
This article describes Alcoholics Anonymous (AA), a prime community resource for physicians to help the change process in patients with substance use disorders, ie, those with alcohol or drug dependence. The structure of AA, the process of AA participation, and how or why it works, will be described. AA is presented as the generic 12-step program. The information presented about AA can be applied to other 12-step programs such as Narcotics Anonymous, Cocaine Anonymous, and Gamblers Anonymous.
Structure of Alcoholics Anonymous
Founded in 1935, AA has 97,000 groups worldwide.3 It is a fellowship open to anyone who wants to do something positive about their drinking problem. One need not consider oneself an alcoholic in order to participate in AA and there are no age limits, educational requirements, or fees. The only requirement for membership is a desire to stop drinking. Meetings typically last 1 hour and may be speaker meetings during which members tell about their experiences with drinking, what happened to make them want to stop drinking, and how they feel now that they are not drinking. Another meeting format is discussion, during which a member leads a discussion on a topic related to recovery, such as gratitude. In step meetings, the discussion focuses on one of the “12 steps” of AA. Meetings may be open or closed. Closed meetings are for AA members or prospective members only, whereas open meetings include nonalcoholics as well.
The program of AA consists of studying and following the 12 steps (Table 1). AA groups adhere to the “12 traditions” of AA (Table 2). By working the 12 steps and following the 12 traditions,4 AA members can expect to obtain the “12 promises” (Table 3). There are several things that AA is against, such as soliciting members, providing initial motivation for recovery, or participating in or sponsoring research (Table 4).5
The Growth of Alcoholics Anonymous
AA was founded by Bob Smith, MD, a surgeon from Akron, Ohio, and Bill Wilson, an alcoholic from New York City. The birth date of AA is given as June 10, 1935, the day Smith had his last drink. Two and a half years later, “Dr. Bob” and “Bill W” estimated that, as a result of their combined efforts, there was a total of only 40 sober recovering alcoholics in their respective cities. Most alcoholics who were contacted were not maintaining sobriety nor had any interest in Dr. Bob or Bill W’s ideas.6 However, the co-founders knew they were onto something and continued the efforts of carrying hope, strength, and experience to other alcoholics. After 4 years, membership was estimated to be about 100, and by the end of 1941, there were 8,000 members. By 1968, 170,000 members were estimated.7 In spite of early periods of discouragement, the growth of AA has been phenomenal and continues today, exceeding 1 million in membership worldwide.
Affiliation With Alcoholics Anonymous
The 2001 AA General Services Office survey3 reported that 32% of AA newcomers were referred by treatment facilities, 33% were attracted to AA by an AA member, and 33% reported being self-motivated to seek AA.
A study from Great Britain reported that 65% of general practitioners believed that AA had something to offer beyond what could be obtained through medical efforts.8 The 2001 General Services Survey3 reported that 38% of members were referred to AA by a healthcare professional and that 73% of member’s physicians are aware that they are attending AA.
Once an individual begins attending AA meetings, what are the chances that he or she will continue? Estimates from AA General Services Office surveys indicate that only 50% of those who start AA remain for more than 3 months. In a review of AA affiliation,9 approximately 20% of problem drinkers referred to AA were found to attend regularly. In a 4-year follow-up of alcoholism treatment,10 27% of those who had ever gone to AA reported attendance at AA the month prior to follow-up, and of those who reported attending AA regularly, 39% had attended a meeting during the month prior to follow-up. In a review of the literature,10 dropout rates from AA varied from 68% before 10 meetings were attended to 88% by 1 year after discharge. A recent follow-up study of an outpatient program found that a majority of patients were attending AA 6 months after discharge.11 The latter study plus data from the 2001 AA Survey3 indicate an emerging trend—that counseling or other related treatments seem to be influencing AA affiliation; 74% of AA members who received such treatment reported that it played an important part in their seeking help with AA.
