Excerpts from Must Read Books & Articles
on Mental Health Topics
Articles- Part XXXV
Malcolm Gladwell, The New Yorker- 2/15/2010
In 1956, Dwight Heath, a graduate student in anthropology at Yale University, was preparing to do field work for his dissertation. He was interested in land reform and social change, and his first choice as a study site was Tibet. But six months before he was to go there he got a letter from the Chinese government rejecting his request for a visa. "I had to find a place where you can master the literature in four months, and that was accessible," Heath says now. "It was a hustle." Bolivia was the next best choice. He and his wife, Anna Cooper Heath, flew to Lima with their baby boy, and then waited for five hours while mechanics put boosters on the plane's engines. "These were planes that the U.S. had dumped after World War II," Heath recalls. "They weren't supposed to go above ten thousand feet. But La Paz, where we were headed, was at twelve thousand feet." As they flew into the Andes, Cooper Heath says, they looked down and saw the remnants of "all the planes where the boosters didn't work."
From La Paz, they travelled five hundred miles into the interior of eastern Bolivia, to a small frontier town called Montero. It was the part of Bolivia where the Amazon Basin meets the Chaco—vast stretches of jungle and lush prairie. The area was inhabited by the Camba, a mestizo people descended from the indigenous Indian populations and Spanish settlers. The Camba spoke a language that was a mixture of the local Indian languages and seventeenth-century Andalusian Spanish. "It was an empty spot on the map," Heath says. "There was a railroad coming. There was a highway coming. There was a national government . . . coming."
They lived in a tiny house just outside of town. "There was no pavement, no sidewalks," Cooper Heath recalls. "If there was meat in town, they'd throw out the hide in front, so you'd know where it was, and you would bring banana leaves in your hand, so it was your dish. There were adobe houses with stucco and tile roofs, and the town plaza, with three palm trees. You heard the rumble of oxcarts. The padres had a jeep. Some of the women would serve a big pot of rice and some sauce. That was the restaurant. The guy who did the coffee was German. The year we came to Bolivia, a total of eighty-five foreigners came into the country. It wasn't exactly a hot spot."
In Montero, the Heaths engaged in old-fashioned ethnography—"vacuuming up everything," Dwight says, "learning everything." They convinced the Camba that they weren't missionaries by openly smoking cigarettes. They took thousands of photographs. They walked around the town and talked to whomever they could, and then Dwight went home and spent the night typing up his notes. They had a Coleman lantern, which became a prized social commodity. Heath taught some of the locals how to build a split-rail fence. They sometimes shared a beer in the evenings with a Bolivian Air Force officer who had been exiled to Montero from La Paz. "He kept on saying, Watch me, I will be somebody," Dwight says. (His name was Rene Barrientos; eight years later he became the President of Bolivia, and the Heaths were invited to his inauguration.) After a year and a half, the Heaths packed up their photographs and notes and returned to New Haven. There Dwight Heath sat down to write his dissertation—only to discover that he had nearly missed what was perhaps the most fascinating fact about the community he had been studying.
Today, the Heaths are in their late seventies. Dwight has neatly combed gray hair and thick tortoiseshell glasses, a reserved New Englander through and through. Anna is more outgoing. They live not far from the Brown University campus, in Providence, in a house filled with hundreds of African statues and sculptures, with books and papers piled high on tables, and they sat, in facing armchairs, and told the story of what happened half a century ago, finishing each other's sentences.
"It was August or September of 1957," Heath said. "We had just gotten back. She's tanned. I'm tanned. I mean, really tanned, which you didn't see a lot of in New Haven in those days." "I'm an architecture nut," Anna said. "And I said I wanted to see the inside of this building near the campus. It was always closed. But Dwight says, 'You never know,' so he walked over and pulls on the door and it opens." Anna looked over at her husband. "So we go in," Dwight went on, "and there was a couple of little white-haired guys there. And they said, `You're tanned. Where have you been?' And I said Bolivia. And one of them said, `Well, can you tell me how they drink?'" The building was Yale's Center of Alcohol Culture a Studies. One of the white-haired men was E. M. Jellinek, perhaps the world's leading expert on alcoholism at the time; the other was Mark Keller, the editor of the well-regarded Quarterly Journal of Studies on Alcohol. Keller stood up and grabbed Heath by the lapels: "I don't know anyone who has ever been to Bolivia. Tell me about it!" He invited Heath to write up his alcohol-related observations for his journal.
