Anyone who deals with addiction in America has to reckon with Alcoholics Anonymous and other 12-step programs. Though the basic principles have changed surprisingly little since Bill W. and Dr. Bob founded AA in 1935, the Steps are still used in some 90 percent of rehabs. It’s a bit like the Catholic Church in the Middle Ages—an inescapable influence, sometimes imposed by the state (or even by torture), although coercion is not sanctioned by AA itself.
At least two-thirds of abstinence-based programs—meaning virtually all treatment that isn’t opioid maintenance (and some of those as well)—require meeting attendance and are based, in whole or in part, on a 12-step model, according to a survey conducted in 2009 and 2010 by the University of Georgia’s National Treatment Center Study. It’s fair to say that if you seek help for addiction in 2014, it’s almost impossible to avoid the program, despite the fact that research shows that the 12-step model is not superior to alternatives and that most people don’t stick with it.
The 12 steps and indoctrination into their ideology should play no role at all in professional care. Insurance companies and the government should not be paying counselors whose only training is in 12-step methods.
So, what is my position on AA after more than 25 years (yikes!) of writing about drugs and addiction? I’ll note up front that I’m a former cocaine and heroin addict. I attended a 28-day rehab in 1988, when it was pretty much all 12-step, all of the time. And I did find meetings—and the warm, generous support I received from other 12-steppers—to be helpful for the first few years of my recovery. (From my own anecdotal experience, however, no firm conclusions can be drawn.)
The 12-Step Approach Should Not Be Confused With Treatment
On balance, I believe that these programs can be a wonderful resource for those who find them amenable. Treatment centers should recommend them and offer meetings in order to help people discover whether or not it’s for them. Because they are free, available 24/7, and provide social support for abstinence that is otherwise unavailable, they may play a role in some people’s recovery that is not easily filled by anything else.
But I believe that the 12 steps and indoctrination into their ideology should play no role at all in professional care. No one should be court-mandated or otherwise forced to attend. I also believe that it is malpractice for any professional to claim that these programs are the only or the best way to recover.
To start, selling the steps—as private rehabs do—violates AA’s own tradition that it is a non-professional, non-profit organization. Insurance companies and the government should not be paying counselors whose only training is in 12-step methods and their own story to provide the “experience, strength and hope” that anyone can get for free in a church basement. Addiction treatment resources are limited and there are evidence-based therapies that aren’t freely available—so let’s pay for those, not “12-step facilitation.”
Further, like most interventions powerful enough to have any effect, 12-step programs can clearly harm as well as help. To mitigate this possibility, people who are being introduced to the program in any official way—through the court system, say, or in treatment—need to be warned about these possible “side effects,” some of which may be severe enough to requirealternative approaches.
As mutual aid organizations, 12-step programs shine. But when forced on people, when misused by those with their own agendas, and when treated as the One True Way, they can be very destructive.
In this regard, the most important 12-step slogan is “Take what you like and leave the rest.” The idea that the steps are suggestions and that the recovery process is for “people who want it, not people who need it” is key to avoiding harm. Although the judgment of people in early recovery may be somewhat skewed, research shows that even then people can and do make informed and intelligent choices, just like patients made vulnerable by other medical conditions.
How the 12 Steps Can Harm Instead of Help
Many 12-step concepts are a double-edged sword. Consider the principle of powerlessness. Research shows that the more you believe that you are powerless over the disease of addiction, the worse your relapses will be—if you have them. Of course, for some, the idea of powerlessness or “the first drink gets you drunk” allows them to avoid relapse—but keep in mind that most people do, in fact, slip at least once. If you do, while your judgment may well be impaired, you do not have to turn a slip into a binge. Powerlessness is best viewed with a skeptical eye—recognizing that self-control is much harder after taking a substance that increases impulsiveness, while not taking on board extreme notions like “I’m powerless over everything,” as some AA members do.
A more insidious harm can come from the idea of powerlessness when it is pushed by treatment programs rather than fellow self-help participants. This is the notion that treatment should force people to feel powerless, in order to aid their recovery. In fact, research shows over and over that empowering people, treating them with respect and giving them options, rather than infantilizing them, is both more effective and less potentially dangerous.
A treatment philosophy that contends that it is acceptable to treat “powerless” people as such—and to rub their faces in it with strict rules and restrictions—creates a program that inevitably abuses those who are in its care. While entitled people—particularly white middle- or upper-class men, for example—might occasionally benefit from realizing that they can’t control everything, using a rehab program to enforce the idea of powerlessness on already-marginalized people—often poor, minority, and/or female addicts—risks additional types of harm because of their experience of being made to feel inferior by institutional and social biases.
