12-step organizations (AA, NA, and others) are the most commonly sought sources of help for substance-related problems in the U.S. All are considered mutual help organizations (MHOs) and have certain features in common: They are self-supporting, open to anyone with a desire to stop substance use, and do not have professional facilitators.
Alcoholics Anonymous (AA), founded in 1935, is the original and by far the most popular MHO, with more than 50,000 meetings a week nationwide. AA grew out of a Christian organization called the Oxford Group, which was founded in 1931 by Frank Buchman, an American Lutheran minister.
Buchman had a religious conversion experience on a trip to England, and in 1921, during a visit to Oxford University, he formed a religious fellowship called A First Century Christian Fellowship.
By 1931, its name had changed to the Oxford Group. This group had elements that would later be adopted by AA, including a rejection of hierarchies, an emphasis on beliefs rather than religion, and a specific series of stages to follow in order to improve one’s life (mirrored later in AA’s Twelve Steps).
The eventual co-founder of AA, William Griffith Wilson, was born in 1895 in East Dorset, Vermont, where his parents ran an inn and tavern. At some point, both of his parents abandoned him, and Wilson was raised by his grandparents. Not surprisingly, he suffered episodes of depression from an early age, and also had significant social anxiety.
He discovered alcohol in 1917, and it quickly became his constant companion. Though he went to law school, he did not graduate because he was too drunk to pick up his diploma. A subsequent career as a stock broker also ended in shambles. When an old drinking buddy, Ebby Thacher, visited him in 1934, Wilson was astonished to find that Thacher had been sober for several weeks. Thacher credited the Oxford Group, which had opened branches in New York City and Akron, Ohio, with helping him gain sobriety through Christian fellowship.
With his encouragement, Wilson attended a meeting, but continued drinking and soon thereafter was admitted to a detox hospital, where he went into delirium tremens. During that hospitalization, he had a life-changing religious experience in which he saw a flash of light and felt the presence of God. Wilson never drank again. The following year, in 1935, he met another alcoholic member of the Oxford Group, a physician named Bob Smith, and the two of them formed a sub-group within the Oxford Group that eventually split off to become AA.
In 1939, Wilson published Alcoholics Anonymous, eventually known as “The Big Book” because of its heft. Still the basic textbook for AA, it is one of the best-selling books of all time, having sold over 30 million copies. NA was formed as an offshoot of AA in the 1950s and follows the same principles.
Does AA work?
AA has been a fixture of alcoholism treatment for decades. But does it actually work? The question is hard to answer, in part because it’s difficult to do a randomized controlled trial of AA. Such a study would have to track whether patients assigned to AA treatment are attending meetings—a difficult proposition since AA, by definition, is anonymous. Another challenge is that AA groups vary in size, content, and focus, making it hard to define the treatment under study.
This doesn’t mean that AA can’t be studied—just that doing so requires creative methods. One such method was Project MATCH. This was a large randomized trial in which 1,726 alcoholics were randomly assigned to one of three treatments: cognitive behavioral therapy (CBT), motivational enhancement therapy (MET), and a third treatment that was a stand-in for AA: a psychotherapy, based on encouraging AA attendance, called twelve step facilitation (TSF) (Project MATCH Research Group, 1997). At both one- and three-year follow-ups, all three interventions were equally helpful at reducing the quantity and frequency of alcohol use. However, TSF was superior to CBT and MET at increasing rates of continuous abstinence: 24% of patients in the TSF condition were continuously abstinent at one year after treatment, compared with 15% and 14% in CBT and MET, respectively.
Does Project MATCH prove that AA is effective? Not really, but it shows that if you base a therapy around AA principles and encourage patients to go to meetings, they will probably do at least as well as other well-validated treatments. A systematic Cochrane review of the best scientific studies on AA and TSF found that they were as effective as any of the interventions to which they were compared for some factors, such as retention in treatment; however, the review found that no studies unequivocally proved AA and TSF were superior to other treatments (Ferri et al, 2006).
