What makes the 12 steps (and other social support groups) a good part of addiction treatment aftercare?

I’m not a devout 12-step believer, though I think that AA and the offspring programs have some serious merit, especially when it comes to addiction treatment aftercare. In this discussion, I’m talking about all group-support based programs, including Smart Recovery and others. I’m personally a fan of non-religious groups, but that’s just me.

Chronic conditions require long term care

I’ve already talked about my view of addiction as a long-term, chronic condition. Regardless of the “disease” moniker, I think it’s undeniable that, at least for some people, addiction treatment needs to continue long past their initial “quitting” phase, regardless of whether they went through an inpatient or outpatient treatment (or quit alone at home).

Without getting hung-up on my misgivings about 12-step programs (I have a few), I’d like to talk about some of the factors that make me believe in the system as a continuous aftercare resource:

  1. It’s free – Most people, especially given current insurance limitations, can’t afford ongoing outpatient help be it through a psychologist or an addiction-treatment provider. While the latter two are can be superior in their knowledge about recent developments in addiction, they cost money.
  2. It normalizes behavior – One of the difficulties many addicts share is in talking to non-addicts about their problems. They feel ashamed, misunderstood, or judged. Being with like-minded individuals can eliminate some of those issues. Nevertheless, people often find understanding only regarding the specific issue a program deal with and therefore find they need to attend many different support groups to address all their issues.
  3. It provides ongoing support outside of meetings – The social connections people make in meetings can often help them outside the rooms. Your psychologist isn’t likely to do the same.
  4. It keeps the focus on relevant issues – When following the 12 step rigorously, one is always working on bettering his/her program. That sort of attention can help catch problems early on before they develop into real difficulties.
  5. It keeps people busy – Some addicts need to stay occupied to keep out of trouble, especially in the transition from their acute treatment back to everyday life. Attending social-support meetings can make the time go faster while providing a relatively safe social environment.

Even with all these advantages, I can’t help but object to some of the AA dogma, especially when it comes to religion and to the unwavering resistance to adapt their system as it was handed down in the late 30s. We’ve learned a lot since and I think 12-Step programs could benefit greatly by incorporating recent knowledge. In fact, reviews of studies regarding the effectiveness of AA find it no more useful than other interventions overall. This is why I believe that 12-Step programs are best used along with, and no instead of, additional treatment options.

Citation:

Cochrane Review – Alcoholics Anonymous and other 12-step programmes for alcohol dependence

18 Replies to “What makes the 12 steps (and other social support groups) a good part of addiction treatment aftercare?”

  1. I converted to atheism during the course of my recovery and I’ve got to say that 12-step meetings are the only place I “come out.”

    I generally do that only when a newcomer is worried that the steps aren’t for them because they do not or cannot believe in God, because most of the time, it’s just not that relevant.

    You WILL have to tolerate hearing a lot of god-talk. That can be the “I’m different” hook that hinders recovery. Maybe that’s easier for me since in my 12-step fellowship we regularly replace the word alcohol and alcoholic for lust and sexaholic in the AA Big Book.
    .-= GentlePath┬┤s last blog ..Self Care =-.

  2. An interesting review of the theoretical basis for substance use treatment modalities suggests these active ingredients [1] bonding with a social network of abstinence-oriented peers {social control theory}; [2] engaging in religious or spiritual pursuits {behavioral choice theory, specifically by new activities that offer rewards alternative to substance use}; [3] coping skills for sober living {social learning theory} and [4] enhanced self-efficacy {stress and coping theory}. [See Moos RH. Theory-based ingredients of effective treatments for substance use disorders. Drug Alcohol Depend 2007;88(2-3):109-122].

    Regarding ingredient #2, it’s regrettable that the “God-talk” becomes a stumbling block given evidence supporting meditation (with or without theological trappings) as a valuable facilitator of recovery.

    Especially in large cities, 12-step groups have formed specifically for atheists/agnostics; when “open-mindedness” and “willingness” are not enough, maybe those are valuable sanctuaries for the doubtful.

