Addiction Research 6:131-145, 1998.
Addiction Research Foundation
33 Russell Street
Toronto, Ontario M5S 2S1, Canada
Mutual-help groups in the alcohol field were first organized 150 years ago,
and some European groups continue from the late 19th century. After the Second
World War, Alcoholics Anonymous (AA) began to spread internationally, and new
national mutual help movements were founded, to some extent drawing on or
reacting to the AA model. While AA is dominant in North America and many
English-speaking countries, other mutual-help movements are stronger in such
countries as France, Germany, Italy, Sweden and Japan. Several dimensions of
differentiation between the movements are discussed, including: professional or
institutional sponsorship vs. autonomous organization; the movement's religious,
spiritual or secular basis; whether family members and others are members as well
as alcoholics; whether there are external affiliations and activities; and patterns of
internal organization and functioning.
The alcohol field is unusual among health or social service fields in the long continuation and strength of its mutual-help movements. In many societies, these movements reach at least as broadly into the population as any organized professional effort in the field, and sometimes more broadly. This can be illustrated from general population surveys in each of the three main countries of North America. In the U.S., more than half of those who ever sought help with an alcohol problem of their own went to Alcoholics Anonymous -- considerably more than ever sought help from a formal alcohol treatment program, or from a physician or health worker (Weisner et al., 1995). When asked what treatment for alcohol problems they would recommend if a friend or relative asked their advice, four-fifths of Mexicans in the Tlalpan district of Mexico City recommended AA (Rootman and Moser, 1985:96). Among those in Ontario, Canada who had actually recommended help to a relative, friend or acquaintance in the preceding year, as many recommended AA or another mutual support group as recommended any kind of professional or institutional help (Room et al., 1996).
In this discussion I have chosen to use the term "mutual help movements", while the more usual term in studies of the phenomenon is "self help" (e.g., Katz, 1993; Katz and Bender, 1976). "Self-help" tends to imply the individual is acting by him- or herself, whereas group process and mutual support are at the heart of the movements we are considering.
The largest and best-known mutual help movement in our field, of course, is Alcoholics Anonymous. This paper in part draws on the work of the recently-concluded International Collaborative Study of Alcoholics Anonymous (ICSAA). ICSAA was organized as an autonomous group of scholars from eight countries: Finland, Sweden, Iceland, Poland, Switzerland, Mexico and the United States, with Klaus Mäkelä serving as the study coordinator. In the jointly-authored book from the project (Mäkelä et al., 1996), we set out to analyze what varied and what stayed constant in AA as it became rooted in very different societies. We did, indeed, find differences from one society to another, but also impressive commonalities; in large part, over more than half a century and in dozens of societies, AA has stayed true to its original organizational principles as a social movement, to its belief system, and to a well-developed system of interactions in regular meetings and other social ties.
The ICSAA project will also result in a second volume of case studies of AA in the eight
societies, edited by Pia Rosenqvist and Irmgard Eisenbach-Stangl (see also Eisenbach-Stangl and Rehm, 1992). But as often with such projects, its existence also stimulated a outpouring of related
work, including work on other mutual help movements. This included studies of the relations
between AA and professional treatment (Eisenbach-Stangl and Rehm, 1994), of the international
dissemination of "12-step treatment" as a model of institutional alcohol treatment, of Polish
Abstainer Clubs, of Links in Sweden, of several national mutual-help movements which are
members of Sobriety International, of Women for Sobriety, and of the emergence in the U.S. of
a generalized 12-step consciousness (see Rosenqvist, 1991 and Room and Rehm, 1992). In the
wake of the ICSAA project, an international conference on Addiction and Mutual Help
Movements in a Comparative Perspective was held in Toronto on September 12-16, 1994. The
37 papers by scholars from 13 countries discussed and compared features of a number of other
mutual-help movements as well as AA.(1) This paper also draws on this broad range of recent work
on mutual help groups in the addictions field.