The dropout problem raises the question of who is likely to make a stable affiliation with AA. Early research on this problem12,13 suggests that those who join AA are middle-class, guilt-ridden, sociable, cognitively rigid, and socially stable. They are also more likely to be chronic alcoholics or loss-of-control drinkers and to have more alcohol-related problems. A comprehensive recent review of the affiliation process fails to support earlier findings. Emrick10 compared variables used to distinguish between stable and unstable affiliations and found that 64% bear no relationship, 29% show a positive relationship favoring AA affiliation, and only 7% bear a negative relationship to AA affiliation. This leads to the conclusion that most alcoholics have the possibility of making an affiliation with AA. Only those whose goal is not to abstain from alcohol would be seen as exceptions. Currently, it is best to accept that a patient’s affiliation with AA is unpredictable, which again emphasizes the importance of recommending AA to all possible members.
Effectiveness of Alcoholics Anonymous
Efforts have been made to assess the effectiveness of AA attendance. Measurement of outcome typically is limited to abstinence or lack of abstinence from alcohol. In studies of AA from the 1940s to the early 1970s,14 sampling difficulties and other methodological problems were prominent. Nevertheless, the findings indicated that thousands of AA members had achieved sobriety through AA. In a study of 393 AA members, it was determined that 70% of those who stayed sober for 1 year would still be sober at 2 years, and that 90% of those sober at 2 years would remain sober at 3 years.14 In two early studies of AA, sobriety of >2 years’ duration was found in 46% of those sampled.15,16
A review of survey studies10 found that 35% to 40% of respondents reported abstinence of <1 year, with 26% to 40% reporting abstinence of 1–5 years, and 20% to 30% having been sober for ≥5 years. Overall, 47% to 62% of active AA members had ≥1 year of continuous sobriety. The 1989 AA General Services Office survey consisting of 9,994 responses from a mailing of 12,000 reported an average sobriety length of 50 months. The 2001 survey reported the average sobriety of members to be 84 months with 18% sober >5 years and 30% sober <1 year.
AA involvement has been found to correlate favorably with a variety of outcome measures. Those patients who attend AA before, during, or after a treatment experience have a more favorable outcome in regard to drinking.10 In the few studies available that assess the outcome on other variables, AA involvement is associated with a more stable social adjustment, more active religious life, internal locus of control, and better employment adjustment.10 Increased ethical concern for others, an increased sense of well-being, and increasing dependence on a spiritual “higher power” with less dependence on others have also been described.17 Finally, there is a positive relationship between outcome and extent of AA participation.10 Outcome is more favorable for those who attend more than one meeting per week and for those who have a sponsor, sponsor others, lead meetings, and work steps 6 through 12 after completing a treatment program.
The Dynamics of Alcoholics Anonymous
The reasons for AA’s effectiveness may be as varied as the individuals involved. At the most basic level, the program works because one follows the 12 steps. It may be that these deceptively simple steps provide a concrete, tangible course of action; they may trigger cognitive processes previously unformed, unfocused, or abandoned and they may encapsulate powerful dynamics capable of having an impact on craving, conditioning, and character. The AA program revolves around the 12 steps, and most members would offer the common-sense explanation that working the steps keeps them sober.18
Additional explanations for AA’s effectiveness include strengthening self-control, decreasing pathological narcissism, empathetic understanding of alcoholics, and spiritual growth. The latter processes are not mutually exclusive and most likely impact a given AA member differently.
Strengthening of Self-Control
Mack19 and Khantzian and Mack20 refer to an aspect of the ego (or self) concerned with choosing, deciding, and directing the personality. Self-governance, or more simply, self-control, encompasses a group of functions in the ego system that provides the individual with a sense of being and a sense of power to be in charge of oneself. The concept of self-control implies a sharing of control with others, and, indeed, indicates that survival and sense of personal value require interdependent participation in social structures.
The alcoholic has lost control over alcohol, and in turn, his or life has become unmanageable. AA recognizes the powerlessness of the individual in the face of the drive to drink and provides a counterforce to the drive to drink through caring and supportive interaction with others. The social aspects of group process operating in AA strengthen the individual’s capacity for self-control by “borrowing” such capacity from fellowship with AA members, the group process, and the acceptance of a higher power. In the most simple terms, the alcoholic learns to substitute people for alcohol.