Other studies have found a linear dose-response relationship between AA attendance and favorable drinking outcomes (Kaskutas, 2009). Attending one meeting per week, on average, appears to be the minimum threshold to realize benefit, and higher meeting frequency is associated with progressively greater rates of abstinence.
The Books of AA
While we often hear about “The Big Book,” many may not understand exactly what it is and how it is used. The Big Book is a thick blue volume, just short of 600 pages. The first edition was written in 1939, and it has been updated periodically since then. In each edition, the first 164 pages are always the same: the original description of the Twelve Steps written by Bill Wilson.
The language from the 1930s is old-fashioned and can be difficult to read for many. The remainder of the book consists of short stories about people’s journey to recovery that are written in a modern style. For those seeking to understand the philosophy of AA, many would agree that the better book to read is Twelve Steps and Twelve Traditions (known informally as “the Twelve and Twelve”), which was originally written in the 1940s but is updated and revised regularly.
Clocking in at 192 pages, the Twelve and Twelve is more readable and is recommended for those who want to achieve a better understanding of the organization.
Finally, some research has tried to pinpoint the means by which AA works. AA’s key ingredients appear to be helping people make positive changes in their social networks (eg, disassociating themselves with heavy drinkers/drug users and increasing ties with abstainers/low-risk drinkers), and enhancing coping skills and self-efficacy for abstinence when encountering high-risk social situations (see, for example, Kelly JF et al, Drug Alcohol Depend 2011;114(2–3):119–126).
WHAT ARE THE TWELVE STEPS?
The underlying idea behind the 12-step program is that stopping alcohol or other drug use is only the beginning of a journey. In order to maintain sobriety, alcohol and drugs must be replaced with something just as compelling. The Twelve Steps represent a series of guidelines for how people might choose to live their lives without alcohol. Because the steps can be confusing for those not in the program, here is a good way to remember the gist.
There are three phases: surrendering, confessing, and maintaining.
- Steps 1–3 involve realizing that substances have rendered life unmanageable, and that the way out is to surrender to the program (sometimes conceptualized as God in AA literature).
- Steps 4–9 are a process of listing one’s “bad” deeds and confessing them.
- Steps 10–12 describe how one can best maintain a commitment to sobriety.
- The surrender: “We admitted we were powerless over alcohol— that our lives had become unmanageable.” Patients understand that repeated attempts to cut down or stop drinking have not worked—in other words, they have been “powerless.” In addition, they understand that there is a connection between drinking and what has brought them to treatment, such as financial problems, job loss, family problems, arrest, or feeling sick—that is the “unmanageable” piece. The sense of relief that comes with the admission of powerlessness and unmanageability in terms of alcohol is liberating for many.
- The higher power: “Came to believe that a Power greater than ourselves could restore us to sanity.” Many patients who go to AA talk about a “spiritual awakening” that often occurs very early in recovery. That awakening is often a result of Step 2. While going to AA meetings, patients become engaged in the process of recovery, sometimes for the first time. The act of going to the meetings, and of speaking in a supportive setting, gives patients the feeling of taking the initiative. It also inspires a sense of hope, which can be experienced so intensely as to seem religious or spiritual.
- The decision: “Made a decision to turn our will and our lives over to the care of God as we understood Him.” This step is really just an extension of Step 2, which was about believing in a higher power; this step says explicitly that the patients will trust that higher power. Many members will substitute other terms or concepts for God, such as spirit, nature, the AA process, or the support of AA members.
- The self-assessment: “Made a searching and fearless moral inventory of ourselves.” In some ways, Step 4 is the crux of AA. It entails writing down (or typing out) the list of behaviors and negative emotions that have caused patients shame over the years. For example, “I told my wife that I would stop drinking but continued to drink, hiding bottles of vodka in the garbage shed. I would say I was taking out the garbage in order to take a few swigs.” Unresolved guilt tends to fester and often helps drive people to continue drinking. The therapeutic value of this step lies in patients’ strengthened insight into what spurs their drinking, and in preparing for Step 5.