After the Heaths went home that day, Anna said to Dwight, "Do you realize that every weekend we were in Bolivia we went out drinking?" The code he used for alcohol in his notebooks was 30A, and when he went over his notes he found 30A references everywhere. Still, nothing about the alcohol question struck him as particularly noteworthy. People drank every weekend in New Haven, too. His focus was on land reform. But who was he to say no to the Quarterly Journal of Studies on Alcohol? So he sat down and wrote up what he knew. Only after his article, "Drinking Patterns of the Bolivian Camba," was published, in September of 1958, and the queries and reprint requests began flooding in from around the world, did he realize what he had found. "This is so often true in anthropology," Anna said. "It is not anthropologists who recognize the value of what they've done. It's everyone else. The anthropologist is just reporting."
The abuse of alcohol has, historically, been thought of as a moral failing Muslims and Mormons and many kinds of fundamentalist Christians do not drink, because they consider alcohol an invitation to weakness and sin. Around the middle of the last century, alcoholism began to be widely considered a disease: it was recognized that some proportion of the population was genetically susceptible to the effects of drinking. Policymakers, meanwhile, have become increasingly interested in using economic and legal tools to control alcohol-related behavior: that's why the drinking age has been raised from eighteen to twenty-one, why drunk-driving laws have been toughened, and why alcohol is taxed heavily. Today, our approach to the social burden of alcohol is best described as a mixture of all three: we moralize, medicalize, and legalize.
In the nineteen-fifties, however, the researchers at the Yale Center of Alcohol Studies found something lacking in this emerging approach, and the reason had to do with what they observed right in their own town. New Haven was a city of immigrants—Jewish, Irish, and, most of all, Italian. Recent Italian immigrants made up about a third of the population, and whenever the Yale researchers went into the Italian neighborhoods they found an astonishing thirst for alcohol. The overwhelming majority of Italian-American men in New Haven drank. A group led by the director of the Yale alcohol-treatment clinic, Giorgio Lolli, once interviewed a sixty-one-year-old father of four who consumed more than three thousand calories a day of food and beverages—of which a third was wine. "He usually has an 8-oz. glass of wine immediately following his breakfast every morning," Lolli and his colleagues wrote. "He always takes wine with his noonday lunch—as much as 24 oz." But he didn't display the pathologies that typically accompany that kind of alcohol consumption. The man was successfully employed, and had been drunk only twice in his life. He was, Lolli concluded, "a healthy, happy individual who has made a satisfactory adjustment to life."
By the late fifties, Lolli's clinic had admitted twelve hundred alcoholics. Plenty of them were Irish. But just forty were Italians (all of whom were second- or third-generation immigrants). New Haven was a natural experiment. Here were two groups who practiced the same religion, who were subject to the same laws and constraints, and who, it seemed reasonable to suppose, should have the same assortment within their community of those genetically predisposed to alcoholism. Yet the heavy-drinking Italians had nothing like the problems that afflicted their Irish counterparts.
"That drinking must precede alcoholism is obvious," Mark Keller once wrote. "Equally obvious, but not always sufficiently considered, is the fact that drinking is not necessarily followed by alcoholism." This was the puzzle of New Haven, and why Keller demanded of Dwight Heath, that day on the Yale campus, Tell me how the Camba drink. The crucial ingredient, in Keller's eyes, had to be cultural.
