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admin — Fri, 23 Mar 2007 00:00:00 -0500

AA - Goals and Means

Do You Know Someone In Trouble with Alcohol?

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An Excellent A.A. Article - 60th Birthday from the New Yorker

Early Intervention Proves Effective

Online Alcohol Screening Test

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Withdrawal Symptoms

A Short History of Alcohol Temperance and Prohibition

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Do You Know Someone In Trouble with Alcohol?

admin — Fri, 23 Mar 2007 00:00:00 -0500

Questionnaire: Are you Troubled By Someone's Drinking?

Millions of people are affected by the excessive drinking of someone close. The following twenty questions are designed to help you decide whether or not you need Al-Anon:

Do you worry about how much someone else drinks?
Do you have money problems because of someone else's drinking?
Do you tell lies to cover up for someone else's drinking?
Do you feel that if the drinker loved you, he or she would stop drinking, to please you?
Do you blame the drinker's behavior on his or her companions?
Are plans frequently upset, or cancelled, or meals delayed because of the drinker?
Do you make threats, such as, "If you don't stop drinking, I'll leave you"?
Do you secretly try to smell the drinker's breath?
Are you afraid to upset someone for fear it will set off a drinking bout?
Have you been hurt or embarrassed by a drinker's behaviour?
Are holidays and gatherings spoiled because of drinking?
Have you considered calling the police for help in fear of abuse?
Do you search for hidden alcohol?
Do you often ride in a car with a driver who has been drinking?
Have you refused social invitations out of fear or anxiety?
Do you sometimes feel like a failure when you think of the lengths you have gone to control the drinker?
Do you think that, if the drinker stopped drinking, your other problems would be solved?
Do you ever threaten to hurt yourself to scare the drinker?
Do you feel angry, confused or depressed most of the time?
Do you feel there is no one who understands your problems?

If you have answered 'yes' to three or more of these questions, Al-Anon or Alateen may help. You can contact Al-Anon or Alateen by looking in your local telephone directory or by writing to:

AL-ANON FAMILY GROUP HEADQUARTERS, INC.
P.O. BOX 862, MIDTOWN STATION
NEW YORK, NEW YORK 10018-0862

Or you may call
1-800-356-9996 (USA)
1-800-443-4525 (CANADA)
FAX 212-869-3757

Early Intervention Proves Effective

admin — Fri, 23 Mar 2007 00:00:00 -0500

Early Intervention Proves Effective In Alcohol Consumption

04/03 1500 US HHS:

APR 3, 1997, M2 Communications - Michael Fleming, M.D., M.P.H., and colleagues at the University of Wisconsin Medical School in Madison report in the April 2 Journal of the American Medical Association results from Project TrEAT (Trial for Early Alcohol Treatment), the first large U.S. clinical trial to test the effectiveness of brief physician advice for intervening with nondependent problem drinkers. Supported by a grant from the National Institute on Alcohol Abuse and Alcoholism, the researchers found that brief interventions by general internists and family physicians reduced average drinks each week, excessive drinking, and binge drinking in at-risk drinkers by 20 percent or more at 1 year, twice the reduction rate of patients who did not receive the intervention. Relative to men in the control group, men in the intervention group also experienced a twofold reduction in length of hospitalizations during the followup year.

According to NIAAA Director Enoch Gordis, M.D., several studies in other countries had indicated that brief interventions held promise for the almost 20 percent of American adults who are nondependent problem drinkers: "The Project TrEAT results add to the research base for broadening clinical practice to screen for patients whose drinking practices place them at risk for developing alcohol problems so that these at-risk patients can avoid alcohol damage."

Project TrEAT used a questionnaire on drinking habits and other health behaviors to screen 2,450 problem drinkers from among 17,695 regularly scheduled patients in 17 Wisconsin clinics. Of the 2,450 patients who screened positive (men who drank more than 14 drinks or 168 grams of alcohol and women who drank more than 11 drinks or 121 grams of alcohol each week, those who drank more than 5 drinks on at least four occasions in the prior month, and those who gave two or more positive responses to a simple screening instrument), 1,705 subsequently completed face-to-face interviews in a physician's office. The 774 patients who met all inclusion criteria, including the absence of alcohol dependence symptoms, were randomized to experimental and control conditions and assessed at 6 and 12 months.

Patients in the experimental group were scheduled for two 15-minute sessions one month apart with their physicians. The intervention protocol used during those sessions included a workbook with feedback regarding current health behaviors, information on alcohol effects and problem drinking, a worksheet on drinking cues, a drinking agreement in the form of a prescription, and self-monitoring materials. Physicians were trained to administer the protocol in education sessions at each of the 17 clinics.

According to Richard Fuller, M.D., Director of Clinical and Prevention Research at NIAAA: "Screening for alcohol problems in doctors' offices is rarely done. This study provides further evidence that physicians or personnel in their offices should screen patients to identify those who may be at risk for developing alcohol problems. However, that is only the first step. It also is important to discuss screening results with the patient and advise that the patient cut down or stop drinking. In my view, those who report symptoms of alcohol dependence should be referred to specialized treatment."

Project TrEAT found large reductions in drinking practice measures at both 6 and 12 months in both men and women who received the intervention. At 12 months, men in the intervention group showed a 14 percent and women in the intervention group showed a 31 percent reduction of alcohol use. Both men and women also showed sizable reductions in excessive and binge drinking episodes. Although the control group also experienced reductions on drinking practice measures, patients in the experimental group were twice as likely to reduce their drinking by 20 percent or more.

On health care utilization measures, neither men nor women experienced significantly different numbers of emergency room visits during the course of the study or relative to intervention status. Nor was a change observed for either group in other measures of health status. However, men in the control group experienced substantially longer hospitalizations than men in the intervention group, an effect that the authors call "the first direct evidence of decreases in the utilization of U.S. health services as a result of physician intervention with problem drinkers."

Conducted in four managed care organizations and community- based private practices in urban and rural settings, Project TrEAT produced results that may be generalizable across the U.S. health care system, state the authors. For most patients, such settings are the first point of contact with the health care system and more than 90 percent of health care in the United States occurs in community-based practices.

"Since 70 percent of people in the U.S. visit their physician at least once every 2 years, brief physician advice could have enormous implications for the U.S. health care system. This trial supports the implementation of screening, assessment, and brief intervention for all patients who seek health care services in primary care community-based settings."

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Alcohol & Drug Resources

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AA: Common Goals and Means

admin — Fri, 23 Mar 2007 00:00:00 -0500

Common Goal Distinct Means
Dick B.