  3. Both comments are great. Gentle, there’s no doubt that “coming out” as an atheist is 12-step meetings can be hard. Michael, I love that comment so much I want you to start writing for us! Here are my thoughts back:
    1) There’s no doubt that bonding with others who are focused on abstinence is important for people in recovery, especially early on. I think the focus on abstinence along goes a bit far in some groups as people focus on the problem, and not the solution.
    2) I like the notion of engaging in new reward alternatives. The notion that these have to come from spiritual/religious pursuits bothers me, but that could obviously be my own issue. I think that educational, vocational, and related opportunities could also work here.
    3) Coping skills are important, viz CBT and modeling of others who are behaving well (like in these social support settings).
    4) Self-efficacy improvement could come via proper provision of 1,2, and 3.

    I’m going to look in to that article though whenever I have a chance.

  4. I’m what you might call a late bloomer addict – and was actually in a highly intensive PhD program when got caught up in illicit drugs. When they first pushed AA on me at my first stint in rehab, there was no way I was going to buy it without the research to back it up. It eerily reminded me of a cult, the rituals, the whole if-you’re-not-with-us-you’re-against-us mentality. What I came to realize though is that the reason why AA “appears” to work is because there are very little, or no alternatives in most parts of the country (especially the Bible Belt). In my opinion, the actual 12 steps have nothing to do with AA’s success – simply put, it offers community (and a non-paid one at that) which instills accountability, and a “safe” place where you can discuss your concerns about your addiction. As I’ve told one too many addiction counselors – if AA really worked, why is it so important that people find the “right” AA meeting? Finding the “right” meeting means finding the right people you can open up to, in my opinion. Despite the lack of alternatives, I have found smart recovery to be one of the best in terms of a non-religious yet non-profit group.

    I’ve avoided having to go to AA meetings despite legal troubles by citing a Supreme Court ruling that requiring people to go to AA is unconstitutional due to its religious foundation. No citation, sorry – but googling will probably pull it right up.

    I am outspoken about this issue, and I’m glad to see that someone else is also questioning the one-size-fits-all mentality of rehab aftercare.

    1. Great input Chloe. Thanks!

      I myself have some trouble with the 12-step religiosity, but I find that most groups will let you simply ignore that part of the program. I certainly think that it’s time for more progressive programs to take hold and Smart Recovery is a good alternative.

  5. Adi, Your responses are unfailingly kind, enthusiastic, and open-minded. Mine will counterbalance that. Chloe’s comment is a perfect example of “contempt prior to investigation.”

    It’s false that there’s no evidence of the efficacy of AA. Literally thousands of research studies later, there’s a strong scientific consensus on its benefits. [See, for instance, William White’s careful review in Peer-based Addiction Recovery Support at http://www.atforum.com/addiction-resources/documents/2009Peer-BasedRecoverySupportServices.pdf%5D.

    There are also much more sophisticated evaluations of the “therapeutic” ingredients associated with 12-step programs than the simplistic single one that Chloe mentions [see for example the Moos article mentioned above].

    Even without the complex apparatus of psychosocial theory, focusing only on fellowship misrepresents the nature of 12-step programs, all of which emphasize three components of engagement: participation in the fellowship, working the steps, and helping others. There are multiple reasons for suggesting people attend various meetings to find those that feel comfortable, including the importance of hope that’s inspired by being in a room with those whose sobriety one respects and/or admires, and finding an admirable and compatible sponsor to serve as a guide to working the steps.

    Chloe may have spoken with “one too many addiction counselors,” but apparently not enough to know that no well-trained counselor considers 12-step programs of any flavor the only path to recovery or the only means of remaining clean and/or sober.

    On the issue of religion and spirituality, they’re different. Almost all 12-step programs [except those explicitly Christian based, which identify as such] deliberately eschew religious dogma and, in my experience, there’s a tremendous discipline in meetings about avoiding getting into doctrinal disputes or even discussions even when people make reference freely to their higher power.

