For people entering recovery, whether on an inpatient or outpatient basis, or some option in between, it is highly likely they will be encouraged to attend a 12-step group such as Alcoholics Anonymous or Narcotics Anonymous. In fact, many facilities and therapists require participation in these types of programs.
A 2014 study found that nearly 80% of clinicians surveyed had referred clients to 12-step groups, which are also routinely mandated by the judicial system for individuals convicted of offenses involving alcohol or illicit drugs.1 A 2013 paper in Social Work and Public Health reported that approximately 5 million people in the US aged 12 or older attended a self-help group for substance use issues.2 AA membership has expanded continually in the past 4 decades; it has an estimated 1.4 million members in the US and Canada, and 2.1 million worldwide, with roughly 64 000 and 114 000 groups, respectively. Membership in Narcotics Anonymous and Cocaine Anonymous has increased as well.
As the number of attendees continues to grow, there remain several points of contention that have been raised in recent years. “Essentially, the criticism of 12-step programs is that it is a one-size fits all approach to a complex problem, and it also it seems out of touch with an emerging science-based approach towards a disease that grips the brain” according to Jeffrey Cohen, LPC, a psychotherapist and addiction specialist in Smyrna, Georgia. The slogan “It works if you work it” can be demoralizing due to the implication that those who are unable to maintain abstinence simply are not trying hard enough, when the reality is that “success rates are not high with any approach to addiction treatment, even residential or partial hospitalization with medication management, and they are even lower with 12-step alone,” Cohen told Psychiatry Advisor.
Twelve-step groups have long been presented as the only viable option, in large part because they were the only one available and are often effective, but Cohen has seen the options expanding as research emerges on other effective approaches.3
One topic of criticism is the relative dearth of scientific evidence regarding the efficacy of 12-step programs, though some have linked it with better recovery outcomes such as longer periods of abstinence.4,5 Melanie Storrusten, LCSW, a psychotherapist in private practice in Atlanta who specializes in addiction, pointed out that research on success rates for any treatment approach is difficult and is made especially so by the anonymous nature of 12-step groups. “What we do have is anecdotal evidence of the many people that groups like AA have helped, including many within the treatment industry, who are now providing treatment,” she told Psychiatry Advisor.
Additional elements of 12-step participation that can evoke resistance include the focus on spirituality and a “higher power,” the requirement that an individual identify as an addict, and the amount of time typically involved, Storrestun noted. Some people get past the initial discomfort while others do not, and she believes that response is warranted in some cases. However, in therapy she would “want to explore the real reasons for their discomfort with anything that might be supportive to their recovery–is this a true issue of goodness of fit, or is it avoidance?” she said.
Despite such issues, she and Cohen are advocates–albeit objective ones–of 12-step groups, as they have proven to be effective for many individuals. Cohen is a “big fan of 12-step programs and think that the community and the moral inventory required are essential for most people’s recovery, but I think there are plenty of people who are able to find community and reflection from a variety of sources,” he said. Storrestun recommends 12-step attendance to patients because of the powerful benefits she has observed, and it offers a widely accessible support group with common principles. “There is research that shows the value of enhancing connection, attachment, healthy relationships, and meaning in our lives in regard to success in recovery–these are things that I think the 12 steps provide that some more medical models lack,” she said.
She also recommends alternatives, including Refuge Recovery, SMART Recovery, yoga, meditation, fitness, and engagement with a spiritual community of some kind. “Anything that works for my clients and is supportive of their recovery, I’m a fan of,” she said. Further possibilities include Secular Organizations for Sobriety and Women for Sobriety. Moderation Management is another program, though controversial in its own right, and Cohen noted that he is strongly against any approach that endorses moderation “because it just does not seem to work.”
Storrusten suggests that clinicians explore available options firsthand in order to optimally guide patients toward the best fit. Web listings for 12-step meetings will indicate whether they are open or closed to visitors. “It’s a great experience not only to get familiar with meetings so you can talk them through with your clients, but also to gain some insight about what it feels like to walk into a meeting for the first time, which is what we are asking our clients to do,” she explained.
“I believe that the best care is individualized care. And the most effective approach is sometimes whatever the patient will actually do,” she concluded.
1. Wall R, Sondhi A, Day E. What influences referral to 12-step mutual self-help groups by treatment professionals? Eur Addict Res. 2014;20(5):241-7.
2. Donovan DM, Ingalsbe MH, Benbow J, Daley DC. 12-Step Interventions and Mutual Support Programs for Substance Use Disorders: An Overview. Soc Work Public Health. 2013;28(0): 313–332.
3. Mendola A, Gibson RL. Addiction, 12-Step Programs, and Evidentiary Standards for Ethically and Clinically Sound Treatment Recommendations: What Should Clinicians Do? AMA Journal of Ethics. 2016;18 (6): 646-55.
4. Timko C, Debenedetti A, Billow R. Intensive referral to 12-Step self-help groups and 6-month substance use disorder outcomes. Addiction. 2006;101(5):678-88.
5. Manning V, Best D, Faulkner N, et al. Does active referral by a doctor or 12-Step peer improve 12-Step meeting attendance? Results from a pilot randomised control trial. Drug Alcohol Depend. 2012;126(1-2):131-7.