- The sponsor (or psychiatrist): “Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.” This is a natural extension of Step 4, and entails verbalizing the written inventory, usually to a sponsor. This may take a couple of hours or a couple of days, as patients read from the list and talk about the feelings that are generated. The sponsor has lived through a similar litany of events and is completely nonjudgmental. Therapeutically, this step reduces shame and guilt. A common AA expression is, “We are as sick as our secrets.”
- Readiness to change: “Were entirely ready to have God remove all these defects of character.”Patients have done their self-assessment (Step 4, the moral inventory), and they’ve shared it with someone (Step 5). With Step 6, it’s time for patients to accept that they need to take action to resolve their problems and address any character defects. This is a very short step, something that patients do by themselves. It is a kind of quiet meditation or affirmation of one’s readiness to make changes.
- Humility: “Humbly asked Him to remove our shortcomings.” This is similar to and closely tied to Step 6, with an emphasis on humility and a commitment to use the AA process to stop whatever behaviors led to drinking.
- Taking responsibility: “Made a list of all persons we had harmed, and became willing to make amends to them all.” AA members often say there are lots of side effects to being an addict. These side effects include the damage done to other people as a result of an addiction. In this step, which is a natural prelude to Step 9, patients make a list of people whom they have harmed, and also list whether they feel harmed by those people. This process helps patients achieve peace of mind, which is another goal of Step 8. Forgiveness of perceived harms is required so that honest amends can be made in the next step.
- Restitution and amends: “Made direct amends to such people wherever possible, except when to do so would injure them or others.” Whenever possible, patients should make direct amends in order to achieve peace of mind. It is okay to take some time to determine the best way to make amends to a particular individual. Making amends also includes paying—or promising to pay—whatever financial or other obligations are necessary. If a particular form of making amends would harm another person or the patient further, it should generally not be done. However, some members have confessed to crimes as part of Step 9. For example, one member had hit and killed a bicyclist while driving drunk, and left the scene. After long discussions with his sponsor, it was clear that he would not be able to achieve calmness or inner peace until he admitted to the crime. He did so, and served five years in prison—and did not regret that decision.
- Balance: “Continued to take personal inventory and when we were wrong promptly admitted it.” Step 10 means patients put aside some time at the beginning or end of each day to reflect on their recent behaviors and to judge whether those behaviors have been in alignment with their values. It’s a kind of self-regulation that seeks to ensure any new problems will be corrected quickly.
- Connectedness: “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.” AA members try to maintain a sense of connection to something outside of themselves. This step often entails some type of meditation or reflection about patients’ place in the world. The point is to have some regular form of emotional balance-keeping, such as meditation or daily reflective walks. This step helps patients’ awareness of themselves and improves well-being.
- Helping others: “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.” Part of continuing recovery for patients—usually former patients by this point—includes helping other alcoholics. This might entail becoming a sponsor, but according to AA philosophy, the best way to help others is to embody AA’s principles in one’s own life, which will naturally attract other alcoholics to a different way of living. Helping others is a unique aspect of mutual support groups based on the Twelve Steps. The Twelve Traditions: AA’s instruction manual Aside from the Twelve Steps, AA also has the “Twelve Traditions.” These are less well-known, but constitute a sort of manual for how meetings should operate. For example, one tradition involves eligibility: The only requirement for AA membership, which means attending meetings, is “a desire to stop drinking.” All AA groups must be self-supporting, can collect donations from members but nobody else, and must not own any property. Money, according to AA tradition, just distracts from the primary purpose—“helping alcoholics achieve sobriety.” Another tradition is that AA doesn’t take any positions on anything. Finally, AA members are supposed to be anonymous and not disclose their membership to the media. This is not the same as disclosing that they are in recovery.