Recovery from alcoholism was a true miracle in 1939 when Alcoholics Anonymous entered the scene. Quite unlike today's world in which the recovery process, which has come to be identified with A.A., finds broad acceptance and is seen as common-place. Alcoholics Anonymous is most often described as a "self-help" program, even among the members of the Fellowship itself. This description, along with the "group therapy" nomenclature, has led to much confusion among professionals of all kinds, members of the media, writers in general, and the public at large. So much so that it has begun to displace the original concept in the minds of AA members, many who received their first description of AA through these "third party care-givers." In order to retain its own concept of its purpose and function, the time is upon the members of Alcoholics Anonymous to clarify their place in the alcoholism recovery experience.

"Self help," while an easily used description of AA is in actuality a misrepresentation of the recovery experience as provided by the Twelve Steps of Alcoholics Anonymous. A far more accurate description would be to present AA's program as a "spiritual help" or "self responsibility" program. While those using the self-help term do so with the very best of intentions, the common usage of that term implies a return to the age old idea of "will power."

It is at this early juncture that a difficulty begins for the potential recovering alcoholic who is headed, or being guided, in the direction of membership in Alcoholics Anonymous. Whole societies have sprung up due to this simple miscue. The alcoholic, who has sought a lifetime to exercise his or her own power, comes to Alcoholics Anonymous with the misconception that they must exercise this power. Self-empowerment appears to the newcomer to be the proper approach to the problem at hand.

In the professional setting this may well be the correct approach. There exists a contained environment, a vehicle to exert peer pressure, and professionals trained in determining whether the power exerted by the individual is focused in a reasonable direction. Behavior modification requires effort on the part of the patient and the medical/treatment approach places a great store on treating the symptoms first in order to stabilize the patient. This to good effect and purpose.

This approach, however, does not transfer well into the AA environment. Here the accurate description would be self responsibility. The responsibility falls to the individual to seek out the methods and actions which might be used to remain sober. While this takes every bit as much personal exertion as previously noted in the professional environment, its focus is quite different.

In the professional setting a standard is set and the person must exert their will in order to reach this agreed upon goal. The intended end-point predicts the direction and the effort. Working within the framework of the Twelve Steps the goal is unattainable in its complete form -"_to fit ourselves to be of maximum service to God and our fellows." Therefore the small actions which constitute the attempt to reach maximum usefulness are what are paramount. Working with a focus which is less definitive in its end-point, self determination becomes virtually impossible. Only by placing oneself in a environment whereby ones progress can be viewed through the eyes and experience of others is it possible to make progress in any substantial way. The full responsibility falls upon the individual to seek rather than decide, to make the effort toward the goal rather than accomplishing it.

One of the unfortunate side-effects of this misunderstanding has been an erosion of the level of responsibility with the AA fellowship. With large numbers of AA members focused on "helping themselves" the natural sense of purpose and responsibility for survival of the whole has faded almost out of view. The impact has been to create more self-centeredness rather than other-centeredness.

To underscore this misconception, the term "group therapy" has provided additional impetus. The "group" in a professional setting fulfills a considerably different role than it does within Alcoholics Anonymous. In the professional world the group shoulders the burden of setting standards, judging performance, and communication of the demand that performance meet the standards set. In the near past this was often where the practice confrontation took place. Today one will find more of a negotiation approach being used. None-the-less, this differs greatly from the AA approach.

As is noted in the book, Alcoholics Anonymous, "defiance is the outstanding character of the alcoholic. The Twelve Steps and Twelve Traditions take this central fact into account in presenting a program of recovery to the potential member. They place the responsibility squarely on the individual for becoming aware of and modifying their behavior. Life, in general, and active alcoholism, in particular, become the disciplinarians. For most it takes little time to come to the realization that their battle is with, and within, themselves. With great wisdom, born out of tragic experiences, Alcoholics Anonymous refuses to offer the alcoholic an opportunity to create the illusion that the problem lies anywhere other than with themselves.

Confrontation and "group therapy," on the other hand, provide excellent distractions unless carefully managed in a professional manner. Since AA has made it a policy to remain free of professional services, these two endeavors lies beyond its scope.

Another difficulty felt by Alcoholics Anonymous, also tied to the "self-help/group therapy" misconception is the perception that "a drug is a drug." The inference is that the common denominator need only be an illness from which the person wishes to recover. In its severest cases this extrapolates to emotional restlessness as the core factor. Many a battle has raged before, during, and after group meetings over this attempt at global inclusiveness.

Here again we see practices used within the treatment community which are significantly different from those within AA. In the treatment setting there is a significant need to educate and, as noted earlier, treat the immediate symptoms. There occurs a sharing of definitions, discussions concerning life styles, a comparison of experiences looking for the common pattern, and a fueling of the resolve to change. The exchange is primarily intellectual and educational.

The process within Alcoholics Anonymous is significantly different. Here the exchange must occur across a bridge built of shared experiences. The luxury of appealing to the intellect is, at best, a dubious one for the AA who wishes to assist someone in getting or staying sober. When on the firing line of daily living the newcomer is faced with the temptation to drink, or take an action which would result in drinking, time is of the essence. There is simply not enough time to achieve common definitions or provide attractive scenarios as alternatives. There must be a link established over which virtually absolute trust flows easily. Often it is only that link which means the difference between sobriety and drunkenness. Time and time again it has been across this connection that the "hand of AA" has meant the most.

It will be the most devastating of errors for the person who suffers from an affliction other than alcoholism to think that they, too, can rely upon this safeguard. What a terrible shock it must be to reach that moment of despair only to slip slowly back to the horror of the past. To do so as the result of incorrect information given by those one has trusted must be an entirely disheartening experience. What works well in a closed environment fares poorly in the open world.

It comes as no real surprise, when the concept of "self help" is used, that the next step would be to bolster a persons sense of themselves. Self-esteem is vital to self-help. Again, what works under one set of conditions suffers badly under another. In a carefully monitored setting it is possible to affect a new self-concept in a person. This can occur after much examination and reassurance by others. Essentially the experience is "if they can believe this of me, then I can too." Thus the professional friends of Alcoholics Anonymous attempt to prepare their charges for AA. Theirs is the hope of convincing the person of their inherent value or goodness. In the professional setting there is time to turn illusion into reality, but as noted earlier, this is a luxury not attainable in the open world.