The Heaths had been invited to a party soon after arriving in Montero, and every weekend and holiday thereafter. It was their Coleman lantern. "Whatever the occasion, it didn't matter," Anna recalled. "As long as the party was at night, we were first on the list." The parties would have been more aptly described as drinking parties. The host would buy the first bottle and issue the invitations. A dozen or so people would show up on Saturday night, and the party would proceed—often until everyone went back to work on Monday morning. The composition of the group was informal: sometimes people passing by would be invited. But the structure of the party was heavily ritualized. The group would sit in a circle. Someone might play the drums or a guitar. A bottle of rum, from one of the sugar refineries in the area, and a small drinking glass were placed on a table. The host stood, filled the glass with rum, and then walked toward someone in the circle. He stood before the "toastee," nodded, and raised the glass. The toastee smiled and nodded in return. The host then drank half the glass and handed it to the toastee, who would finish it. The toastee eventually stood, refilled the glass, and repeated the ritual with someone else in the circle. When people got too tired or too drunk, they curled up on the ground and passed out, rejoining the party when they awoke. The Camba did not drink alone. They did not drink on work nights. And they drank only within the structure of this elaborate ritual.
"The alcohol they drank was awful," Anna recalled. "Literally, your eyes poured tears. The first time I had it, I thought, I wonder what will happen if I just vomit in the middle of the floor. Not even the Camba said they liked it. They say it tastes bad. It burns. The next day they are sweating this stuff. You can smell it." But the Heaths gamely persevered. "The anthropology graduate student in the nineteen-fifties felt that he had to adapt," Dwight Heath said. "You don't want to offend anyone, you don't want to decline anything. I gritted my teeth and accepted those drinks."
"We didn't get drunk that much," Anna went on, "because we didn't get toasted as much as the other folks around. We were strangers. But one night there was this really big party—sixty to eighty people. They'd drink. Then pass out. Then wake up and party for a while. And I found, in their drinking patterns, that I could turn my drink over to Dwight. The husband is obliged to drink for his wife. And Dwight is holding the Coleman lantern with his arm wrapped around it, and I said, 'Dwight, you are burning your arm.'" She mimed her husband peeling his forearm off the hot surface of the lantern. "And he said—very deliberately—'So I am.' "
The above text covers the first two pages of this six page article. For the remainder, visit the archives of the New Yorker Magazine at www.newyorker.com/archive..
Can Psychiatry Be a Science?
Loiuis Menard, The New Yorker- 3/1/2010
You arrive for work and someone informs you that you have until five o’clock to clean out your office. You have been laid off. At first, your family is brave and supportive, and although you’re in shock, you convince yourself that you were ready for something new. Then you start waking up at 3 A.M., apparently in order to stare at the ceiling. You can’t stop picturing the face of the employee who was deputized to give you the bad news. He does not look like George Clooney. You have fantasies of terrible things happening to him, to your boss, to George Clooney. You find—a novel recognition—not only that you have no sex drive but that you don’t care. You react irritably when friends advise you to let go and move on. After a week, you have a hard time getting out of bed in the morning. After two weeks, you have a hard time getting out of the house. You go see a doctor. The doctor hears your story and prescribes an antidepressant. Do you take it?
However you go about making this decision, do not read the psychiatric literature. Everything in it, from the science (do the meds really work?) to the metaphysics (is depression really a disease?), will confuse you. There is little agreement about what causes depression and no consensus about what cures it. Virtually no scientist subscribes to the man-in-the-waiting-room theory, which is that depression is caused by a lack of serotonin, but many people report that they feel better when they take drugs that affect serotonin and other brain chemicals.
There is suspicion that the pharmaceutical industry is cooking the studies that prove that antidepressant drugs are safe and effective, and that the industry’s direct-to-consumer advertising is encouraging people to demand pills to cure conditions that are not diseases (like shyness) or to get through ordinary life problems (like being laid off). The Food and Drug Administration has been accused of setting the bar too low for the approval of brand-name drugs. Critics claim that health-care organizations are corrupted by industry largesse, and that conflict-of-interest rules are lax or nonexistent. Within the profession, the manual that prescribes the criteria for official diagnoses, the Diagnostic and Statistical Manual of Mental Disorders, known as the D.S.M., has been under criticism for decades. And doctors prescribe antidepressants for patients who are not suffering from depression. People take antidepressants for eating disorders, panic attacks, premature ejaculation, and alcoholism.