MUTUAL HELP MOVEMENTS IN THE ALCOHOL FIELD:
BEFORE AA AND SINCE
The history of organized mutual help groups in the alcohol field extends back 150 years, to the Washingtonians and similar groups in the U.S. of the 1840s and 1850s (Blumberg and Pittman, 1991; Baumohl, 1986). In Europe as in North America, many of the temperance organizations of the late 19th century included reformed drunkards among their members. In parts of Europe, organizations such as the Blue Cross and Gold Cross founded in that era continue a vigorous existence today.
The modern era of mutual help movements in the alcohol field begins with the founding of Alcoholics Anonymous in the U.S. in 1935. Alcoholics Anonymous grew rather slowly in its early years, to about 100 members in 1939, and remained relatively unknown even in the U.S. until it received national publicity in 1941. Apart from a couple of small-scale earlier attempts, successful efforts to found AA groups outside the U.S. began only at the end of the Second World War.
A variety of other mutual-help movements and organizations have grown up in the alcohol field since 1945. Many of them have quite different methods of organization and functioning from AA's. But it is difficult to find any example of a mutual-help or self-help movement dealing with alcohol or drug problems initiated in the last 50 years which was not influenced, positively or negatively, by the example of AA. Particularly in earlier years, the influence might be remote and nonspecific -- simply the news that a mutual-help movement of recovering alcoholics existed and was reported to be successful. Thus a 1945 article on AA in the Swedish Reader's Digest contributed to the initiation of what became the Swedish Links movement (Kurube, 1992). Tomofumi Oka notes that the Japanese national alcoholic self-help movements were formed when a leader of a long-established Japanese temperance group "noticed the existence of Alcoholics Anonymous", and wrote about it in the group's newsletter in 1950 (Oka, 1994). One of the two organizations which joined to become the French mutual-help movement Vie Libre, for working-class alcoholics and their families, was formed by an antabuse-prescribing doctor and the recovered drinkers he cared for, as Alain Cerclé puts it, "following the example of AA (of which a group existed already in Paris)" (Cerclé, 1985).
In later years, the influence has usually been direct: the founders of a national mutual-help movement have usually adopted or adapted parts of AA's ideology or program while implicitly or explicitly rejecting other parts. This is true also for the three main alternative mutual-help movements to AA in the U.S., Rational Recovery Systems (founded 1986, reporting 350 groups), Secular Organizations for Sobriety (also known as Save Our Selves and SOS, founded 1986, reporting 1000 groups), and Women for Sobriety (founded 1976, reporting 350 groups).(2) After interviewing the authors of the primary texts of each of these movements, Charlotte Kasl (1992:163) remarks that all three
were pioneering souls who attended AA and left for various reasons, including dislike of the sexism, the powerlessness concept, rigidity, religiosity, the cult-like atmosphere, and the all powerful God approach.
In North America, of course, Alcoholics Anonymous retains its dominance of the mutual-help scene for alcohol problems, with over 50,000 groups. But this is by no means the case everywhere. In France, Cerclé reports, only about 11% of ex-alcoholics in mutual help groups are in AA, with the remainder in four other movements (Mäkelä et al., 1996); in Italy there are at least four times as many groups of the Clubs for Alcoholics in Treatment (CATs) as there are AA groups, and at least half again as many alcoholics in CATs as in AA (Allamani, 1994 and personal communication); in Japan AA groups are less than one-third of all mutual help groups (Oka, 1994), and in the state of Hesse in Germany there are three times as many groups in the traditional temperance-based organizations, and as many groups in a newer mutual-help movement, Freundeskreise, as there are AA groups (Appel, 1996). Other countries in which national or temperance-based mutual-help movements are dominant or important include Croatia, Switzerland, Poland, Sweden and Denmark.
Drawing on recent studies, Table 1 gives approximate relative sizes of mutual help groups for alcohol problems in selected societies. The percentages in the table should be treated with some caution, since they reflect membership claims of organizations which apply different criteria for membership. As the example of Japan shows, a comparison based on size of membership may yield different figures from a comparison based on number of groups. The table underlines the necessity of paying attention to more than AA in discussing in an international perspective mutual help groups in the alcohol field. On the other hand, it should be kept in mind that there are a number of countries -- Iceland, Australia and New Zealand would be examples -- where AA's dominance of the mutual-help scene is even greater than in the U.S. and Canada.