The program of Alcoholics Anonymous provides this element of spiritual growth through another means. AA recognizes the fact that the alcoholic is always aware, within themselves, when they are facing the truth and when an illusion is being created. A positive sense of self is therefore reached by "clearing away the wreckage of the past." In this way the new sense of self is not a cosmetic one, but an actual rebuilding of the psyche. There is no attempt to convince the person of their value-they are set upon a path by which that is a discovery along the way. Being a discovery, it becomes fact far more easily that through any other means. The alcoholic, being essentially of an all or nothing mind, must living entirely with fact or they begin to opt for the ultimate illusion. Since there are no external controls in the AA environment there is little time to move from illusion to reality. It must be reality, or its closest possible facsimile, that is the order of the day for the alcoholic in AA.

Finally, there is one liability AA's professional friends suffer from that Alcoholics Anonymous easily avoids. In the medical/treatment world much of the information upon which decisions are based is arrived at by the self-reporting of the patient/client. Even with the most diligent attempts at ferreting out the truth, the professional is always at a disadvantage. For them it is a matter of carrying out a responsibility to the individual and the professionals own calling. For the alcoholic the battle over truth or illusion is a matter of life and death. Any realistic appraisal of a patient/clients records must allow for a factor of falsehood. Bearing this in mind, the care provider will always be basing their treatment plan on fictional information. There will always be matters unresolved or unattended.

The Fellowship of Alcoholics Anonymous cannot suffer from this quirk of the alcoholic. Since it does not offer advice to the individual, it need not rely on the reporting done by the person. Again, the responsibility falls directly on the alcoholic trying to get sober. This frees AA from attempting to provide anything other than a place whereby examples can be seen of the program of recovery in action. There is nobody to fight, nobody to please, and nobody to make decisions for the person wanting sobriety. The example and the opportunity are clearly present. As is noted in the book, Alcoholics Anonymous, "_the kit of spiritual tools is laid at the feet" (of the newcomer).

And so it is that the ultimate goal of sobriety is met by considerably different means by Alcoholics Anonymous and those treating the illness professionally. Clearly each method has its place. There are those who require only one of the two methods, and legions of others who will take advantage of both. Each also has a responsibility to the other in this common endeavor. Both the professional and the AA member must work diligently to retain the integrity of their respective approaches while ensuring the autonomy of the other. For only through each being able to offer their particular approach can we be sure, with any degree of comfort, that all has been made available to those who suffer. It is not ours to determine where the doorways to sobriety ought to be, for we know not from which direction our fellows suffers will come. Ours is but to ensure that the doorway entrusted to our care is in its place, open to the next alcoholic wanting to gain entrance to our world of the spirit.

An Excellent A.A. Article

admin — Fri, 23 Mar 2007 00:00:00 -0500

The Following is from The New Yorker, March 20, 1995.

In the thirties, Bob Smith and bill Wilson's A.A. was the last stop before the abyss.At some meetings today, they would 'would be appalled."

----------------------------------------------------------------------

ANNALS OF ADDICTION

A. A. AT THE CROSSROADS

Now that America believes less in help-your-fellow than in blame-the-person-who-made, you, a, victim, can
Alcoholics Anonymous still get its message across?

BY ANDREW DELBANCO AND THOMAS DELBANCO

ALCOHOLICS ANONYMOUS turns sixty this year, and while its size and reach show no sign of waning (there are more than a million members in the United States and Canada, and eight hundred thousand more scattered through a hundred and forty other countries), there is a feeling among A.A. veterans that the fellowship is at a crossroads. At A.A.'s General Service Office, in the Interchurch Center in New York City, an austere office building at 120th Street and Riverside Drive that is known in the neighborhood as the God Box, one staff member reflected recently that the Age of the Founders was long gone, Bill Wilson, the New York stockbroker who led the movement for more than thirty years, died in 1971, and Bob Smith, the Ohio surgeon who founded it with him, had died twenty years earlier, and the Age of the Apostles was now ending. "There's practically no one alive today who was there when Bill and Bob met, or in that very first group," she said. "Pretty soon, there will be no early-timers at all."

Standing like a crewcut cadet among fops, the Interchurch Center is set between the ornate spire of Riverside Church, to the north, and a row of neo-baroque apartment houses, to the south. A reasonable facsimile of a midtown corporate fortress, it has revolving doors that spin you onto a mopped marble floor, and a badged guard who eyes you from behind a security counter. In A.A.'s eleventh floor office, described by one staff member as "the visible clearing house of an in visible organization", close to a hundred people are at work, filling orders of A.A.'s publications, referring callers to local groups, disseminating information to the public and to the medical an counseling professions. "We are a repository of group experience," he said. "People write us about a problem they are having in their group, an unruly member, a question about confidentiality. We share experience by telling them what been done in similar situations in the past. We don't issue directives. We don't hand down rules."

Besides being the nerve center for the more than fifty thousand registered A.A. groups in the United States, the General Service Office is a shrine. Its corridors are hung with poster-size photographs of the founders, and placards bearing their sayings; along one long wall of an anteroom that leads into the organization's archive is a locked glass case containing various editions of the Big Book, the basic A.A. text, which has sold thirteen million copies since it was first published, in 1939. "I consider the Big Book an inspired text, written by Bill under the guidance of the spirit," another staff member said. "And I worry that I see a shrinking in the reading and studying of the Big Book. People paraphrase it incorrectly. Some do spot reading, or they don't read it at all."

Some members say that if the Big Book is losing its hold on new members, it may be because its image of the alcoholic is hopelessly cornball and exclusively male: he is a traveling salesman tempted by the hotel bar; he is compared in his desperation to a "gaunt prospector, belt drawn in over the last ounce of food"; or, in his drunken oblivion, to "the farmer who [comes] up out of his cyclone cellar to find his home ruined," looks around, and remarks to his wife, "Don't see anything the matter here, Ma. Ain't it grand the wind stopped blown'?" There is even a condescending chapter addressed "To Wives." Today, A.A. is more than a third women, and twenty per cent of the membership is under thirty, people for whom prospectors and storm shelters are defunct metaphors.

Others think the integrity of the fellowship is being threatened by "people who come in because the courts or rehab centers send them," in the words of Dr. Marc Galanter, a New York psychiatrist who has written extensively about A.A. "Many of these people have to get a meeting card checked off to show that they're fulfilling the obligations of, say, their suspended sentence, and though A.A. welcomes them, this is something that's basically against what makes the fellowship work. Coming in is supposed to be voluntary, an act of spiritual surrender, not acquiescence to some legal requirement.