    One of the remarkable features of 12-step programs is the large fraction of agnostics and atheists who find them effective ways to address universal spiritual questions [of purpose, meaning, one’s place in the ‘grand scheme of things,’ etc.]; after all, the Big Book expressively traces Bill’s own journey from rationalistic agnosticism to faith. [My own favorite account is “A Skeptic’s Guide to the 12 Steps” by Phillip Z.].

    For those who prefer a non-theistic approach, there’s a long shelf of books that describe ways to integrate Buddhism into 12-step spirituality, and you can even subtract the word “Buddhism” and find mindfulness meditation-based approaches.

    On the “if you’re not with us, you’re against us,” that sounds like projection. Certainly such dogmatism contradicts the explicit principles of 12-step programs. Having attended hundreds of meetings and having listened to nearly as many 12-step speaker tapes, I’ve never heard anything like that sentiment expressed.

    Fellowship members do often interpret relapse as a consequence of not “working the program,” and that does start to seem tautological until you listen to people who have relapsed talk about what happened and why, who interpret it the same way.

    It’s fascinating how fast the fever pitch of dissent can reach the boiling point [which releases so much vapor]. Would so many words be wasted debating whether my preference for butter almond ice cream trumps your fondness for pistachio [or, ohmygosh, vanilla]?

    My own temperature rises because ill-informed appraisals do a disservice to suffering addicts looking for a way up and out: 12-step programs aren’t the only way, but for many they are a way, and we ought not condone closed-mindedness or misrepresentation.

    Specifically with regard to Smart Recovery, the underlying theoretical framework also is supported by reasonably convincing research. It remains to be seen whether that approach and other [SOS, Rational Recovery, Moderation Management] will prove to be scalable.

    In the meantime, it’s interesting to note that while all 12-step programs deliberately sidestep controversy [Tradition 10] Smart Recovery literature is deliberately partisan e.g., http://www.smartrecovery.org/resources/library/Articles_and_Essays/Rational_Thinking/How_to_Work_It.pdf%5D except that SR also seems to need the mystique of 12 it its “twelve principles.”

    1. Hi Michael,
      As I’ve written before, I think 12-step, and other similar groups, offer a great service for addicts. I may disagree with you a bit when you say that “no well-trained counselor considers 12-step programs of any flavor the only path to recovery.” While this should be the case, I’ve met many 12-step oriented counselors who used their own views and dogma to “persuade” people that the 12 steps are the way.
      Additionally, I agree that one needs to try many meetings in case specific ones seem a bad fit; still, this seems a pretty convincing piece of evidence regarding the strong role of fellowship in the program as, supposedly, the manual to be used shouldn’t change between meetings.
      Lastly, it’s the dogmatic insistence on the Big Book of Alcoholics Anonymous as an essential “Bible” that bothers me a bit, but that could easily be my own projection regarding religious organizations. There’s little doubt in my mind that like religion, AA and other related groups have helped millions of people but I think it’s due time we made other, equally effective, fellowship and social-intervention-based programs widely available.
      As long as we agree that different people need different solutions and it is our work, as professionals in the field, to make every tool as available as its evidence warrants, we’re playing for the same team.

  6. Sorry, responding late. This is a response to Michael:

    I am neither an atheist nor do I consider myself a non-spiritual person – but I have always believed that my struggle with spirituality will, and should be, separate from my struggle with recovery. The fact that the two are so tied together in the AA context is what makes me skeptical.

    (By the way, I will read that article you linked – seems fascinating, but just wanted to preface by saying I haven’t read it yet)

    I may have been harsh in my words, so let me back up a bit… AA works, but not for everyone. It is also true that there are not a lot of alternatives to AA, nor are any offered alongside AA in terms of recovery groups. When AA -doesn’t- work, often times, it is assumed that the person has not really worked the program, and no alternative is presented.

    You say there is scientific basis for the efficacy of AA programs – and I have also done my research. Most of these studies look at AA versus nothing. A truly balanced study would include alternatives to AA in their study, while also controlling for such factors (that may be inclusive in AA but by no facts exclusive) community support, regular meetings, etc. Would the effect size be quite as large as you purport were these factors taken into account?