The whole spirituality question—AA’s insistence on a “Higher Power”—is yet another problem. In my view, if addiction is a medical disorder, spirituality should not be central to treating it. Whether or not you want to believe in a Judeo-Christian “God as we understand him,” Allah, Body Thetans, or a doorknob should have nothing to do with medical care. The same goes for AA’s principle of anonymity: Whether or not you want to be “out” about a disease or disorder should be a personal decision. It’s silly to try to hide in code words like “support group” if you are going to be open about how you cope with your addiction.
A further danger of 12-step ideology lies in being pushed to adopt an addict identity, to view yourself as permanently sick or damaged. In my own case, I actually found seeing myself as an addict to be helpful—it was better to be “sick” than “bad.” This relieved some of the self-hatred that drove my drug use. But like powerlessness, this self-pathologizing can be taken too far, with people focusing only on their character defects, which prevents them from moving on with their lives. If it works better for you not to assume this potentially stigmatizing persona, “Take what you like and leave the rest” is, again, in order.
Although it would be lovely if the rooms were a truly safe space, the reality is quite different. Too many victims of rape, domestic violence and even murder have met their perpetrators there.
Adopting an addict identity is especially problematic for young people whose identities are not yet fully formed. Doing so may make what may well be a transient problem into a long-term one, by teaching them that addiction is inevitably chronic and relapsing. Since no one can predict which youth will mature out of addiction and which will not, teens should never be forced to attend 12-step groups—nor should they be made to label themselves as addicts.
Human Hazards in 12-Step Programs
Another danger, which primarily affects both youth and women, is particularly acute at meetings where large numbers of people are court-mandated to attend. Since these programs quite rightly do not exclude anyone who has an addiction, some of those in attendance may be actively criminal or sexual predators.
Indeed, in general, people with antisocial personality disorder—who often enjoy manipulating and even harming others and do not believe the rules apply to them—are overrepresented among the addicted. The reputation we have for being liars and manipulators comes largely from this group. While most addicted people actually don’t qualify for this diagnosis, which affects about one percent of the general population, alcoholics are five times more likely to have it, and illegal drug addicts are 12 times more likely than those without addictions, according to a large population-based study.
This means that at any given meeting, the odds of running into someone who is not only not “working the program” but who may actually be dangerous are greater than they would be at, say, your average coffee shop. Like many jokes, the “13th step” idea of “get them on their backs before they get on their feet” contains an element of sick truth.
While it would be lovely if everyone who claims to want to help you at a meeting were pure of heart and the rooms were a truly safe space, the reality is quite different. Too many victims of rape, domestic violence, and even murder have met their perpetrators at meetings—and too many have put their trust in him or her because of that fact.
Sadly, virtually every woman I know who has spent significant time in AA has at least one story of sexual harassment or worse. In my case, when I was in my 20s, I had to physically fight off one member who wouldn’t take no for an answer. I had trusted him enough to go on a date, in part because he said he had long-term recovery. Around the same time, a newcomer told me she was raped by a man whom she invited home for a discussion of the steps.
Less extreme but still troubling are cases where young people meet dealers or new running buddies at meetings—particularly when their initial drug of choice was marijuana and alcohol and they get introduced to cocaine and heroin. This “deviancy training” risk is especially strong at meetings where many people are forced to attend and are not actively seeking to be abstinent.
These issues, of course, can arise at any type of group that brings addicts together—and for that reason I believe that young people should generally be treated individually, not in groups like AA. The risks of both creating a permanent addict identity and of meeting up with adults with antisocial personality disorders or other bad influences are just too high.
Adopting an addict identity is especially problematic for young people whose identities are not yet fully formed. Doing so may make what may well be a transient problem into a long-term one by teaching them that addiction is inevitably chronic and relapsing.
One last but important source of potential harm is 12-steppers who play doctor or counselor by telling people to avoid trying, or to stop taking, antidepressants or any other medications. AA’s own literature admits that suicides have occurred as a result—and again, anyone who attends meetings needs to be warned that fellow members are not professionals and should not be heeded as such.
For me, this was the final straw: I left the program after I decided to take medication for depression and realized that this disease, not a failure to work the steps properly, was behind many of my problems. Once my depression was treated, I didn’t need the extra social support of meetings and a sponsor—I could simply have normal relationships with my friends and loved ones. As I discovered this, I gradually stopped attending, because meetings became more irritating than stress-relieving.
Twelve-step programs can do much good as a self-help group for people who find the approach comforting and supportive. But they are not professional treatment and professional treatment should not consist of instruction in their ideology. In their rightful place as mutual aid organizations, 12-step programs shine. But when forced on people, when misused by those with their own agendas, and when treated as the One True Way, they can be very destructive.
As a result, if we are to see addiction as a genuine medical problem, the primary treatment approach cannot be meeting, confession, and prayer, nor can people whose only experience of the condition is having had it be recognized as experts. Social support is critical to health and to recovery from virtually all psychiatric disorders—but it isn’t medical care. Twelve-steps groups are not treatment—and separating the two will improve the health of both.