These complaints are not coming just from sociologists, English professors, and other troublemakers; they are being made by people within the field of psychiatry itself. As a branch of medicine, depression seems to be a mess. Business, however, is extremely good. Between 1988, the year after Prozac was approved by the F.D.A., and 2000, adult use of antidepressants almost tripled. By 2005, one out of every ten Americans had a prescription for an antidepressant. IMS Health, a company that gathers data on health care, reports that in the United States in 2008 a hundred and sixty-four million prescriptions were written for antidepressants, and sales totalled $9.6 billion. As a depressed person might ask, What does it all mean? Two new books, Gary Greenberg’s “Manufacturing Depression” (Simon & Schuster; $27) and Irving Kirsch’s “The Emperor’s New Drugs” (Basic; $23.95), suggest that dissensus prevails even among the dissidents. Both authors are hostile to the current psychotherapeutic regime, but for reasons that are incompatible. Greenberg is a psychologist who has a practice in Connecticut. He is an unusually eloquent writer, and his book offers a grand tour of the history of modern medicine, as well as an up-close look at contemporary practices, including clinical drug trials, cognitive-behavioral therapy, and brain imaging. The National Institute of Mental Health estimates that more than fourteen million Americans suffer from major depression every year, and more than three million suffer from minor depression (whose symptoms are milder but last longer than two years). Greenberg thinks that numbers like these are ridiculous—not because people aren’t depressed but because, in most cases, their depression is not a mental illness. It’s a sane response to a crazy world.
Greenberg basically regards the pathologizing of melancholy and despair, and the invention of pills designed to relieve people of those feelings, as a vast capitalist conspiracy to paste a big smiley face over a world that we have good reason to feel sick about. The aim of the conspiracy is to convince us that it’s all in our heads, or, specifically, in our brains—that our unhappiness is a chemical problem, not an existential one. Greenberg is critical of psychopharmacology, but he is even more critical of cognitive-behavioral therapy, or C.B.T., a form of talk therapy that helps patients build coping strategies, and does not rely on medication. He calls C.B.T. “a method of indoctrination into the pieties of American optimism, an ideology as much as a medical treatment.”
In fact, Greenberg seems to believe that contemporary psychiatry in most of its forms except existential-humanistic talk therapy, which is an actual school of psychotherapy, and which appears to be what he practices, is mainly about getting people to accept current arrangements. And it’s not even that drug companies and the psychiatric establishment have some kind of moral or political stake in these arrangements—that they’re in the game in order to protect the status quo. They just see, in the world’s unhappiness, a chance to make money. They invented a disease so that they could sell the cure.
Greenberg is repeating a common criticism of contemporary psychiatry, which is that the profession is creating ever more expansive criteria for mental illness that end up labelling as sick people who are just different—a phenomenon that has consequences for the insurance system, the justice system, the administration of social welfare, and the cost of health care.
Jerome Wakefield, a professor of social work at New York University, has been calling out the D.S.M. on this issue for a number of years. In “The Loss of Sadness” (2007), Wakefield and Allan Horwitz, a sociologist at Rutgers, argue that the increase in the number of people who are given a diagnosis of depression suggests that what has changed is not the number of people who are clinically depressed but the definition of depression, which has been defined in a way that includes normal sadness. In the case of a patient who exhibits the required number of symptoms, the D.S.M. specifies only one exception to a diagnosis of depression: bereavement. But, Wakefield and Horwitz point out, there are many other life problems for which intense sadness is a natural response—being laid off, for example. There is nothing in the D.S.M. to prevent a physician from labelling someone who is living through one of these problems mentally disordered.
