12 Step Programs

by Brian Dunning
July 15, 2014

In 1935, Alcoholics Anonymous was formed by two men struggling for sobriety, Bill Wilson and Bob Smith. Theirs was a new type of program in that it formalized a series of twelve steps that an alcoholic must follow in order to get sober and stay that way. The original Alcoholics Anonymous was only the first of many such programs set up to address just about every type of addiction and obsessive behavior you can think of: Overeaters Anonymous, Marijuana Anonymous, Underearners Anonymous, Sexaholics Anonymous, Clutterers Anonymous, Gamblers Anonymous, and even Online Gamers Anonymous. Today we're going to look a bit into the history of twelve stepping and also how it compares to mainstream psychological treatment of addiction, but mainly into the most important question: Does it work?

It's impossible to discuss the history of the twelve steps without acknowledging that it is first a religious practice, and second a recovery method. Seven of the twelve steps invoke God. This is the main thing that separates it from medical or psychological addiction treatments that are primarily targeted at the biochemical and psychological causes of addiction. So let's get started by reviewing the actual twelve steps, and these are the steps as published by Alcoholics Anonymous:

1. We admitted we were powerless over alcohol — that our lives had become unmanageable.
   
   
2. Came to believe that a power greater than ourselves could restore us to sanity.
   
   
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
   
   
4. Made a searching and fearless moral inventory of ourselves.
   
   
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
   
   
6. Were entirely ready to have God remove all these defects of character.
   
   
7. Humbly asked Him to remove our shortcomings.
   
   
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
   
   
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
   
   
10. Continued to take personal inventory, and when we were wrong, promptly admitted it.
    
    
11. 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.
    
    
12. 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.

Wilson and Smith were both from an evangelical Christian organization called the Oxford Group, and the twelve steps they formalized were reminiscent of practices from the Oxford Group. It had standards it called the Four Absolutes (honesty, purity, unselfishness, love), a set of four spiritual practices, and the "Five Cs" procedures: confidence, confession, conviction, conversion, and continuance. Thus, salvation through evangelical Christianity was deeply interwoven with the concept of twelve stepping. In the words of Bob Wilson:

"...Early AA got its ideas of self-examination, acknowledgment of character defects, restitution for harm done, and working with others straight from the Oxford Group and directly from Rev. Sam Shoemaker, their former religious counsel in America, and from nowhere else."

Because of this, twelve step programs have been strongly criticized, usually by people who dropped out of the programs for one reason or another, and became disgruntled. Some have written books and devoted whole websites to the idea that twelve stepping is just a bait-and-switch program; come to stop your addiction, but stay to join our church. It's the same criticism that's been leveled at Scientology's Narcanon; it promises to help you get off drugs, but is in reality just a side door into the Church of Scientology.

Twelve step programs, however, have no central church. They're nearly always run by Christian groups, but there is no one specific church into which its followers are funneled. However, at this point in the discussion, we're seeing how an analysis of twelve step programs can so easily become derailed. To determine the validity of a therapy, we don't only look at its founders and their motivations or beliefs; instead, we have to look at the data of whether or not the therapy works. Too often, critics will dismiss twelve stepping as "just a religious practice" without even considering the effectiveness of its other goal: to help you stop your addictive behavior.

Significantly, perhaps the most impactful aspect of a twelve step program is a part of it that has nothing to do with the twelve steps: the support group that goes along with it. Twelve step programs such as Alcoholics Anonymous meet regularly; many of them have daily meetings available and participants attend as many as they want. This facet of such programs may play a much more important role than the steps themselves. To see whether this is the case, let's take a look (for comparison purposes) at the latest and greatest science on addiction recovery, at least according to the United States' National Institutes of Health's National Institute on Drug Abuse. It's complicated and an effective treatment is likely to be different for every patient:

Because drug abuse and addiction have so many dimensions and disrupt so many aspects of an individual's life, treatment is not simple. Effective treatment programs typically incorporate many components, each directed to a particular aspect of the illness and its consequences. Addiction treatment must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society. Because addiction is typically a chronic disease, people cannot simply stop using drugs for a few days and be cured. Most patients require long-term or repeated episodes of care to achieve the ultimate goal of sustained abstinence and recovery of their lives.