Khantzian and Mack20 further implicate ego functions in the etiology of and recovery from alcoholism. They view the alcoholic as having certain ego functions that have poorly developed. One such ego disability observed in alcoholics and other addicts is a diminished capacity to recognize, regulate, and tolerate affect. Feelings may seem unmanageable and, therefore, threatening. The ability to describe how one feels may be lacking. The individual, who feels overwhelmed, confused, or painfully uncomfortable with emotion, is subject to develop pseudoindependent personality traits that serve to defend one from painful feelings.21 Such defenses constitute, in part, the defects of character that the AA step program seeks to remove. Thus AA, through the working of the steps (particularly 6, 7, and 11), challenges the past faulty coping strategies of the alcoholic through its recognition that failure to do so will lead one back to drinking.
Another ego function that may be deficient in substance-abusing individuals is that of self-care. This capacity involves reality testing, judgment, anticipation of consequences, and impulse control. AA may strengthen the self-care capacity of the individual by offering self-soothing slogans (eg, “easy does it,” “one day at a time,” “live and let live”) and by providing a caring milieu that the alcoholic gradually identifies with, internalizes, and uses to modulate his or her behavior.
Decreasing Pathological Narcissism
In addition to the specific ego dysfunctions mentioned earlier, Khantzian and Mack20 emphasize the importance of pathological narcissism in substance abusers. Strands of pathological narcissism that may be observed in alcoholics and other addicts include the belief that they can take care of problems themselves, that they are self-sufficient, and that they are able to retain the necessary control over alcohol as well as other areas of their lives. Further, alcohol induces a feeling of personal power and adequacy.22 The person vulnerable to alcoholism or drug addiction may enter adult life wounded by empathic failures in being parented and therefore may retain archaic narcissistic tendencies, such as grandiosity (including self-sufficiency), an overvaluation or devaluation of others, and a reliance on external sources to feel complete.23 An adult burdened by these narcissistic themes is doomed to continuous disappointment in self and others. Depression, anxiety, guilt, and shame can be expected. It is a short step to the discovery of relief from such emotional pain through alcohol. In addition, alcohol’s pharmacologic restoration of a feeling of personal power22 reinforces the original pathological narcissism.24
Cogent to the theme of narcissism are the 12 steps. Step 1, acknowledging powerlessness and loss of control, is the sine qua non, an essential element or condition,of recovery. Without the recognition and acceptance of one’s loss of control, recovery is postponed. Brown25 places particular emphasis on the alcoholic’s need to accept loss of control (ie, accept steps 1 and 2), for such acceptance is considered the nucleus of one’s identity as an alcoholic from which the stages of recovery may unfold. A reading of the steps makes clear how they offer a healthy alternative to pathological expressions of personality. Humility, powerlessness, consideration of others, the need for self-examination, and service are clearly put forth, not as abstract ideals, but as tools to ward off a return to the insanity of alcoholism.
An Empathic Understanding of the Alcoholic
As Bean26 describes, AA has “accomplished a shift from a society-centered view of alcoholism to an abuser-centered one.” AA provides the alcoholic with a protected environment. After years of feeling debased and worthless, the alcoholic is offered an environment free from the conventional view of drunken behavior. The alcoholic discovers that his or her experience is of value and even interesting to others. Further, the alcoholic’s experiences may be useful to someone else, and others thank him or her for sharing it. As Bean explains, “This idea, that a person’s experience is of value, is gratifying to anyone and is especially heady stuff to the chronically self-deprecating alcoholic.”27
Along with the shift in how alcoholism is viewed, AA provides a shift in what is expected of the alcoholic. First, the alcoholic is not asked to admit that he or she is an alcoholic. AA simply asks that one have a sincere desire to stop drinking. There is no effort to point out the error of one’s ways or the evils of alcohol. In fact, the attraction of alcohol and the pleasure of alcohol are openly acknowledged but linked with the statement that “we could not handle it.” The alcoholic who comes to AA is not asked to change, only to listen, identify, and keep coming back. The style of interpersonal contact is nonthreatening. Last names are not given, attendance is not taken, the setting is casual, and humor and friendliness abound. Nevertheless, the meeting is serious. Each member conveys that there is a lot to lose, regardless of how much has actually been lost, but also that there is much to gain in sobriety. Sobriety is the focus, and remains so, unvaryingly. Relapses or “slips” do not represent a failure on the part of the alcoholic or of AA. Rather, slips are further demonstration of the power of alcohol and, therefore, the necessity of AA as a counterforce.