Where there is more than one strong mutual-help movement for the same problem, a
certain amount of organizational competition is inevitable. But public antagonism seems to be
unusual. Even in Sweden, where the Links movement has fractionated into seven different
organizations and where AA membership grew strongly in the 1980s along with the advent of
Minnesota Model treatment institutions, Noriko Kurube notes that "the relationship between the
Links and AA in Sweden seems peaceful and without serious conflicts" (Kurube, 1992).
Sometimes the relation between movements is closer and even symbiotic, as Grayna witkiewicz
(1992) reports has been true for the Abstainer Clubs and AA in Poland. Often the movements
tend to divide the market of potential recruits by appealing to different population segments: for
instance, compared to the national movement, AA seems to appeal to the better off in Sweden,
and to the less well-off and to the uncoupled in Japan (Kurube, 1992; Oka, 1994). At the level
of the individual members, overlapping active membership seems to be common even where the
movements are in clear ideological conflict. Thus Kaskutas (1992a) found that 29% of members
of Women for Sobriety, a primarily North American movement based on a feminist critique of
AA's ideology, also concurrently attend AA. Likewise, Connors and Dermen (1994) found 35%
of members of SOS -- a movement aiming to provide a secular alternative to AA's spiritual
emphasis -- planned to continue attending AA as well as SOS.
TOWARDS A TAXONOMY OF MUTUAL-HELP MOVEMENTS IN ADDICTIONS
The recent spate of studies of mutual-help organizations for alcohol problems allows us to
begin to define dimensions of differentiation between the various movements. In this discussion,
I will use AA as the index case to which other movements are compared. There are several
reasons for this. One is the ubiquity of AA: Croatia may provide a unique example of a country
with a strong mutual-help movement for alcohol problems but with little AA activity. A second
reason, already remarked on, is the influence of the example of AA in the formation of other
mutual-help movements since the Second World War. Related to this, the example of AA also
seems to exert a continuing influence on other movements, including those with older roots: thus
Appel (1994) remarks that "many features of AA meetings and beliefs have been incorporated as
well in the other [German] groups.... The knowledge of [AA's] democracy however poses a
challenge to the ... very hierarchical structures within the abstinence organizations". A further
reason for using AA as the index case is the clear bench-mark it has set, in its Twelve Traditions
and in its other organizational principles and practices (Room, 1993), at one end of a number of
different dimensions on which other mutual-help organizations are differentiated.
Professional/institutional sponsorship vs. autonomous organization:
Whether the mutual-help group is professionally or institutionally sponsored or is autonomously organized by ex-alcoholics or addicts is probably the single most important dimension of differentiation between mutual-help organizations, since it carries with it many implications in terms of such issues as ideology, autonomy, hierarchical or egalitarian relations within the movement, and financing. AA is, of course, the archetype of the lay-led autonomous organization. But the AA story on this issue is actually quite complex. Even in the U.S., friendly professionals played an important role in AA's early development -- and one of the co-founders was a medical doctor who used his prerogatives as a physician to help other alcoholics. In the majority of the other societies studied by the ICSAA project, professionals played an important role as initiators or supporters of the first AA groups (Mäkelä, 1993), and elsewhere the spread of institutional 12-step treatment -- the "Minnesota Model" -- has played an important role in AA's growth (Stenius, 1991).
In other mutual-help movements, however, the role of professionals has often been much more directive and determinative than anywhere in AA. The benchmark case here might be Croatia (and, more generally, former Yugoslavia) (Poldrugo et al., 1994). The first Club of Treated Alcoholics was started in 1964 by staff of a treatment hospital in Zagreb under the direction of Dr. Vladimir Hudolin. From the first, the developing network of clubs was seen as part of a continuum of professional treatment and aftercare for alcoholics (Hudolin, 1984). The Clubs (sometimes known as "Hudolin groups") spread under professional sponsorship all over Croatia and eventually elsewhere in Yugoslavia and Italy. Each group session was led by a trained professional or semi-professional, often with other therapists also working regularly in the group (Matijevi and Paunovi, 1973).