And others think that A.A. is becoming a social club where people of leisure show up casually, in order to make deals or dates. "It used to be that when someone talked about suffering, you could hear a pin drop," a retired advertising writer who has been in AA. for sixteen years said. "But now people come to the meetings with a bottle of designer water in hand, and there's more and more talk about success. It kills the meeting. People get up to pee, or to look for an ashtray." One member, a carpenter of about forty who lives near a posh New York suburb, put it this way:

"We have actually become afraid of the still suffering alcoholic. If a drunk walked into a meeting in my town, people would be aghast. We've become too nice for that." He still attends his home meeting, he said, but he goes once a month to a meeting in a men's shelter in a neighboring town, to get "the real thing."

It is not only this squeamishness before the hard-core alcoholic that bothers A.A. veterans, but what they see as a growing expectation among some members that meetings will amount to a form of public coddling. Sometimes this expectation is met ("unconditional love" is how one member described what she encountered at her first meeting); but sometimes it is disappointed. When a young woman at a meeting we attended said in a private schoolish whine that she, as a recovering alcoholic, deserved "more space" than she was getting from her non-drinking friends, a young man in dreadlocks looked at her with a mischievous grin and said, 'When I was drinking, I had the same problem you have now. I had not yet achieved low self-esteem."

The rebuke was a pure expression of "the real thing", of the Big Book's principle that "self-delusion, self-seeking, and self-pity" are "the root of our troubles," that we "must be rid of this selfishness. We must, or it kills us!" But some veterans are troubled that this basic A.A. insight is invoked less often than it used to be. They worry that alcoholism, which was once a source of convicting shame in America, is being turned into an alibi. They mention the recent case of a West-ch ester man who confessed at an A.A. meeting to a murder committed while he was on a binge, and then mounted a legal defense based on the claim that alcohol had led him to confuse his victims with the parents who had emotionally abused him as a child. And they laugh, though not with real amusement, about the case of Leonard Tose, the former owner of the Philadelphia Eagles, who responded to a suit to collect gambling debts brought by an Atlantic City casino a few years ago by countersuing and claiming that the casino had allowed him to gamble away his fortune while he was manifestly drunk. "A.A. is not about excuses," one longtime member said. "It's about obligations. Bill and Bob would b& appalled."

A.A. came into existence at a time when Americans were introduced to fear and futility on a scale that had not been previously imagined and has not been matched since, a time when it was a common experience for a man to feel prosperous one day and to be reduced to nothing the next. When A.A. first took form, in the nineteen-thirties, it was not a place where one came to ventilate anxiety about the enervation of a stressful life. It was the last stop before the abyss.

For many drinking Americans, Prohibition had been less an obstacle than a nuisance. (H. L. Mencken reported that he failed only twice during Prohibition to find a drink, once when he was traveling in Pennsylvania and did not realize that "seafood" was the local euphemism for beer.) During "the dry years," Bill Wilson had made his living as a kind of mobile industrial-espionage agent, scouting out companies for his brokerage house by befriending research- and-development men in their local watering holes, and then stiffening his will with another drink before attempting to persuade investors of the truth of tips he only half believed himself By the time of Repeal, in 1933, he bad drunk himself out of his job.

He and his wife, Lois, who at that time worked as a salesclerk in Macy's, joined the ranks of Depression vagabonds, living with her parents, with friends, or on their own in shabby apartments. Paul Lang, the archivist in charge of the Wilson family papers at Stepping Stones, their eventual permanent home, in northern Westchester County (it is now a historic site, maintained by a foundation established upon Lois's death), counts fifty-four different addresses for the couple in the early nineteen-thirties. These were hellish years, during which three ectopic pregnancies ended Lois's hope of bearing children and the pace of Bill's drinking grew in proportion to his shame. Bill would dry out periodically in a clinic on Central Park West called the Towns Hospital, then try to stay sober until the "small, cold ball of fear ... in his stomach would surge up," and only a drink could mitigate his terror of its return. He promised abstinence and was meanwhile hiding his liquor from his wife "as a squirrel would cherish nuts ... in the attic, on beams, underneath the flooring. . . in the flush box of toilets." The archive at Stepping Stones contains Lois's personal Bible, in which Bill wrote periodic pledges to stay sober, promises whose ingenuousness is matched by a fear legible in the handwriting itself, which becomes increasingly spidery as it moves down the page:

To my beloved wife that has endured so much let this stand as evidence of my pledge to you that I have finished with drink forever.

Bill

Oct. 20, 1928.

Thanksgiving Day 1928. My strength is renewed a thousandfold in my love for you.

To tell you once more that I am finished with it. I love you. Jan. 12, 1929.

Finally and for a lifetime. Thank you for your love. Sept. 3, 1930.

As Bill later wrote in the Big Book, he was locked in this cycle of resolution and relapse by his inveterate tendency to compensate for pain by finding someone or something to blame:

With the alcoholic.. . this business of resentment is infinitely grave. We found that it is fatal. For when harboring such feelings we shut ourselves off from the sunlight of the Spirit. The insanity of alcohol returns and we drink again. And with us, to drink is to die.

It was in the detox hospital in 1934 that Bill first arrived at this difficult knowledge. The epiphany came as his doctors were putting him through the usual regimen: sedating him with belladonna and purging him with castor oil. (Medicine had, and has, made little progress in treating alcoholism since the eighteenth century, when the pioneer physician Benjamin Rush treated a man "habitually fond of ardent spirits" by mixing tartar emetic with his rum.) Left to endure the craving and the cramps in a room that had been cleared of potential suicide instruments, Bill had the experience that broke the cycle:

My depression deepened unbearably and finally it seemed to me as though I were at the bottom of the pit. I still gagged badly on the notion of a Power greater than myself, but finally, just for the moment, the last vestige of my proud obstinacy was crushed. All at once I found myself crying our, "If there is a God, let Him show Himself! I am ready to do anything, anything! "Suddenly the room lit up with a great white light. I was caught up into an ecstasy which there are to describe it. 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. And then it burst upon me that I was a free man. Slowly the ecstasy subsided. I lay on the bed, but now for a time I was in another world, a new world of consciousness. All about me and through me there was a wonderful feeling of Presence, and I thought to myself, 'So this is the God of the preachers!"

Bill left the hospital as a man possessed, roaming New York, in the words of his biographer, Robert Thomsen, "at all hours, indefatigable and incorrigible, totally convinced that if he could do it, could find a way out, [anyone] could do it." He literally dragged drunks home from the gutter, inflicting them on his wife, who fed and bunked them in their Brooklyn home while he pleaded that they consign themselves to "the Presence.' Mostly, what the Wilson's got in return was petty thievery and, sometimes, vomit on the floor.

