Part 4: The Role of Peers and Mutual Support in Alcoholic's Anonymous

In our previous blog in this series, we discussed how peer’s roles have become an important part of mainstream behavioral health even with ongoing disagreements about peers’ roles in healthcare. This advancement was due in no small part to changes in public policy that enhanced the visibility and viability of peers in mental health care.

A discussion about the use of peers would not be complete without an explanation of the use of peers in addictions treatment, especially the treatment of alcoholism. The history of Alcoholics Anonymous (AA) is as interesting as it is diverse involving elements of psychoanalysis, morality, psychedelic drugs and using peers for mutual support.

AA started in the United States in the 1930s, in an era that was preceded by the implementation and removal of prohibition and the Great Depression. These major events coincided with the closure of many “drying out” facilities, the main form of alcoholic treatment in that time, leading to a void in treatment options for those suffering from alcoholism. The “moral failing” view of alcoholism was common and those who were not able to control their drinking were looked down upon as people unable or unwilling to “pull themselves up by their own bootstraps” – a reprimand made to the American people in general by President Teddy Roosevelt in a State of the Union Address. It was in this context of limited treatment options and high need that Bill Wilson, a stockbroker from New York and Dr. Robert Smith (Dr. Bob) randomly found each other and developed the mutual assistance group we now know as AA.

Wilson’s journey to sobriety and to the formation of AA was complicated at best. Despite repeated attempts at sobriety, Wilson continued to binge drink, steal and suffer blackouts and delirium tremens (DTs). A contemporary of Wilson’s, Rowland Hazard, was facing his own challenges with alcoholism but he took a very different approach to secure sobriety. Hazard went to Switzerland to be treated via psychoanalysis by none other than Dr. Carl Jung. After Hazard relapsed, Jung told him there was nothing more he could do for him and that he would need to experience a “spiritual awakening,” but such experiences were neither within the realm of psychoanalysis nor were they very common.

Hazard continued to seek help including from the “lay therapist” Courtenay Baylor, arguably the first person in recovery to be professionally paid as an alcoholism counselor. But Hazard also got in touch with The Oxford Group, an organization focused on the notion that problems of all kinds could be healed through personal spiritual change. The Oxford Group was not specifically for alcoholics. Their mission was much broader (including the desire to achieve world peace) but many aspects of the organization were attractive to alcoholics in part because unlike many religious-focused groups of the time, abstinence was not a prerequisite for joining. What was required though was a commitment to demonstrable change and this provided the context for voluntary abstinence to occur. Some elements advocated by The Oxford Group will be familiar to those who know how AA works – spiritual surrender, relying on a higher power (i.e., God for The Oxford Group), personal self- inventories, confession of one’s wrongs and helping others.

Hazard, now sober along with two Oxford Group colleagues visited a friend named Ebby Thacher, who was at the time in jail for alcohol related offenses. Rowland shared his story and convinced his friend to participate in The Oxford Group. Ultimately Thacher also achieved sobriety and took his message to his old friend, Bill Wilson. Wilson was unable to attend any Oxford Group meetings before being admitted for the fourth time to Town Hospital to “dry out.” While there Wilson had a transformative experience that he described as his “hot flash." In a fit of hopelessness, Wilson emotionally surrendered saying he would do anything to get well. This was followed by what Wilson would describe as a sudden bright light combined with an ecstatic experience. The fact he was being treated with belladonna and henbane, drugs known to cause delirium and hallucinations, led to decades of debate about the value of psychedelics in the treatment of alcoholism. However, Bill’s physician Dr. William Silkwood, did not attribute the experience to the drugs. Rather he explained it as a conversion experience which sometimes helped alcoholics break the hold the substance had over them. Dr. Silkwood also provided Wilson with a physiological explanation of alcoholism that resonated metaphorically if not medically with Wilson. Silkwood told his patient that he had an “allergy to alcohol” which provided Wilson with an easily understood, if not exactly medically accurate, explanation for why alcoholism affects some people but not others. After his discharge from the hospital, Wilson and his wife Lois began regular attendance at Oxford Group meetings and like Rowland Hazard and Ebby Thacher before him, Wilson began reaching out to alcoholics to help them as he had been helped.

While on a business trip in 1935, Wilson had now been sober for approximately six months when he found himself tempted to drink again. To address this, he began calling local Oxford Group members for support. He said he needed to help another drunk in order to maintain his own sobriety. He was introduced through a mutual friend to Dr. Robert Smith. That meeting, along with Thacher’s visit to Bill Wilson are considered two of the pivotal moments in the formation of AA. Dr. Smith would later say the following about that experience and about Wilson, “He was the first living human with whom I had ever talked who knew what he was talking about in regard to alcoholism from personal experience.” Dr. Smith did not get sober immediately after their visit. In fact, after going through a round of withdrawal he would drink his last beer to steady his nerves before performing a scheduled surgery. That meeting on June 10, 1935, is celebrated as the founding date of Alcoholics Anonymous.

AA was not the first group to try to utilize the power of mutual support in the treatment of alcoholism.  In 1906, two ministers and a physician opened the Emmanuel Clinic in Boston advocating for an integrated model of healthcare that combined the various disciplines of medicine, psychology, social work and religion to provide a wholistic approach to the problem. Along with other progressive aspects of care that are today considered typical treatment elements (medical screening, medical records, accurate diagnoses, psychological counseling and spirituality), they also encouraged the involvement of “recovered” alcoholics as “lay therapists.” The clinic’s integration of psychology and religion was the predecessor to today’s focus on spirituality in recovery. Their use of self-inventories and confession preceded The Oxford Group and AA. In addition, by emphasizing the importance of “lay therapists” they set the stage for professional alcoholism counselors, case managers and recovery coaches. Along with Courtenay Baylor, who was employed by the Emmanuel Clinic, Richard Peabody, a former client of Baylor’s, became one of the first lay therapists to integrate the newly emerging field of psychology into his practice. His 1931 book The Common Sense of Drinking was considered a mainstay of alcoholism treatment into the 1950s.

While the Emmanuel Clinic and others focused on the value of mutual support, none has been as successful or as widespread as AA and its spinoffs, e.g., Narcotics Anonymous (NA). According to the 2018 AA Fact Book, there were an estimated 2.1 million AA members in over 120,000 AA groups worldwide.

In the next blog of this series, we will discuss the degree to which peers are being used in the United States and the economic impact they have. We will also look at efforts to expand the professionalization of peers by improving credentialing efforts and supporting billing of peer services.

A look back on the rest of the peer support series:

Part 1: Origins of Peer Support in Mental Health

Part 2: Development of Peer Support in the United States and Other Regions of the World

Part 3: Public Policy and the Professionalization of Peers