AA MEETINGS: HOW THEY WORK
AA meetings are held in churches, community centers, hospitals, and similar settings. There are many meeting options in most cities, and the best way to find them is through the AA website. Entering a ZIP code will retrieve a list of meetings with dates, times, and, importantly, characteristics of available groups. There are also online meetings. Here are some examples of meeting types:
- Open meetings (anyone may attend) vs. closed meetings (only substance users may attend)
- Alcohol-focused vs. polysubstance abuse
- Gender-specific meetings (women only)
- Older people (eg, “Gray AA”)
- Special professional groups, such as “caduceus meetings” for health care professionals and “birds of a feather” for airline pilots • Groups that focus on a reading from a book or a pamphlet
Beyond these categories, different meetings tend to attract people of different socioeconomic groups, varying degrees of religiosity, etc. I emphasize to my patients that if they don’t like the first meeting they attend, they may be able to find a different meeting where they feel more comfortable. I’ll sometimes use the analogy of drinking: “The first time you went to a bar, if you didn’t feel comfortable, you didn’t say, ‘Well, I’m not going to drink at all.’ Instead, you went to another bar. AA is a little like that.” People are allowed to come to meetings drunk, as long as they are not disruptive—the only requirement is a desire to quit. While I certainly don’t encourage combining drinking with AA attendance, people have found that they can benefit from meetings under any circumstance. Patients have told me, “Every hour I spend in a meeting is an hour I’m not drinking or using.” AA groups often have a steering committee of members who make decisions about how their meetings will be organized. Various officers are elected, such as a treasurer and a secretary, who run the meetings.
72 THE CARLAT GUIDE SERIES | ADDICTION TREATMENT
Depending on the steering group’s decision, most meetings take one of three forms: 1. Speaker meetings. A speaker, usually a member of the group, is invited to tell his or her story of recovery. The floor is then opened for questions or comments. Members often find their sponsors by approaching speakers whose stories are similar to their own. 2. Topic meetings. These meetings are organized around a particular topic, such as coping with the holidays, the place of gratitude in people’s lives, or dealing with road rage. Sometimes the topic is a particular AA step, in which case they are called “step meetings.” 3. Reading meetings. Such meetings begin with a reading from the library of AA literature, such as The Big Book, and proceed to a discussion of issues raised. AA meetings usually last about an hour. People gradually arrive, and there is some pre-meeting chitchat, snacking, and coffee drinking. Then the secretary will start the meeting, often with the serenity prayer: “God grant me the courage to change the things I can change, the serenity to accept the things I can’t change, and the wisdom to know the difference.”
CLINICAL PEARL: Attending an AA Meeting I highly recommend that you go to at least one AA meeting. It’s a moving experience that reminds us why we are doing our work with clients.
Meetings are quite welcoming to new members. Often, someone will ask, “Anyone here for the first time?” First-timers will raise their hands (which is optional) and introduce themselves, usually with the standard, “Hi, my name is Michael, and I’m an alcoholic.” Everyone responds, “Hi, Michael.” (AA is on a first-name basis only, and members don’t even have to use their real names.) As a health professional attending an open meeting, you might say something like, “I’m Michael, and I’m a local treatment professional here to see what this group is like. I’m thinking of recommending it to my clients.” After these opening rituals, the meeting proper will get underway. For example, in a step meeting, the secretary might say, “Today we are going to look at Step 4—everyone get out your Big Book.” There might be a reading
Chapter 5: 12-STEP PROGRAMS 73
from the book, and then someone might stand up and say, “Here’s how I’ve dealt with Step 4,” and share something about how they made amends. The floor might then be opened for anybody to stand up and respond to the speaker, or to share something unrelated. How AA sponsorship works A key element of AA is the networking that occurs between meetings. Patients who benefit the most are those who participate actively in the meetings, but also those who connect with other members, which is how they find a sponsor. The process of finding a sponsor is often gradual. Clients might start by getting together a “phone list,” which includes a few people they are comfortable with who are willing to make themselves available to talk. Some groups have a list of people who have volunteered to serve that purpose. We hear a lot about the importance of sponsors in a patient’s recovery. Sponsors must have at least 2 years of solid recovery and have worked through the Twelve Steps completely. They are comfortable and willing to pass on some of their hard-won wisdom to newer members. They may have tools to share, such as 12-step workbooks and worksheets. Clients will have regular contact with a sponsor, though the specific frequency will vary. Some sponsors will say, “Call or text me once a day to see how you’re doing.” Others will say, “We’ll get together after the meeting each week and go to a diner and talk, or work through the steps.” It’s fine to work with a sponsor “candidate” to see how comfortable the relationship is. Sponsors should generally be the same gender as the member in order to ensure the focus stays on working the steps.