In the grip of his new obsession, Bill found himself ridiculed not as a drunk but as a fit successor to temperance fanatics like Carry Nation. In the first decade of this century, Carry Nation had toured the country from saloon to saloon, smashing, as her biographer Robert Lewis Taylor puts it, "Venetian mirror[s] with brickbats," ripping "candid and stimulating prints from the walls," and, on one notorious occasion, throwing "a billiard ball at what she mistakenly took to be Satan lounging behind the bar." She ended her life, in the words of the historian Norman Clark, as a carnival freak. . . a sideshow for a series of county fairs, armed with hatchets and her Bible", and to many who watched Bill on the prowl he seemed headed for the same oblivion. Yet however unavailing these efforts were for his "patients," they had the strange effect of somehow keeping him sober himself.

Bill did not come close to a "slip" until the spring of 1935, when he found himself in an Akron hotel lobby with nothing to do on a weekend afternoon. A business deal that had brought him to town had fallen through, and he was drawn by the sociable sounds of the bar.

Retreating to a phone booth as if to a pocket of air in a room fast filling with smoke, he dialed all the church numbers he could find in the local directory, and when a clergyman answered he said, not knowing quite why, that he was a "rum-hound from New York" who needed "to speak now" with another alcoholic.

He ended up visiting a local surgeon named Bob Smith, who was known around town as a hopeless boozer; and their encounter was, in effect, the first A.A. meeting. Dr. Bob never touched another drop for the remaining fifteen years of his life, going "dry into his casket," as the poet John Berryman wrote in his novel "Recovery," which is about his own A.A. experience. "Look up his life sometime, there must be stuff"

It took a while for the two men to identify the "stuff" that had saved them: the therapeutic value for oneself of helping another person stay sober. "Our talk was a completely mutual thing," Bill called. "I had quit preaching. I knew that I needed this alcoholic as much as he needed me. This was it." Together, they began to visit patients in detox, telling their story, and inviting them to give the new talking therapy a try. Let us talk to you, for our own sakes, they said, in effect, and then talk to us and we'll listen. Sometimes they were shooed away like pestering salesmen. But soon they had a success, with a businessman who was going through his eighth detoxification in six months, the previous one having begun with his punching two nurses in the eye. At first, he resisted, and railed at his wife for revealing his drinking to strangers. When she coaxed him into seeing them, he braced himself for another sales pitch. But he relented when he realized that "all the other people he had talked to me wanted to help me, an my pride prevented me from listening them. . . but I felt as if I would be a re stinker if I did not listen to a couple o fellows for a short time, if that would cure them", and he became the third member of the new fellowship that called itself "bunch of nameless alcoholics."

The principle on which the new group was based was that no one is responsible for the wreckage of the alcoholic's life except the alcoholic himself. No mart what has been done to you, member would be told, you are responsible f what is done by you. They would refuse to project evil onto some blamable cause, even though they might speak of alcoholism as (in the Big Book's words) an "illness" or "allergy," and of some people as alcoholic before they ever touched a drop, as if they were born tinctured by a poison activated by the first drink.

Within Alcoholics Anonymous (the name was adopted in 1939), some people speak of its astonishing growth after the Akron meeting as the expansion of God's dominion. But there has always been a palpable tension between what might be called the pietist and the rationalist wings of the movement; and traces of this division remain in the Twelve Steps, the list of principles that Bill Wilson drew up as he wrote the Big Book:

We admitted we were powerless over alcohol, that our lives had become unmanageable.
Came to believe that a Power greater than ourselves could restore us to sanity.
Made a decision to turn our will and our lives over to the care of God as we understood Him.
Made a searching and fearless moral inventory of ourselves.
Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
Were entirely ready to have God remove all these defects of character.
Humbly asked Him to remove our shortcomings.
Made a list of all persons we had harmed, and became willing to make amends to them all.
Made direct amends to such people wherever possible, except when to do so would injure them or others.
Continued to take personal inventory and when we were wrong promptly admitted it.
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.
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.

Although some members still speak of these steps as if they were brought down from Sinai or were revealed, like the Book of Mormon, by a messenger angel, they are in fact products of contention that is still discernible in them. Their wording was under debate until just before release of the Big Book, when the phrase "on our knees" was deleted from Step 7 and "as we understood Him" was inserted in Steps 3 and 11. Some regard such concessions as proof of the democratic genius of the fellowship, of its ability to modulate the idea of a personal deity into an abstraction that can accommodate all members, including non-Christians and agnostics. Others worry that God has become so vague a conception that he has disappeared. Evidently wearied by the prevalence of the term "self-help," one member complains, "We're not a self-help program. If we were helping ourselves, we'd be in trouble. We are a spirit-help program, a God-help program."

God has always been A.A.'s raw nerve, Bill confided in only a few friends about how "the Presence" had manifested itself to him, lest A.A. become linked in the public mind with crackpots and ranters. But shortly after that hospital experience a friend recommended to him William James's "The Varieties of Religious Experience." Bill read the book with the gratitude one feels toward a respectable witness who confirms that he, too, has heard the disembodied voice or seen the ghost that has brought one under suspicion of madness. James (whom Bill came to refer to as "one of the founders") seemed to know at first hand the power of alcohol to make one feel uncontested at the center of the universe, to turn any party into your fete, any music into your serenade:

Sobriety diminishes, discriminates, and says no; drunkenness expands, unites, and says yes. It is in fact the great exciter of the Yes function in man. It brings its votary from the chill periphery of things to the radiant core.

And when James wrote about the futility of mental effort he seemed to grasp exactly what Bill had undergone in Towns Hospital:

You know how it is when you try to recollect a forgotten name. Usually you help the recall by working for it, by mentally running over the places, persons, and things with which the word was connected. But sometimes this effort fails: you feel then as if the harder you tried the less hope there would be, as though the name were jammed, and pressure in its direction only kept it all the more from rising. And then the opposite expedient often succeeds. Give up the effort entirely; think of something altogether different, and in half an hour the lost name comes sauntering into your mind, as Emerson says, as carelessly as if it had never been invited. Some hidden process was starred in you by the effort, which went on after the effort ceased, and made the result come as if it came spontaneously.

James ratified the value of giving oneself up rather than "pulling oneself together, an ineffably strange reversal for a man like Bill, whose life had once been all about seizing opportunities, looking for the main chance, training, disciplining, driving himself. When Bill read that "something must give way, a native hardness must break down and liquefy," he recognized an account of what had happened to him.