The conversion of stuff that people used to live with into disorders that physicians can treat is not limited to psychiatry, of course. Once, people had heartburn (“I can’t believe I ate the whole thing”) and bought Alka-Seltzer over the counter; now they are given a diagnosis of gastroesophageal reflux disease (“Ask your doctor whether you might be suffering from GERD”) and are written a prescription for Zantac. But people tend to find the medicalization of mood and personality more distressing. It has been claimed, for example, that up to 18.7 per cent of Americans suffer from social-anxiety disorder. In “Shyness” (2007), Christopher Lane, a professor of English at Northwestern, argues that this is a blatant pathologization of a common personality trait for the financial benefit of the psychiatric profession and the pharmaceutical industry. It’s a case of what David Healy, in his invaluable history “The Antidepressant Era” (1997), calls “the pharmacological scalpel”: if a drug (in this case, Paxil) proves to change something in patients (shyness), then that something becomes a disorder to be treated (social anxiety). The discovery of the remedy creates the disease.
Turning shyness into a mental disorder has many downstream consequences. As Steven Hyman, a former director of the National Institute of Mental Health, argues in a recent article, once a diagnosis is ensconced in the manual, it is legitimatized as a subject of scientific research. Centers are established (there is now a Shyness Research Institute, at Indiana University Southeast) and scientists get funding to, for example, find “the gene for shyness”—even though there was never any evidence that the condition has an organic basis. A juggernaut effect is built into the system.
Irving Kirsch is an American psychologist who now works in the United Kingdom. Fifteen years ago, he began conducting meta-analyses of antidepressant drug trials. A meta-analysis is a statistical abstract of many individual drug trials, and the method is controversial. Drug trials are designed for different reasons—some are done to secure government approval for a new drug, and some are done to compare treatments—and they have different processes for everything from selecting participants to measuring outcomes. Adjusting for these differences is complicated, and Kirsch’s early work was roundly criticized on methodological grounds by Donald Klein, of Columbia University, who was one of the key figures in the transformation of psychiatry to a biologically based practice. But, as Kirsch points out, meta-analyses have since become more commonly used and accepted. Kirsch’s conclusion is that antidepressants are just fancy placebos. Obviously, this is not what the individual tests showed. If they had, then none of the drugs tested would have received approval. Drug trials normally test medications against placebos—sugar pills—which are given to a control group. What a successful test typically shows is a small but statistically significant superiority (that is, greater than could be due to chance) of the drug to the placebo. So how can Kirsch claim that the drugs have zero medicinal value?
His answer is that the statistical edge, when it turns up, is a placebo effect. Drug trials are double-blind: neither the patients (paid volunteers) nor the doctors (also paid) are told which group is getting the drug and which is getting the placebo. But antidepressants have side effects, and sugar pills don’t. Commonly, side effects of antidepressants are tolerable things like nausea, restlessness, dry mouth, and so on. (Uncommonly, there is, for example, hepatitis; but patients who develop hepatitis don’t complete the trial.) This means that a patient who experiences minor side effects can conclude that he is taking the drug, and start to feel better, and a patient who doesn’t experience side effects can conclude that she’s taking the placebo, and feel worse. On Kirsch’s calculation, the placebo effect—you believe that you are taking a pill that will make you feel better; therefore, you feel better—wipes out the statistical difference.
The above text covers the first two pages of this seven page article. For the remainder, visit the archives of the New Yorker Magazine at www.newyorker.com/archive..
Secret of AA: After 75 Years, We Don’t Know How It Works
Brendan I. Koerner, Wired July 2010
The church will be closed tomorrow, and the drunks are freaking out. An elderly lady in a prim white blouse has just delivered the bad news, with deep apologies: A major blizzard is scheduled to wallop Manhattan tonight, and up to a foot of snow will cover the ground by dawn. The church, located on the Upper West Side, can’t ask its staff to risk a dangerous commute. Unfortunately, that means it must cancel the Alcoholics Anonymous meeting held daily in the basement.
A worried murmur ripples through the room. “Wha… what are we supposed to do?” asks a woman in her mid-twenties with smudged black eyeliner. She’s in rough shape, having emerged from a multiday alcohol-and-cocaine bender that morning. “The snow, it’s going to close everything,” she says, her cigarette-addled voice tinged with panic. “Everything!” She’s on the verge of tears.