CASE REVISITED: During recovery, E gets to know a few of the people she continually sees at meetings, so she obtains their phone numbers and calls them periodically . After a while, she gets to know a woman close to her age who has been in recovery for nearly 15 years; she asks this woman to be her sponsor .
Working with patients as they attend meetings Other than attending a meeting to understand what it’s like, I don’t think it’s beneficial for a therapist to get involved in continual meeting attendance,
74 THE CARLAT GUIDE SERIES | ADDICTION TREATMENT
beyond asking clients whether they are going to meetings. By the time patients have gone to a few meetings, they’ll know more about the process than you do. Once you start talking about the steps in detail, this knowledge gap can be damaging. For example, most first-timers find the first of the Twelve Steps very scary—they’re telling people what they are ashamed of. Use a lot of discretion when broaching this subject and a disclaimer about how little you know. As a psychiatrist doing relatively brief medication-focused visits, you won’t have the time to discuss 12-step meetings in great depth, but there are various questions that you can ask your patient during the appointment to reinforce meaningful participation: • “How often are you attending meetings?” For those with severe alcohol use, attending a minimum of 2 to 3 meetings per week is optimal. If patients have only been to one meeting and didn’t like it, ask them about the experience. This will not only help you figure out what sort of meeting might be a better fit, but also may be useful in helping another patient. You should have a few meetings that you think are appropriate to refer patients to. Avoid meetings that are too hardline, or where the members are too domineering. I tend to steer patients who are new to AA to larger meetings to help them feel less self-conscious. • “Have you gotten your phone list together? Have you thought about looking for a sponsor?” I ask these questions during follow-up visits. If patients haven’t assembled their list, probe a bit: “Why not? Have you not been staying after the meeting?” You want to establish that they are interacting with someone individually, someone they can work the steps with outside of the meetings, rather than just with the general group. Research has found that individual involvement is more strongly associated with drinking outcomes than meeting attendance alone (Krentzman et al, 2013). • “What step are you working on?” While you don’t want to take on the role of a sponsor, you should be familiar enough with the Twelve Steps to discuss them with your patients, at least at a superficial level. This is helpful for treatment, and if a patient rejects AA after a couple meetings, you can often use an understanding of the steps to reinforce further attendance. Unless you have substantial experience with the Twelve Steps, either because you have been treating addictions or because you have worked the program yourself, I don’t recommend getting into detailed discussions of
Chapter 5: 12-STEP PROGRAMS 75
the steps with your patients. For those who do have some experience, here are some of the issues that often come up. Step 1, powerlessness and unmanageability . Some criticize the first step as undermining the individual’s self-empowerment. But in my view, it is in sync with the DSM-5 criteria for alcohol use disorder, which include a loss of control (“powerlessness”) over one’s alcohol use in the face of very negative effects on relationships, work, and other aspects of life (“unmanageability”). I might say, “Step 1 doesn’t mean that you are unable to address your problem or have no responsibility for it. As a matter of fact, it’s quite the opposite; the steps are about you taking responsibility for your own recovery and moving forward.” Understanding this step can also be helpful for patients who are having trouble with cravings and are on the brink of relapse. I often say something like, “Let’s just take a look at the first step again and your recognition of the powerlessness and unmanageability of the disease.” That helps to remind patients of the consequences of using. Of course, for any patients who feel close to relapsing, it can be helpful to encourage them to go to an AA meeting and share with the group that they feel like drinking. In AA, this response is viewed as an act of courage and strength rather than weakness—it is normal for an alcoholic to feel like drinking. Assure patients that they will receive a great deal of support from