This experience of giving way and breaking down remains the key to every A.A. meeting, as it was at one we attended on a rainy Saturday morning in a Boston mental-health center, one of those nineteen-sixties scored-concrete buildings with all the charm of a highway trestle. On the steps outside, men slept curled in the rain. Inside, the atmosphere was festive. A tidy-looking young man (polo shirt, pressed khakis) was telling a group of about forty men and women how he had stepped, for no apparent reason, in front of a mirrored column in a subway station. Walking around it, as if he had been suddenly vouchsafed the ability to see himself from without, he stared at his own face, yellow and jowly, really seeing it for the first time. For months, he said, he had been drinking two bottles of wine every night in between aperitifs and chasers. In that instant, he knew he would never drink again. But he had no idea why.

One hears as many metaphors for such an experience as there are members who speak. One member at the Boston meeting likened it to the feeling of a runner who gets a second wind, that eerie sensation when exertion suddenly subsides into limpid ease. Another compared it to what happens when you learn to ride a bicycle, to that moment when you stop straining to find your balance and suddenly it's there. One young man at a New York meeting described the splitting away of his old self as if he had been a plank with a fault line running through it until a pressure came that made the board break.

The later editions of the Big Book play down this expectation of "sudden and spectacular upheaval," and report instead that "most of our experiences are what the psychologist William James calls the 'educational variety' because they develop slowly over a period of time." But, whether the release is sudden or slow, public testimony about the hell in which one lived before deliverance is indispensable for both speakers and listeners; and the talking therapy has no designated end.

Like cancer patients in remission, A.A. members think of themselves as "arrested," not "cured." With the possibility of backsliding never far out of mind, they regard each day of sobriety as an merited gift, and each A.A. meeting as a holding action, because "each lapse," as James wrote, "is like the letting fall of a ball of string which one is carefully winding up; a single slip undoes more than a great many turns will wind again."

As A.A. took form, Bill and Bob had no particular historical model in mind. They were not bookish men. But it is uncanny how closely their new fellowship resembled the first American churches that had been "gathered" three centuries before. The founders of those churches, named Puritans because of their implacable objections to the rituals of England's state church, had instituted in America a practice of public confession, in which each member of the congregation spoke of his or her enslavement to sin and of how the bondage had been broken. The Puritans had called these testimonies "conversion relations" or "professions of faith." A.A. called them "drunkalogues."

In the A.A. view, just as in that of the Puritans, salvation is not something one can possess by means of a penitential act now and then. Rather, it is a state of endless striving. The work of salvation, as the Puritan theologian Jonathan Edwards wrote in the seventeen-forties, must be, for each person, "not only.., the business of Sabbath days, or certain extraordinary times, or the business of a month, or a year, or of seven years... but the business of his life . .. which he perseveres in through all changes, and under all trials, as long as he lives." The convert's obligation to his fellows is not satisfied by a coin in the Sunday collection basket. "Faith has to work twenty-four hours a day in and through us," as the Big Book puts it, "or we perish." There is no evidence that Bill himself ever followed James back to Edwards (in whose writings James found an "admirably rich and delicate description" of conversion), but if he had he would have found more than a congenial spirit. He would have experienced a shock of recognition when he came upon

Edwards's list of signs by which the anxious seeker tests the validity of his or her spiritual experience. Did it come from God, or was it hallucinatory? Edwards enumerated twelve signs by which one could tell. They do not match A.A.'s Twelve Steps with the exactness of a stencil, but they come close. Here is the twelfth sign, which he called the "sign of signs" and "evidence of evidences" (the Big Book calls the Twelfth Step "the capstone" and "foundation stone" of all the rest):

Whatever pretenses persons may make to great discoveries, great Love and joys, they are no further to be regarded, than they have influence on their practice.

Substantially the same as A. A.'s Twelfth Step, this statement contains what James called the whole of Edwards' work. It is "an elaborate working out of [the] thesis [that] the roots of a man's virtue are inaccessible to us," James wrote. "No appearances whatever are infallible proofs of grace. Our practice is the only sure evidence, even to ourselves, that we are genuinely Christians." If, in other words, two people claim they are saved, and one sees Jesus' blood running down the bedroom wall, while the other sees only the swirls and cracks in the plaster, this difference between them has not the slightest significance. The only evidence that one's inner spiritual condition has changed is visible evidence of a new responsibility toward others in one's outward practice.

James repeated this point again and again, as if to rebuke his Harvard colleagues, who thought he had gone soft on God. The question of whether someone s conversion had a supernatural cause or could be explained in purely psychological terms held no interest for James. (Freud, working with a dualistic model of the mind, later described such events as an internal rupture in the psyche through which the unconscious pours into consciousness.) Like Edwards, James was not interested in causes, only in results. It matters not a whit if the convert is transformed by God or by the smile of a child. The only thing that matters is the result of the experience. "If the fruits for life of the state of conversion are good," James wrote, "we ought to idealize and venerate it... if not, we ought to make short work with it....

When it comes to applying this standard of results to A.A., not much is known about its aggregate impact on American alcoholics. Most experts estimate the number of alcoholics in the United States at ten to fifteen million, and some believe that nearly one in ten adults has attended an A.A. meeting at some time in his life. In 1968, recognizing that "our communications to the professional community had very little credibility because of a lack of objective data," A.A. began to conduct periodic surveys of its members in order to assess its own efficacy. In a 1989 survey of almost ten thousand members chosen at random, thirty-five per cent of the respondents reported less than a year of sobriety, thirty-six per cent between one and five years, and twenty-nine per cent more than five years.

But what such numbers mean is fat from clear. For example, the survey also revealed that about half of newcomers leave A.A. after less than three months, and that "after the first year... attrition continues, but at a much slower rate." If you try to adjust the numbers to reflect these facts, it is still difficult to come up with a true sobriety (or "salvation") rate. The best the editors of an exhaustive recent monograph on research on .A.A. can do is conclude that "long-term sobriety occurs within a select minority of those who initially attend A.A." For certain cancers this would represent a good outcome For most bacterial diseases, it would not To the theological father of Puritanism John Calvin, who wrote in 1536 that "the same sermon is addressed to a hundred persons, twenty receive it with the obedience of faith; the others despise, or ridicule, or reject, or condemn it," a "select minority" would seem about right.

It was the test of results that clarified for Bill what had happened to him in Towns Hospital. It gave him a way to answer those who said he had simply substituted a new addiction, A.A., for his old one When he had been drinking, he had been "at the gates of insanity," he wrote, and other people were obliterated by the intensity of his narcissism. But when, first in Brooklyn and then in Akron, and then through AA., his mind had been directed outward, he was restored to the world persons. Edwards called this new engage ment with other people "consent to being." A.A. calls it "Twelve-Stepping."