In the Yugoslavian Communist system, the professionals involved were paid for their work with the clubs. As Hudolin (1984) put it, "it is hard to imagine that a professional could regularly and permanently get engaged on a voluntary basis.... This activity should be a part of his regular working hours or it should be paid extra". But with the change in system and the ensuing economic difficulties, "public funds for rehabilitative programs were drastically reduced". As a result, Thaller and his associates (1994) report, on the one hand the "number of self-help groups decreased", but on the other hand, "the organization of the Clubs is becoming more independent and economically self-sufficient". witkiewicz (1992) reports a somewhat parallel development for the Polish Abstainer Clubs.
Both in Poland and in Italy, observers report a move on the part of the national clubs
movement towards somewhat greater autonomy from professional oversight. This move may have
been influenced in both countries by the context of an upsurge in AA membership. In 1989 the
Warsaw Abstainer Clubs proposed a distinction between patient clubs and self-help abstainer
clubs, noting that moves toward autonomy by the abstainer clubs had been frustrated by doubts
of the professionals who sponsored the clubs "whether alcohol-dependent persons could be trusted
and whether they could manage money and material goods" (witkiewicz, 1992). Bazzani and
his colleagues (1994) report that there has been an evolution in the definition of the role of the
facilitator in the Italian Clubs for Alcoholics in Treatment, from "therapist" to "catalyst" to
"servant" of the group. While the Clubs had sometimes been integrated into the structure of
social- or health-service institutions, a situation in which they are "of course ... not self-sufficient
or autonomous", in recent years "a debate has arisen within the [Club] system regarding the two
contrasting needs: the need to be in the community as an autonomous body, and the need to work
with or next to the social-health services,... thus running the risk of having the self-help concept
A religious, a spiritual or a secular basis
The main traditional temperance-based mutual-help organizations in continental Europe were by origin also explicitly Christian and denominationally linked, either to Catholicism (Croix d'Or, Kreuzbund) or to Protestantism (Croix Bleu, Blaues Kreuz), although religious adherence is often not required of members. Despite its spiritual emphasis, AA represented a step away from a direct connection between mutual help and religion; Cerclé (1985) reports that the founders of Vie Libre, while taking inspiration from AA, had found the Croix d'Or too traditionally "moralizing". The noncreedal and indeed not explicitly Christian nature of AA has given rise in North America to an explicitly Christian mutual-help movement, "Overcomers, Victory Through Christ" (White and Madara, 1992).
From the other side of the spectrum, the spiritual emphasis in AA's Twelve Steps program
proved to be a repeated stumbling-block to the acceptance of AA, since it collided with the
commitment to secularism of descendants of the European Enlightenment -- including many
doctors and other treatment professionals as well as Marxists. A major differentiation between
Swedish Links and AA is the downplaying of reference to a Higher Power in the Seven Points of
Links, otherwise adapted from the Twelve Steps (Kurube, 1992). In a Japanese context, Oka
reports (1994), AA's spiritual roots seem very Judeo-Christian; the concept of "Higher Power"
is not a part of Japanese vocabulary. Allamani (1994) notes that the relationship between AA and
Italian health institutions was long "far from optimal" because until recently "physicians were
skeptical of and not attracted by the spiritualism of the twelve-step program". Conversely, one
of the attractions of the Clubs movement to physicians was that "their approach, initially non-spiritual, was more acceptable to the medical paradigm".
Basis of membership: alcoholics, family members, others
Although AA meetings in the early days of the movement often included the wives of alcoholics, the formation of Al-Anon in 1951 for members of alcoholics' families settled the issue that membership in AA was for the alcoholic as an individual. From the first, AA had also been clear that, while it welcomed professional and other friends, they were not AA members. Although AA's ideology is in many ways an attack on rampant individualism, on what it terms "self will run riot" (Room, 1993), AA thus presumes an individuation on the part of the member, a sense of an individual identity distinct from family identification.