the AA group following such an admission. Step 2, the higher power . Patients may express discomfort with the idea of a higher power, especially those who are not interested in religion. I emphasize that there are many ways to conceive of the higher power. Some people, indeed, think of it as a Christian god. For others, it’s the group dynamic itself. One group literally had a box on a shelf with “higher power” written on it. Another group said that the higher power was the light bulb in the room, something that provides light and facilitates important conversations at meetings. One person told me he viewed it as the ocean, because it is large and powerful and all-surrounding. In AA it is defined as “God as we understand Him,” which allows a lot of latitude. Step 4, the moral inventory . Doing a moral inventory is difficult because it means looking at negative events of an individual’s life. This can contribute to depression, and some people get stuck on this step and feel worse and
76 THE CARLAT GUIDE SERIES | ADDICTION TREATMENT
worse. One way to facilitate this step is to say, “So, it’s great that you’re on the fourth step; when are you planning to complete it?” You could also say, “It may be beneficial if you set a date for the fifth step (where the inventory is shared with another person), carry this out and get it over with, and move on to the other steps.” It’s important to point out that identifying one’s strengths can also be a part of the fourth step’s inventory. Step 9, making amends . Making amends can take time to carry out. Family relationships in particular can be tricky for patients who are adult children of alcoholics, who were molested as children, or whose harmed relatives are now deceased. In those cases, attempts to make amends may harm the other person or simply be unfeasible, and you can point out these issues to your patients. Steps 10, 11, 12, maintenance steps . When patients are tempted to use again, I emphasize the last three steps, which are considered maintenance steps— meant to be continued throughout a person’s life on a regular basis. Ask, “Are you using the 10th, 11th, and 12th steps on a daily basis?” (Some people in 12-step meetings call them “daily disciplines.”) “What are you doing daily to support your recovery?” “You’ve stayed sober today; how did you accomplish that?” Some people will say, “I attend a meeting every day” or, “I call someone in AA everyday just to check in and discuss things.” Some people use prayer or meditation. Others do a daily reading from one of the AA textbooks. Regardless of the exact ritual, the key is consistency, and you can emphasize the importance of this practice. Potential barriers to AA attendance Research has shown that you can increase patients’ chance of attending a meeting by introducing them to other patients in recovery who are AA members and would be willing to accompany them to a local AA meeting. You can accomplish this by asking for an experienced patient’s consent to be contacted by patients who are new to AA. Here are some potential barriers that clients may bring up: • “What if someone recognizes me?” Some patients are worried about seeing someone they know at a meeting. I point out that the group is called Alcoholics Anonymous for a reason—participants promise to maintain confidentiality. I note, “If someone recognizes you, that also means you
Chapter 5: 12-STEP PROGRAMS 77
recognize them, so it’s a standoff.” I also say, “You may be surprised at who you end up seeing at a meeting!” • “I don’t have a ride.” There is an easy answer to that: “If you can get to the first meeting, you can get to any meeting.” People at AA are there to help one another, and helping new members get to meetings is one of the more common forms of mutual self-help. If patients are having a hard time arranging transportation to their first meeting, suggest that they call the local AA central office, which will be able to arrange a ride. • “What if they find out I’m on medication?” It is true that in the past, AA disapproved of members taking medication, but that attitude is now quite rare. Some older groups may still be militant about not using anything other than the program to quit, but in general, prescribed medications for psychiatric conditions are now accepted, and in fact the majority of meeting attendants are likely taking some medication. There may be more resistance to medication-assisted treatment, such as methadone for opioid use disorder. If patients are nervous about this issue, I might advise a “don’t ask, don’t tell” approach.