    My point in terms of looking for a good fit with an AA meeting was in suggesting that maybe it’s not the doctrine that’s helping, but the -community- aspect of the program. Also, I have read somewhere (sorry, I don’t keep citations, but I can find it) that AA on the national level has always rejected any systematic research into its program, at its statistics, etc.

    The program has not changed in many respects from what it was over 70 years ago. I know of no other “disease” in which no progress has in made in terms of treatment, nor in which the course of treatment hasn’t been tweaked in some way. A recovery system should be constantly evolving, taking into account new research, technology, etc.

    AA definitely works for a subset of people – but people who have an external locus of control versus an internal locus of control. For those with an external locus, the program, I believe works. This is exactly what they need when everything starts falling apart around them. On the other hand, for those who have the latter – it doesn’t matter how much we try to look outside ourselves, because we inevitably hold ourselves accountable for everything – including our inability to give over to a higher being or to “powerlessness”.

    Personality traits like this cannot be changed – these are stable, biological factors that are incredibly hard to change. (I think the percentage of people whose personality traits do change is maybe 5%). Instead of working with these differences, AA often tries to force people into a mindset that is next to impossible for some people to adopt.

    There never is an explicit “you’re against us” sentiment in AA groups – but there is definitely pressure, whether overt or covert on the part of the group to align with their ideology.

    Again – AA works for some – but not for all.

    http://www.time.com/time/health/article/0,8599,1872779,00.html?iid=digg_share

  7. We’re in agreement that AA works but not for everyone. A nearly vacuous statement. The way to move this futile back-and-forth forward is to further acknowledge a lack of community recovery resources for aftercare other than 12-step programs and to ask ourselves what to do to mitigate that regrettable reality. As it evolves, this website could serve a valuable purpose by expanding its mission to encompass such resources as well as facilitated access to appropriate treatment programs, an immediate priority.

    But the problem remains that such resources generally are absent. The de facto near-monopoly of 12-step programs stems partly from the pragmatic factor of cost: to the extent that other approaches depend upon professionals they don’t seem to be self-supporting through participants’ voluntary contributions. Another factor is structural, and intrinsic to the contrast between conventional organizations and the 12 traditions that guide 12-step programs: the latter depend upon participants’ engagement with the pivotal concept of service and the associated quasi-evangelical mandate to “carry the message.” “Graduates” of Rational Recovery, Smart Recovery, and Moderation Management principally aspire to return to a “normal life” of “business as usual.” In other words, understanding the pacity of 12-step options requires looking not only at the disparate benefits and appeals of other recovery resources but also thinking about the socio-economic considerations.

    I disagree with Chloe’s characterization of the existing effectiveness research, though I think it’s problematic for other reasons mentioned below. Even if her claims were viable, it seems contradictory to bemoan the lack of aftercare alternatives to 12-step programs while complaining about studies that contrast 12-step programs with nothing — the unfortunate reality in many localities.

    On the the preceding topic as well as that of locus of control, what this blog needs is a moderator committed to refereeing the scientific validity of its opinionators’ claims.

    I’m no social psychologist but my cursory scan of the literature suggests that locus of control is not as stable over the life course as Chloe claims, even absent the impact of potentially dramatic experiences (e.g., early recovery) that might alter it. It also suggests the opposite of what Chloe claims: that, if anything, retention and outcomes are superior among 12-step participants with an internal locus of control. The issue is clouded by the usual suspects: differing assessment instruments, populations, outcomes, follow-up periods, etc.

    The central problem in discussions of 12-step program effectiveness is Implicit in Chloe’s complaints. Although AA came into being as a last resort, the only alternative to “jails, institutions, and death” for alcoholics who were otherwise “beyond human aid,” (i.e.., the ministrations of available medical, psychiatric, and religious efforts), its open-door membership criterion has made these programs the dumping ground of first resort for anyone with a drug/alcohol problem. As a result, they include a large population, maybe a majority, of participants who never make it past Step 1 (for instance, because their “internal locus of control” prevents them from acknowledging their powerlessness over drugs or alcohol). Thus, at least in terms of its own literature, arguably the only population that should be evaluated in studies of 12-step effectiveness are those for whom all other moderation or abstinence efforts and interventions have failed.