As the alcoholic advances in recovery, self-esteem is protected by abstinence but threatened by remorse over the past. AA techniques to handle this aspect of recovery are:
• When one makes the decision not to drink, encourage that they repent, reform, and build from the wreckage of the past.
• Place blame on the illness, not the alcoholic.
• Avoid censure.
• Reward good behavior by dispensing 30-day, 60-day, 90-day, or
1 year “chips” as milestones in sobriety are achieved.
• Allow expression of low self-esteem in nondestructive ways rather than by drinking.
AA does not ask the alcoholic to get a job, be a better family member, or become more responsible. Sobriety is the goal from which other desirable efforts may emerge. The “depressurization” techniques of AA (“one day at a time,” “keep it simple,” etc.) and the social dimension (sharing “experiences, strength, and hope”) are critical components of the AA experience.
An essential insight of AA for the alcoholic is its recognition and acceptance that one is “not-God.”6 This refers to the necessity for the alcoholic to accept personal limitation. Step 1 of AA communicates to the alcoholic: “We admitted we were powerless over alcohol and that our lives had become unmanageable.” The acceptance of personal limitation—a condition of existence for all—is a life-or-death matter for the alcoholic. In teaching that the first drink gets the alcoholic drunk, AA proclaims that the alcoholic does not have a drinking limit, rather the alcoholic is limited.28 To experience limitation is tantamount to experiencing shame. As painful as the shame is, it is a feeling pivotal to recovery. Acceptance of shame distinguishes the alcoholic who, in Tiebout’s29 terms, complies rather than surrenders. Compliance is motivated by guilt, is superficial, and is ultimately useless to extended recovery. Surrender involves recognition of powerlessness (and the feeling associated with feeling limited or of having fallen short). Through surrender the alcoholic becomes open to the healing forces within AA. The AA program treats shame by enabling the alcoholic to accept his or her need for others, by promoting the acceptance of others as they are (“live and let live”), and by valuing and reinforcing traits of honesty, sharing, and caring.
Spirituality rarely is referred to in medical treatment but is a dimension of the AA program and understood by those who work and live the 12 steps. The spirituality of the AA program may be understood as a series of overlapping themes:
• Release. This refers to the “chains being broken”—freedom from the compulsion to drink. The experience of release is a powerful and welcoming event for the alcoholic and seems to occur naturally or to be given rather than achieved.
• Gratitude. Gratitude may flow from the feeling of release and includes an awareness of what we have, for example, the gift of life. According to Kurtz,30 the words “think” and “thank” share a common derivation. Thinking leads to remembrance (eg, as the AA speaker tells his or her story), and from remembrance an attitude of thankfulness (gratitude) may be experienced (eg, gratitude that one is now sober).
• Humility. Humility conveys the attitude that it is acceptable to be limited, to be simply human. The alcoholic’s awareness of powerlessness over alcohol engenders humility.
• Tolerance. Tolerance of differences and limitations fosters the serenity often experienced by AA members.
Recently, Emmonds31 empirically demonstrated that goals, especially those of spiritual striving and those with religious significance, seem to promote personality integration and assist in resolving the pernicious effect of conflict on mental and physical health. AA provides goals for the alcoholic; not only the goal and “promises” of sobriety, but the goals of understanding, embracing, and following the 12 steps.