Twelve-Stepping is based on the in sight that altruism has selfish value, in the charity gives hope to the giver: "When the phone rings at two in the morning," one member told us, "and it's a member in my group who needs help, I get up and go. Anything else in my life I will negotiate. But in A.A. I just do it. It doesn't make any sense to get up at two on a snowy night. But you do it all the same."

In light of the fact that the religious dimension of A.A. has made many prospective joiners uneasy (newcomers sometimes have the self-conscious look of stragglers in the pews when everyone else is taking communion), it is striking how respectfully A.A. is regarded by even the most secular-minded experts in the field of addiction. We spoke with one such authority, Dr. Steven Hyman, who is the director of the Mind, Brain, Behavior Initiative, at Harvard University, in a squat brick building at the old Charlestown Navy Yard which used to be a storehouse for torpedoes but is now a research facility of the Massachusetts General Hospital, complete with atrium and cafe. Dr. Hyman, who looks like Pavarotti in fighting trim, does not initially impress one as likely to have much tolerance for a movement that began when a patient was seized in his hospital bed by "the Presence." In this respect, he surprised us.

"The great A.A. insight was not just that alcoholism is a disease but that having this disease is not an excuse for anything, not for missing work, messing up your family, killing people in automobiles," he began. "In terms of cause, alcoholism does have genetic causes, cultural causes, circumstantial causes. But there's nothing deterministic about its consequences. That's the strange paradox A.A. understood, and it seems to be more and more difficult for people to accept.

Dr. Hyman added, "I have no problem with the A.A. method," and launched into an explanation of how a spiritual therapy could relieve a physiological affliction. Rummaging through the papers on his desk, he came up with an M.R.I. film of a rat's brain after the animal had been injected with cocaine. It showed a splatter of bright streaks on a dark background, like fireworks against the night sky. This picture, he said, revealed a neurological system that was more complexly developed in human beings but served basically the same function in people as in rats. He described an experiment done in Canada in the nineteen-fifties, in which electrodes were affixed to a succession of sectors of a rat's brain. A lever was placed within reach of the animal so that it could send current into itself by depressing the switch. "In some places, the effect was highly aversive," Dr. Hyman said. 'You can imagine the experience of feeling electrical sensations in your paws. But when the electrodes were attached to certain other locations, the rat would press the lever thousands of times to get more of it, until exhaustion supervened.

"Now, why do we have such a system-a brain that will light up when you charge it with electricity or drugs? Because some things are too important to leave to cognition. If you left them up to people to calculate, they'd get messed up. Nature's experience with sexual reproduction would have been a big failure unless sex were profoundly rewarding. So we have a neurological system that says, That was good, let's do it again.' A few natural substances, including alcohol, tap into this system in the brain that says, 'That was good, lets do it again, and let's remember exactly how we did it.' And, since you're bombarded every day by millions of sensations, the brain is organized in such a way that certain indispensable experiences, like sex, have the greatest affective valence, and become objects of desire."

Dr. Hyman's name for the process by which this system is captured by drugs is "adaptation," which is "a way of making long-term changes in the way the brain works, so that you can remember experience." This kind of "learning" uses many of the same biological processes in the brain as in other parts of the body. "Let's say you wanted to look like Schwarze-negger, and you went to the gym and started pumping iron," he said. "Your arms would really hurt. But eventually you would have an adaptive response. The genes in the nuclei in your muscle cells would start making more messenger RNA and then more protein to build up those muscles, and pretty soon, especially if you also took anabolic steroids, you would look like Schwarzenegger. These adaptive responses are universal. Some are helpful, like hulking up, which is essentially a response to injury. Others are a problem-as when people develop a tolerance for their asthma medicine. In fact, they not only need stronger doses but become dependent. If they don't get their asthma medicine, they have worse asthma attacks.

"Addiction, in other words, is a form of adaptation. Our best current understanding of alcoholic addiction is that, in response to bombardment by the chemical ethanol, chronic adaptations occur in the brain's reward circuitry. There are individual genetic and developmental and environmental factors that help deter-

mine who will get addicted to alcohol or how soon, matters we know very little about. But, in the context of individual vulnerability, adaptations will occur in the circuitry in response to the drug. Once this happens, the user becomes dependent on it for his world to be O.K. The brain says, 'That was good, I feel O.K.' If you're an alcoholic, you simply can't imagine a day without drinking. You need that hit. Your brain demands it." With almost reverent intensity, Hyman said, "If you understand addiction, you understand something very profound about the human brain, how it hijacks the cortex in the service of the primordial lizard brain.

Hyman went on, "Now, to help people with these molecular changes in their brain, we have to come up with things that will deliver compensatory pleasure, a requirement that it's tough to get the medical and scientific professions to accept. A.A. understood this. In fact, they're still ahead of us. Most pharmacological research is still focussed on the development of drugs that block pleasure. An example is naltrexone, a long-acting blocker of opiate receptors. If you take it every morning, and shoot up heroin later in the day, you will not get high. It looked terrific in the lab. The trouble is that, once it was approved for heroin users, the compliance rates were about fifteen per cent, because the addicts said it made them feel lousy. Naltrexone has just been approved as a drug for decreasing craving in alcoholism. My prediction is that it won't work, because it doesn't give something back."

Hyman's account of addiction is an impeccably accurate rendition of the doctrine of original sin as Jonathan Edwards expounded it. What Hyman calls "the reward-circuitry of the brain" Edwards called the "faculty by which the soul.. . is inclined to.. . or disinclined from... sensible objects." Both regard it as inborn, and yet both insist that people are fully responsible for how they act on its inclinations. Edwards thought of this paradox as a war in the soul between the destructive desires that he called sin or self-love ("self-will run riot" is the Big Book's phrase) and the productive love that goes outward, asking no reward, to other people and, through them, to God. Hyman believes that you can actually see the war in a picture. "I suspect that if I could compare scans of the brain of an alcoholic person before and after treatment in a twelve-step program, you would see clear changes. Of course, the altruistic activity affects the brain as much as a drug does," he said.

Edwards would have been delighted with this idea. It has been said, by the historian Perry Miller, that when Edwards preached he deployed words as an "engine against the brain" in order to stimulate in his hearers a "taste," or "relish," for what he called "divine excellency." The point was to use words to "let... light into the soul" by describing vividly the plenitude of nature or the charitable acts of saintly persons or the selfless love of Christ, and thereby to entice the imagination away from its usual focus on worldly glitter. And if Edwards would have liked Hyman's notion that one might actually see pictures of this battle within the soul, he would have loved the metaphoric picture of the lizard brain, of the reptile within getting hold of the leash.