A mustachioed man in skintight jeans stands and reads off the number for a hotline that provides up-to-the-minute meeting schedules. He assures his fellow alcoholics that some groups will still convene tomorrow despite the weather. Anyone who needs an AA fix will be able to get one, though it may require an icy trek across the city. That won’t be a problem for a thickset man in a baggy beige sweat suit. “Doesn’t matter how much snow we get - a foot, 10 feet piled up in front of the door,” he says. “I will leave my apartment tomorrow and go find a meeting.” He clasps his hands together and draws them to his heart: “You understand me? I need this.” Daily meetings, the man says, are all that prevent him from winding up dead in the gutter, shoes gone because he sold them for booze or crack. And he hasn’t had a drink in more than a decade.
The resolve is striking, though not entirely surprising. AA has been inspiring this sort of ardent devotion for 75 years. It was in June 1935, amid the gloom of the Great Depression, that a failed stockbroker and reformed lush named Bill Wilson founded the organization after meeting God in a hospital room. He codified his method in the 12 steps, the rules at the heart of AA. Entirely lacking in medical training, Wilson created the steps by cribbing ideas from religion and philosophy, then massaging them into a pithy list with a structure inspired by the Bible.
The 200-word instruction set has since become the cornerstone of addiction treatment in this country, where an estimated 23 million people grapple with severe alcohol or drug abuse—more than twice the number of Americans afflicted with cancer. Some 1.2 million people belong to one of AA’s 55,000 meeting groups in the US, while countless others embark on the steps at one of the nation’s 11,000 professional treatment centers. Anyone who seeks help in curbing a drug or alcohol problem is bound to encounter Wilson’s system on the road to recovery.
It’s all quite an achievement for a onetime broken-down drunk. And Wilson’s success is even more impressive when you consider that AA and its steps have become ubiquitous despite the fact that no one is quite sure how - or, for that matter, how well - they work. The organization is notoriously difficult to study, thanks to its insistence on anonymity and its fluid membership. And AA’s method, which requires “surrender” to a vaguely defined “higher power,” involves the kind of spiritual revelations that neuroscientists have only begun to explore.
What we do know, however, is that despite all we’ve learned over the past few decades about psychology, neurology, and human behavior, contemporary medicine has yet to devise anything that works markedly better. “In my 20 years of treating addicts, I’ve never seen anything else that comes close to the 12 steps,” says Drew Pinsky, the addiction-medicine specialist who hosts VH1’s Celebrity Rehab. “In my world, if someone says they don’t want to do the 12 steps, I know they aren’t going to get better.”
Wilson may have operated on intuition, but somehow he managed to tap into mechanisms that counter the complex psychological and neurological processes through which addiction wreaks havoc. And while AA’s ability to accomplish this remarkable feat is not yet understood, modern research into behavior dynamics and neuroscience is beginning to provide some tantalizing clues.
One thing is certain, though: AA doesn’t work for everybody. In fact, it doesn’t work for the vast majority of people who try it. And understanding more about who it does help, and why, is likely our best shot at finally developing a system that improves on Wilson’s amateur scheme for living without the bottle.
AA originated on the worst night of Bill Wilson’s life. It was December 14, 1934, and Wilson was drying out at Towns Hospital, a ritzy Manhattan detox center. He’d been there three times before, but he’d always returned to drinking soon after he was released. The 39-year-old had spent his entire adult life chasing the ecstasy he had felt upon tasting his first cocktail some 17 years earlier. That quest destroyed his career, landed him deeply in debt, and convinced doctors that he was destined for institutionalization.