    Were that to be the entry criterion for study participation, then comparisons between 12-steps and such failed strategies would be unethical. In practice, study populations are more heterogeneous and include those who, like Chloe, declare themselves “in control” and eschew the spiritual side of 12-step programs. (Ask a devotee of such programs what the other side{s} are and the response may well be a vacant stare or puzzled silence. But some participants seem to sustain abstinence exclusively through engagement with the fellowship; given the abundance of 12-step programs and the diversity of meetings within each fellowship, it must take a special sort of selectivity to find no group sufficiently appealing to sustain interest.)

    More technically, there are fundamental distinctions between treatment (DSM-IV-TR) and 12-step formulations of alcoholism/addiction that have the same effect: evaluating 12-step outcomes among populations that may include large subsamples for whom these programs lay no claim to offer help. In the world of the DSM, substance depedency is based essentially on 3 questions:

    > Over time, did you require more of the substance to achieve the same effect? [Tolerance]

    > When you stop using the substance, do you experience severe discomfort? [Withdrawal]

    > Do you find yourself continuing to use despite severe negative consequences associated with use?

    In 12-step terms, the defining questions for alcoholism/addiction are:

    > When you want to stop, can you stay stopped? [Obsession]

    > Once you start using, can you control or moderate your intake? [Craving]

    > When past early recovery, does life become more miserable, not better. [Spiritual malady]

    Consider the term “craving”: in 12-step terms, craving only occurs once use has begun or resumed; in the treatment/DSM world, craving refers to a commanding urge to use while clean and sober (which 12-step language characterizes as the “mental obsession”).

    Because 12-step programs deliberately refrain from conducting research and avoid “public controversy” by refraining from “opinions on outside issues,” they are unable to influence the construction or interpretation of research on 12-step effectiveness so as to assure that studies are conducted among populations they purport to help. This corresponds to their open door policy which uses the most inclusive possible definition of membership. Those policies seem to have served 12-step programs well. People whose personal distaste or uninformed opinions discourage open-minded exploration of what those programs may offer serve addicts poorly.

    1. Wow Michael, quite a bit to work with here. Always good to have informed readers and comments!

      On the topic of a moderator, like AA, my work is done for free, so if you can find a scientifically-knowledgeable individual who would be willing to put 20-30 hours of work per week into making sure that the discussions on the site are balanced, I’ll be open to considering it. Assuming that’s not going to happen, the internet is fortunately a relatively free, democratic, medium and people are free to come and comment when they think I, or someone else on this site, is wrong.

      On the issue of locus of control, I’ve also seen a poster at some conference looking at this and it did indicate that AA attendees are more “external” than “internal,” still, an examination that compares AA members to members of other groups would be preferred and here’s one that indeed finds AA members to be more “external” than members of Smart Recovery It’s a small study, but I couldn’t find anything more comprehensive that directly compares AA to another group. Another study did find that individuals with internal, rather than external, locus of control fared better in treatment, so do with that what you will.

      On the topic of cost, I agree that there’s nothing better than AA at the moment, and this is, in my opinion, the reason for its immense popularity. I also agree that the broad population makes conclusions difficult to make, something that some more systematic research could untangle, though as Chloe mentioned, in-depth studies of AA and similar programs is difficult.

      Lastly, I think that some of the aspects of DSM dependence criteria you left out are important, especially since 3 out of 7 criteria are needed and you only mentioned 3. Two of the other 4 seem to closely mirror the 12-step definition you supply: 1) there is a persistent desire or unsuccessful efforts to cut down or control substance use 2) the substance is often taken in larger amounts or over a longer period than was intended. Not surprisingly, there is no spiritual-malady parallel in the DSM. Still, I think the DSM definition is pretty comprehensive, and it seems that based on your characterization of the 12-step way of thinking, is relatively inclusive.

      Okay, I’m running close to those 20-30 hours. Time to get on with my other work.