In contrast, family members, and often also professionals and interested volunteers, are accepted as members in several mutual-help movements in central and southern Europe -- for instance, in the temperance-based groups, in Vie Libre, and in the Clubs movements in Croatia and Italy. Very likely, the inclusion of the family in these movements reflects cultural differences from the United States in the relation of the individual and family. Changes in this relation may be one factor in the increased strength of AA in countries like Italy.
Perhaps the most explicit challenge to a presumption of individuation is in the written
Traditions of the small Japanese mutual-help movement known as Danshu-Tomo-no-Kai or Dan-Yu, which quote a Japanese proverb: "we think that a married couple should be one body" (Oka,
1994). Both in this movement and in the larger All Nippon Sobriety Association or Danshukai
movement, also largely male-oriented, the wife of the alcoholic is expected to participate along
with the alcoholic. Oka (1994) notes that the male orientation and couple-centredness of the
national Japanese movements have created an opening for the recent growth of AA in urban Japan,
since women and the single and divorced are not organizationally marginalized in AA. This
organizational characteristic may also have created a place for AA in France, despite the existence
of a number of indigenous movements. In a survey of members of the French mutual-help
movements in the early 1970s, AA members were younger, less likely to be married, and much
more likely to be women (30%) than members of Vie Libre (5%) or of the Croix d'Or (10%;
Benichou and Orsel, 1973:125).
External relations and activities
We have already noted that many mutual-help movements accept state subventions or other external funding. The principle that AA would not accept such funding was established early in AA's history, and has been largely adhered to (Mäkelä et al., 1996). As the recent history in Poland and Croatia underlines, where movements have depended on such financing, its removal can pose a serious predicament. Public financing also tends to weaken the autonomy and voluntarism of social movements. Oka (1994) notes this has been the effect in other fields of the Japanese administrative tradition of coopting self-help groups, and is concerned that it may also happen in the alcohol field.
A common ambition of mutual-help movements in the alcohol field has been to set up residential services for alcoholics. The founders of AA in the U.S. flirted with seeking funds to set up hospitals for alcoholics, but the AA traditions eventually established the principle that any such effort should be organizationally separate from AA. The first big split in the Swedish Links movement came over the decision to set up a convalescent home supported by state grants, a decision which necessitated a formal organizational structure and created a role for oversight by the state (Kurube, 1992). A major distinguishing mark of the two "24-Hours Movements" which split off from AA in Mexico was the commitment to set up "annexes" -- rooms for sobering up and for shelter -- to their meetings, and soon after also "rehabilitation farms" for alcoholics (Rosovsky, 1994). State cooptation was not involved in this case; rather, the movements were responding to a need not met by the national welfare and health system.
Mutual help movements in the alcohol field have generally kept out of partisan politics.
Again, AA takes a stand at one end of the spectrum on this; its Traditions forbid any external
affiliations or endorsements. A few mutual-help movements in the alcohol field have involved
themselves in political activity, particularly on matters related to alcohol controls or treatment.
Vie Libre has taken an unusually expansive line on its field of political interest, taking as one of
its aims struggling "against the social and political causes of alcoholism". Its 1976 congress, for
instance, adopted resolutions calling for a ban on gambling games in cafes, for a reduction in the
price of non-alcoholic drinks, and for an increase in the health budget (Cerclé, 1985).
Internal organization and functioning
AA has maintained a radical commitment to a number of principles which, as Bufe (1991) has remarked, carry into practice the organizational ideals of classical anarchist thought. AA groups are self-starting and self-governing; there is no franchise system which allots territories or population segments to any group, and groups are autonomous and financially independent (Mäkelä et al., 1996). Except for the copyrights on its publications, AA as a movement owns no property. Though little is available in the international literature on these matters for other movements, there is clearly substantial variation. Women for Sobriety, for instance, operates on a franchise system, with a moderator for each group certified by the organization's headquarters (Kaskutas, 1992b). Formal membership criteria and organizational structures are typical of the temperance-based movements and of Swedish Links. It is unlikely that many other movements share with AA a prohibition on owning buildings or land.