Wilson had been quite a mess when he checked in the day before, so the attending physician, William Silkworth, subjected him to a detox regimen known as the Belladonna Cure - hourly infusions of a hallucinogenic drug made from a poisonous plant. The drug was coursing through Wilson’s system when he received a visit from an old drinking buddy, Ebby Thacher, who had recently found religion and given up alcohol. Thacher pleaded with Wilson to do likewise. “Realize you are licked, admit it, and get willing to turn your life over to God,” Thacher counseled his desperate friend. Wilson, a confirmed agnostic, gagged at the thought of asking a supernatural being for help. But later, as he writhed in his hospital bed, still heavily under the influence of belladonna, Wilson decided to give God a try. “If there is a God, let Him show Himself!” he cried out. “I am ready to do anything. Anything!”
What happened next is an essential piece of AA lore: A white light filled Wilson’s hospital room, and God revealed himself to the shattered stockbroker. “It seemed to me, in the mind’s eye, that I was on a mountain and that a wind not of air but of spirit was blowing,” he later said. “And then it burst upon me that I was a free man.” Wilson would never drink again.
At that time, the conventional wisdom was that alcoholics simply lacked moral fortitude. The best science could offer was detoxification with an array of purgatives, followed by earnest pleas for the drinker to think of his loved ones. When this approach failed, alcoholics were often consigned to bleak state hospitals. But having come back from the edge himself, Wilson refused to believe his fellow inebriates were hopeless. He resolved to save them by teaching them to surrender to God, exactly as Thacher had taught him.
Following Thacher’s lead, Wilson joined the Oxford Group, a Christian movement that was in vogue among wealthy mainstream Protestants. Headed by a an ex-YMCA missionary named Frank Buchman, who stirred controversy with his lavish lifestyle and attempts to convert Adolf Hitler, the Oxford Group combined religion with pop psychology, stressing that all people can achieve happiness through moral improvement. To help reach this goal, the organization’s members were encouraged to meet in private homes so they could study devotional literature together and share their inmost thoughts.
In May 1935, while on an extended business trip to Akron, Ohio, Wilson began attending Oxford Group meetings at the home of a local industrialist. It was through the group that he met a surgeon and closet alcoholic named Robert Smith. For weeks, Wilson urged the oft-soused doctor to admit that only God could eliminate his compulsion to drink. Finally, on June 10, 1935, Smith (known to millions today as Dr. Bob) gave in. The date of Dr. Bob’s surrender became the official founding date of Alcoholics Anonymous.
In its earliest days, AA existed within the confines of the Oxford Group, offering special meetings for members who wished to end their dependence on alcohol. But Wilson and his followers quickly broke away, in large part because Wilson dreamed of creating a truly mass movement, not one confined to the elites Buchman targeted. To spread his message of salvation, Wilson started writing what would become AA’s sacred text: Alcoholics Anonymous, now better known as the Big Book.
The core of AA is found in chapter five, entitled “How It Works.” It is here that Wilson lists the 12 steps, which he first scrawled out in pencil in 1939. Wilson settled on the number 12 because there were 12 apostles. In writing the steps, Wilson drew on the Oxford Group’s precepts and borrowed heavily from William James’ classic The Varieties of Religious Experience, which Wilson read shortly after his belladonna-fueled revelation at Towns Hospital. He was deeply affected by an observation that James made regarding alcoholism: that the only cure for the affliction is “religiomania.” The steps were thus designed to induce an intense commitment, because Wilson wanted his system to be every bit as habit-forming as booze.
The first steps famously ask members to admit their powerlessness over alcohol and to appeal to a higher power for help. Members are then required to enumerate their faults, share them with their meeting group, apologize to those they’ve wronged, and engage in regular prayer or meditation. Finally, the last step makes AA a lifelong duty: “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.” This requirement guarantees not only that current members will find new recruits but that they can never truly “graduate” from the program.
Aside from the steps, AA has one other cardinal rule: anonymity. Wilson was adamant that the anonymous component of AA be taken seriously, not because of the social stigma associated with alcoholism, but rather to protect the nascent organization from ridicule. He explained the logic in a letter to a friend: [In the past], alcoholics who talked too much on public platforms were likely to become inflated and get drunk again. Our principle of anonymity, so far as the general public is concerned, partly corrects this difficulty by preventing any individual receiving a lot of newspaper or magazine publicity, then collapsing and discrediting AA.