The basic approach is usually two pronged, incorporating both medications and behavioral treatment. Medications have two basic purposes in the treatment of addiction (in the case of drug addictions). First, to ease the symptoms of withdrawal, which might otherwise be too intense. But getting through withdrawal only gets you so far. The physiological component of a chemical addiction is very real; normal brain function is messed up. Chemical receptors are hungry, producing the cravings that overwhelm many addicts' desire to get sober. Medications can act on the same targets within the brain as the addiction chemical does, and thus ease the brain away from the addiction and dramatically reduce cravings.

And, even after this second phase of medication, true addicts will succeed best with therapy. This has to be tailored to every individual, and usually involves a combination of cognitive behavioral therapy to help patients change the behavior that got them into the drug situation to begin with; family therapy to address the family dysfunction that so often results from addictive behavior; and motivational interviewing and incentives that encourage the patient to want the benefits that come with abstinence from the problematic behavior.

This treatment overview offered by the National Institute on Drug Abuse conflicts sharply with the principles of twelve stepping on one important point. Frank Buchman, founder of the Oxford Group, said:

"Only God could change a person, and the work of a 'life-changer' had to be done under His direction, which alone could provide the sensitivity and flexibility required."

Proponents of conventional treatment would not be likely to agree. Obviously there has to be some responsibility on the addict himself; and it's also crucial to allow other inputs such as behavioral therapy and medical treatment when needed. It's neither appropriate nor helpful to say only God, and God alone, can or should address this problem. Nevertheless, twelve step programs have a pretty good track record for keeping people off of drugs for a longer time. How could this be, if the basic principle is unscientific?

It appears that twelve step programs may, to some degree, succeed in spite of themselves. Why? Because, religious or not, they do provide an active support group; and support groups are usually (though not universally) found to be associated with better success rates. This has been studied a lot, but not so much that any overwhelming consensus has emerged. It's possible to find a study that supports almost any point you might want to make about addiction recovery and about twelve step programs, but there are some trends. Let's look at some of the most obvious questions to ask.

Do addiction recovery programs work?

Some studies find that addiction recovery programs, of every kind, work no better than doing nothing. You can go cold turkey on your own, or you can even continue living with your addiction; and your outcome is likely to be no better than the outcomes of people who enter recovery programs. But a larger number of studies find that the opposite is true: people who take active steps to end their addiction will fare better, on average, than those who do nothing about it.

Does group therapy improve outcomes for recovery programs?

Yes. When people do abstain, their period of abstinence lasts longer with regular group meetings; but they also fare better with one-on-one counseling or with any type of meetings. The type and size of group makes little difference. Here's what the National Institute on Drug Abuse has to say:

Most drug addiction treatment programs encourage patients to participate in self-help group therapy during and after formal treatment. These groups can be particularly helpful during recovery, offering an added layer of community-level social support to help people achieve and maintain abstinence and other healthy lifestyle behaviors over the course of a lifetime.

Do twelve step programs have better outcomes than other group therapies?

No. Although plenty of studies disagree, the majority seem to find that it's the regular meeting process itself that makes the difference, not what happens at the meetings, or whether they are twelve step. Interestingly, a small number of groups can be counterproductive and lead to earlier relapse.

Do twelve step participants who are already religious fare better?

Yes, they do. Secular people are significantly less likely to stick with a twelve step program than they are with a non-religious program, and vice versa. This is right in line with what seems self-evident; people are more likely to stick with a program that affirms their existing beliefs or is in line with their existing interests.

So even though there are a lot of studies with a high noise level from the past half century, we can still form a pretty good answer to the question of whether twelve step programs work. If you have an addiction, then you are probably better off seeking a treatment program than you are doing nothing. You're probably better off starting with a full medical intervention. And from there, the road forks: If you're an evangelical Christian, your best chance at recovery is to enter a twelve step program; and if you're not an evangelical Christian, then your best chance is to go with a community support program that is not a twelve stepper.

By Brian Dunning
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