There appears also to be substantial variation in what happens and in styles of discourse at group meetings. At a regular AA meeting, everything said should in principle be related to one's own drinking history or one's struggle to stay sober. In contrast, relating one's drinking history is discouraged at Women for Sobriety meetings, and the meeting is organized around first a discussion of a preset topic and then a round of participants reporting on the experiences of their week (Kaskutas, 1989). AA's rule of "no crosstalk" -- that participants should not directly comment on each other's contributions -- contrasts sharply with the confrontational discourse in much professional 12-step treatment (Mäkelä et al., 1996) and with discourse in meetings of the Mexican 24-Hours Movements, which "practice a direct aggressive therapy" where, Rosovsky (1994) notes, "the use of foul language" is considered "therapeutic for the alcoholic".
Scattered observations in the literature give us hints of some other differences between movements in what goes on at their meetings. While AA is remarkable among social movements in its complete avoidance of songs or anthems, the meetings of the Japanese movement ANSA conclude with a chorus of the movement's Sobriety Song (Oka, 1994). In her observations of Club meetings in Croatia in the early 1980s, Linda Bennett (1984) notes a rather different spirit from an AA meeting:
No one is anonymous: a membership roster is kept, and a roll is taken at each meeting....Each member takes antabuse [disulfiram] ... over the first year. As names are read from the roll, each alcoholic goes to the front of the room where a tray of glasses and pills have been placed and takes a pill.
Much could be learned from explicitly comparative studies of the actual process and functioning
of the different mutual help groups.
The experience of many societies teaches us that mutual help movements provide much of the backbone for an effective societal response to drinking problems. The long-term effects of substantial mutual help activity in a society may well be more significant than the effects of professional treatment activities and of formal availability control systems.
The recent literature on mutual help groups in the alcohol field gives us a sense of the richness of variation and experience which can be tapped by comparative analysis, looking both across movements and across societies. We can already discern, from the work so far available, tantalizing glimpses of the scope of variation between movements on various dimensions, and of the ways in which particular organizational choices are fateful, tending to place the organization also on a number of other dimensions.
But much remains to be done. The recent work allows us to begin to enumerate a number
of significant dimensions and characteristics for a full comparative study. But the data so far
available is selective indeed. Filling in the blanks and undertaking a full comparative analysis is
a worthy task for future collaborative international work.
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Mutual Help Movements in a Comparative Perspective, 12-16 September.
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Weisner, Constance, Thomas Greenfield and Robin Room (1995) Trends in the treatment of
alcohol problems in the US general population, 1979 through 1990, American Journal of Public
White, Barbara J. and Edward J. Madara, compilers and editors (1992) Self-Help Sourcebook:
Finding and Forming Mutual Aid Self-Help Groups, fourth edition. Nutley NJ: American Self-Help Clearinghouse.
Table 1. Approximate relative size of mutual help groups for alcohol problems, by number of
groups, selected societies
|Society and date||Alcoholics Anonymous||Denominational &/or temperance-based groups||Other mutual help groups||References|
|France, late 1980s||11%**||41**||48**||Mäkelä et al., 1996:207|
|Hesse, Germany, 1990||17%||53||30||Appel, 1996|
|Italy, c. 1995||14%||***||86||Allamani & Petrikin, 1996 & personal communication|
|Sweden, 1990||24%||***||76||Kurube, 1992 & personal communication|
|Poland, c. 1991||c. 47%**||***||c. 53**||Swiatkiewicz, 1992|
|Austria, 1993||50%||5||45||Eisenbahc-Stangl, 1996|
|US & Canada,
|95%||2*||3*||White & Madara, 1994|
* includes some members with drug and other addictions and some overseas
** on a base of ex-alcoholic members.
*** small or non-existent
1. Selected papers from the conference, in revised form, were published in a special issue of Contemporary Drug Problems (vol. 23, no. 1, 1996) edited by Alan Ogborne.
2. The dates of founding and numbers of groups are from White and Madara, 1992.