AA boomed in the early 1940s, aided by a glowing Saturday Evening Post profile and the public admission by a Cleveland Indians catcher, Rollie Hemsley, that joining the organization had done wonders for his game. Wilson and the founding members were not quite prepared for the sudden success. “You had really crazy things going on,” says William L. White, author of Slaying the Dragon: The History of Addiction Treatment and Recovery in America. “Some AA groups were preparing to run AA hospitals, and there was this whole question of whether they should have paid AA missionaries. You even had some reports of AA groups drinking beers at their meetings.”
The growing pains spurred Wilson to write AA’s governing principles, known as the 12 traditions. At a time when fraternal orders and churches with strict hierarchies dominated American social life, Wilson opted for something revolutionary: deliberate organizational chaos. He permitted each group to set its own rules, as long as they didn’t conflict with the traditions or the steps. Charging a fee was forbidden, as was the use of the AA brand to endorse anything that might generate revenue. “If you look at this on paper, it seems like it could never work,” White says. “It’s basically anarchy.” But this loose structure actually helped AA flourish. Not only could anyone start an AA group at any time, but they could tailor each meeting to suit regional or local tastes. And by condemning itself to poverty, AA maintained a posture of moral legitimacy.
Despite the decision to forbid members from receiving pay for AA-related activity, it had no problem letting professional institutions integrate the 12 steps into their treatment programs. AA did not object when Hazelden, a Minnesota facility founded in 1947 as “a sanatorium for curable alcoholics of the professional class,” made the steps the foundation of its treatment model. Nor did AA try to stop the proliferation of steps-centered addiction groups from adopting the Anonymous name: Narcotics Anonymous, Gamblers Anonymous, Overeaters Anonymous. No money ever changed hands—the steps essentially served as open source code that anyone was free to build upon, adding whatever features they wished. (Food Addicts Anonymous, for example, requires its members to weigh their meals.)
By the early 1950s, as AA membership reached 100,000, Wilson began to step back from his invention. Deeply depressed and an incorrigible chain smoker, he would go on to experiment with LSD before dying from emphysema in 1971. By that point, AA had become ingrained in American culture; even people who’d never touched a drop of liquor could name at least a few of the steps.
“For nearly 30 years, I have been saying Alcoholics Anonymous is the most effective self-help group in the world,” advice columnist Ann Landers wrote in 1986. “The good accomplished by this fellowship is inestimable … God bless AA.”
There’s no doubt that when AA works, it can be transformative. But what aspect of the program deserves most of the credit? Is it the act of surrendering to a higher power? The making of amends to people a drinker has wronged? The simple admission that you have a problem? Stunningly, even the most highly regarded AA experts have no idea. “These are questions we’ve been trying to answer for, golly, 30 or 40 years now,” says Lee Ann Kaskutas, senior scientist at the Alcohol Research Group in Emeryville, California. “We can’t find anything that completely holds water.”
The problem is so vexing, in fact, that addiction professionals have largely accepted that AA itself will always be an enigma. But research in other fields - primarily behavior change and neurology - offers some insight into what exactly is happening in those church basements. To begin with, there is evidence that a big part of AA’s effectiveness may have nothing to do with the actual steps. It may derive from something more fundamental: the power of the group. Psychologists have long known that one of the best ways to change human behavior is to gather people with similar problems into groups, rather than treat them individually. The first to note this phenomenon was Joseph Pratt, a Boston physician who started organizing weekly meetings of tubercular patients in 1905. These groups were intended to teach members better health habits, but Pratt quickly realized they were also effective at lifting emotional spirits, by giving patients the chance to share their tales of hardship. (“In a common disease, they have a bond,” he would later observe.) More than 70 years later, after a review of nearly 200 articles on group therapy, a pair of Stanford University researchers pinpointed why the approach works so well: “Members find the group to be a compelling emotional experience; they develop close bonds with the other members and are deeply influenced by their acceptance and feedback.”
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