"What A.A. understands is that the essence of dealing with alcoholism is not to blame people for having the disease, yet nevertheless to demand that they take responsibility for themselves," Dr. Hyman said. "That's a hard concept. It is hard to say to somebody, Yes, things are terrible, yes, getting to your present condition involved what was done to you, and it even has something to do with the body with which you were born, but from this day on we have identified the problem, and you have to be involved in the solution.'" Here is Edwards's formula-non of the same compatibility between helplessness and responsibility:

In order to form their notion of faultiness or blameworthiness, [people] don't wait till they have decided .. . what first determines the will.... They don't take any part of their no-ton of fault or blame from the resolution of any such questions. If this were the case . . . nine hundred and ninety-nine out of a thousand would live and die without having any such no-don as that of fault ever entering into their heads, or without so much as once having any conception that anybody was to be either blamed or commended for anything. Edwards believed that this idea accorded perfectly with common sense. And Bill Wilson, through his experience in Towns Hospital, came to the same conclusion, that "what first determines the will" to drink has nothing to do with the question of who bears responsibility for the consequences of drinking.

For much of American history, there seems to have been a consensus that this stringent principle should be applied broadly to the moral life. Among modern Western societies, America has been the country where human beings were most exposed to the possibility of advancement, and least protected from the prospect of decline. It was, in Emerson's phrase, the culture of "self-reliance," in which a man was supposed to take his chances and then collect the reward or pay the price for what he had done or had failed to do.

With the Great Depression, however, this kind of uncompromising individualism became insupportable. For millions of people whose best efforts had availed them nothing, the old doctrine of self-reliance was now experienced as a form of cruelty. At that moment, when the exigencies of the exposed life were judged to be intolerable, and the old stress on individual responsibility had come to seem our of balance with valid claims for individual rights, a profound change took place in America. It was a fusion of the old doctrine of the accountable self with a new kind of public responsibility for the fate of individuals. At the level of politic and public life, this new synthesis came be known as the New Deal. Under rha rubric, the government, mainly through programs that would, today be called "workfare," undertook to provide work opportunities for those whom the private economy had abandoned. At the grassroot level, the most important and enduring expression of this same self-help idea of the founding of A.A.

A.A. was a "church" in which right were kept in steady balance with responsibilities through the mechanisms off expression and requisite community set vice. As such, it kept unflinchingly to Edwardsian principle of what the theol gian Reinhold Niebuhr called, in 193 "responsibility despite inevitability," a at the same time committed itself to pr oviding the unconditional help that suffering human beings have a right expect from others. In this sense, A. was both a religious revival with roots an earlier America and a spontaneous depression of the kind of balanced liberalism that emerged in the Roosevelt years.

But the paradoxically symmetrical idea that lies at the heart of A.A., that helplessness is a fact of human life, yet, at the same time, no one should be spared responsibility for his actions, has proved extremely difficult to sustain. The relation between rights and responsibilities within American liberalism seems to many people to have been thrown out of balance. In response to this apparent distortion, certain liberal institutions (welfare) and ideas (affirmative action) have been charged with misattributing suffering to circumstance rather than to the responsible self. Such an approach to the alleviation of human suffering, its critics say, misleads people into thinking that the world owes them redress, and leaves them in a state of perpetual expectation for a reparation that will never come.

As part of the feeding frenzy on the corpse of liberalism which now passes for political debate, this critique is often a pretext for mean-spirited attacks on "freeloaders", people who are deemed unworthy beneficiaries of a misguided paternalism. Yet even some defenders of liberalism agree that, at least in such conspicuous areas as criminal law, regulated speech, and normative sexual behavior, American society has moved too far toward rights and away from responsibilities. Some of the more spectacular "don't blame me" defendants who have entertained and disgusted Americans in recent years, Lorena Bobbitt, the Menendez brothers, seem to represent a moral decadence in which a once dignified liberalism has been reduced to the claim that maimers and murderers are entitled to sympathy and exoneration if only they can show that they were victims, too. 'The architecture of [their] self-defense plea," as Elizabeth Hardwick has put it, is most often organized around the claim of having suffered sexual abuse, "as pertinent to the therapist," she says, "as a kidney to the urologist." These are people who claim, in contrast to Edwards, that "what determines the will" not only means something but means everything.

It is not surprising that, as this exculpatory idea of the coerced will grows rampant in American life, the balance within A.A. between rights and responsibilities has also shifted. "It's getting harder all the time just to find a volunteer for setting up the coffeepot before the meeting, or scrubbing it out after," one member told us. "The idea of helping others in order to help yourself is in trouble." And some members, pointing to circumstantial factors, remark that the practice of Twelve-Stepping is on the decline. "In the days of Bill and Bob, everyone knew a drunk whom you could seek our and Twelve-Step in what used to be your favorite bar," one member said. "But today they're hidden away in rehab centers and dealt with in a medical setting. The expectation that every A.A. member will seek out someone to help seems to be fading."

There are members who believe that the fellowship actually has begun to break apart into schisms. On the one side, there are the proliferating victim groups ("Shoplifters Anonymous, Tight-Shoes Anonymous, Edsel-Owners Anonymous" was the list offered by Marc Galanter), a sort of endless Oprah Winfrey show that claims the A.A. Twelve Step method as its inspiration, but in which the real meaning of the Twelfth Step is lost amid an incessant whine about the injured self. "There's been an influx of doubletalk from these groups," one veteran remarked. "I've heard about an A.A. meeting in New Jersey where the old-timers have taken to yelling out 'Tough shit, don't drink!' whenever the whiners get started."

On the other side, there is a rival group, called Rational Recovery, which began in 1986 and publishes a guide entitled "The Small Book," in which the addict is promised "sobriety.., without depending on other people or Higher Powers to help you our." This dilute version of the A.A. original seems, to A.A. true believers, a vestigial church, where members make no real commitment to helping others, yet refuse to face the irremediable loneliness of helping only themselves.

How A.A. will respond to these challenges remains an open, and for many members an urgent, question. It is a fellowship based on the proposition that human beings can overcome their existential fear only by recognizing their responsibility for themselves and their obligations to others. To contemplate the history and the destiny of this idea in a culture that seems to be losing its grasp of it is to understand what Bill Wilson meant when he wrote that "bottles were only a symbol" of the endless human struggle against self-deception