In addition to the spiritual themes mentioned earlier, an additional spiritual dimension, forgiveness, may be significant. The seeking of forgiveness is implied, not directly expressed, in the 12 steps. For example, steps 6 and 7 (Table 1) ask God to remove defects of character and remove shortcomings. The behavior of AA members toward newcomers (welcoming, accepting, friendly, caring) communicates forgiveness. Forgiveness is neither asked for nor offered at AA. The word itself may or may not be heard at AA meetings, but its meaning pervades the transactions of the meetings. For example, Bean writes32:
Alcoholics know how deeply and painfully ashamed and guilty other alcoholics are about their drinking, how they lie and minimize it, and how this reinforces their sense of worthlessness. The discovery that others have committed what they thought was their own uniquely unforgivable crime brings longed-for solace. Speakers repeatedly report their sense of relief when they first come to AA. They had no further need for dissembling and fear. Here they were among their own kind and were accepted.
Forgiveness may be a precondition for the dynamic forces described in this chapter to be operative. For example, forgiveness precedes hope. Hope is necessarily very tenuous for a newcomer to AA and requires a future orientation—an orientation minimized by AA’s emphasis on “one day at a time.” Forgiveness is experienced in a moment and may be the foundation for a growing sense of hope. Abandoning narcissistic defenses, strengthening the capacity for self-control, and accepting “powerlessness” over alcohol all may be contingent on feeling forgiven or feeling capable of being forgiven. To be forgiven and to feel forgiven implies being accepted, a common description of the AA experience. The experience of shame28 as a pivotal affect and the treatment of shame in AA may become possible only if preceded by a sense of being forgiven.
Limitations of Alcoholics Anonymous
While the average AA participant is white, male (67%), and an average of 46 years of age, AA does attract a young female population as well. Eleven percent of members are ≤30 years of age3 and 33% are women.3 Adoption of the AA program by minorities has been slower to occur. Yet, most urban areas have several meetings with a predominantly black or Hispanic population. African-American affiliation with AA is growing stronger and may exceed white affiliation on some variables.33
Psychiatric comorbidity may impede AA affiliation for some alcoholics. Personality disorders of the schizoid, avoidant, or paranoid type may not adapt well to the interaction and emotionality of AA meetings. At times, a patient on medication is thrown into conflict by AA members who may advise against the use of any drugs. AA does not hold opinions on psychotropic medications, but occasionally an AA member may inappropriately influence a fellow member who requires specific psychiatric treatment. For example, an alcoholic persuaded to discontinue lithium or neuroleptics may relapse into psychosis at great personal expense. As more alcoholics are reaching AA through rehabilitation programs, AA’s familiarity with and understanding of individual needs may be increased, and the AA member under psychiatric treatment will be less likely to experience conflict and inappropriate advice.
Recommendations for AA should not be limited to certain alcoholics. AA generally seems to accommodate a wide variety of personalities and backgrounds. On a case-by-case basis, social or psychodynamic factors may deter the efficacy of AA utilization, but that can be ascertained on an individual basis only, not by currently available data.
Specific limitations to the AA method have been summarized by Bean12 and include that AA is seen by some as rigid, superficial, inspirational, fanatical, stigmatizing, and focusing only on alcohol. The rigidity is more likely to lie in individual members than the AA program itself. Questioning and intellectualizing are discouraged, but this seems more a means to hold back the ever-present threat of denial. The criticism of superficiality is appropriate if one’s goals are to unravel the complex etiologies of alcoholism or to understand the dynamics of behavior change. AA, however, focuses on abstaining from drinking. It is inspirational rather than reflective, but again, the alcoholic who is early in recovery cannot be expected to obtain or use insight. Morale is of critical concern, and the emotional pitch of AA strikes a respondent chord in the demoralized. Unfortunately, fanaticism or zealotry may form part of the operation of AA loyalty. Such members are repellent to some newcomers, who may feel that their emotional needs are not understood or validated. Some charismatic AA members convert many alcoholics but alienate others. Finally, there may still be a stigma associated with attending AA. However, if there is, it is less so than in past, since acclaim for AA is easily found in popular literature and the media. At the least, any stigma attached to the AA program would be substantially less than that of chronic drunkenness.
By gaining an understanding of this 12-step program the clinician will be prepared to motivate and advocate AA to his or her alcoholic patients. This understanding is gained best by attending AA meetings, discussing AA with experienced members, and reading widely, including the AA literature as well as professional writings on AA. From this effort the physician can inform each patient appropriately of the advantages of AA affiliation. PP
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