  8. LOCUS OF CONTROL: On the issue of locus of control and 12-step group involvement, another source worth gnawing on is Laudet AB et al. Predictors of Retention in Dual-Focus Self-Help Groups. Community Mental Health Journal, 2003;39: 281-297 [http://www.professored.com/index.php/publications/double-focus/predictors-of-retention-in-self-help-groups?format=pdf]. To measure “recovery self-efficacy,” they adapted a well-standardized scale for internal health locus of control and found that higher scores correlated with higher retention and better outcomes. The discussion “address[es] what may be an apparent contradiction between self-efficacy to recover and engaging in a recovery program that requires one begins by admitting ‘powerlessness’… [i.e.,] the inability to change by relying solely on one’s willpower.” The authors suggest that affirming powerlessness dispels “group members’ ‘sense of agency’ while encouraging realism about personal limitations. Thus, while admitting powerlessness over one’s problem is the first step toward recovery, the program puts forth a set of steps that offer hope that recovery is attainable as well as tools to support recovery.”

    We can agree that all the citation-mongering in the world will not resolve this issue definitively, given the current state of the science. Moreover, I’m not sure it’s ultimately a fruitful way to conceptualize one’s suitability for obtaining benefits from 12-step participation, which is probably better assessed by sampling a variety of relevant fellowships and, within them, a diversity of meetings. In doing so, as step study speaker Sandy B. of Washington DC points out [http://xa-speakers.org/pafiledb.php?action=category&id=28], the most important thing may be listening and looking for those members whose sobriety/recovery seems admirable, as a way to make inferences about potential benefits of participation.

    EFFECTIVENESS RESEARCH ENROLLMENT CRITERIA: My general point probably became obscured by the minutiae: I think that one of the major problems with outcome research on 12-step program participation is defining the relevant population. I would hypothesize that using convenience samples — or even more rigorously delimited samples based on DSM-IV-TR criteria for substance dependency — include sizable fractions of participants who are not — within the conceptual frame of the “big book” or the NA basic text — alcoholics/addicts.

    To subject 12-step programs to the test of effectiveness for a more heterogeneous population of persons who qualify as substance dependent may be pertinent from a policy perspective, but it’s not a meaningful way to evaluate whether those programs benefit the population they profess to serve.

    I think we all concur that it is relevant, from a policy perspective, to better characterize those most likely to benefit from 12-step programs and to identify and make available suitable options for everyone else (e.g., those who can’t get past Step 0, and those who wish to “continue their research” into controlled use). Certainly, there are 12-step group members who would welcome the departure of pre-contemplators and others who are ambivalent from their meetings. [There may be no more memorably vociferous proponents of such sifting or self-selection than AA/CA speakers Chris R and his twin brother Myers {http://xa-speakers.org/pafiledb.php?action=category&id=5}].

    DEJA-VU ALL OVER AGAIN: In the midst of this latest exchange, I happened to be reading Ernest Kurtz’ wonderful history of AA, “Not-God,” which refers to a flurry of critical articles written about 45 years ago. They make this back-and-forth seem tepid by comparison. My favorite is Arthur Cain’s “Alcoholics can be cured — despite A.A.” [http://silkworth.net/aahistory/harpers_mag1963.html].

  9. A postscript to the previous post: As I noted in an initial comment, responses to 12-step meetings are a bit like taste preferences: some like strawberry, others chocolate, others vanilla … and still others would rather have peanuts or potato chips. For me, meetings were definitely an acquired taste. I thought it might be helpful to describe how I came to acquire it. The resulting narrative appears on a website associated with Crystal Meth Anonymous at this URL: http://cmainla.blogspot.com/2010/06/meetings.html

  10. I am a addiction therapist, for 25 years, and a clinical director of a rehab. Now I manage the drug program for the NFL plus I do addiction therapy. I have been on all sides of this issue.
    The problem in this discussion should stay with the title of the thread, why do 90% of professional treatment programs (ptp) claim a 12 step modality as a treatment philosophy.
    AA and its program are not the problem, it is the owners and ceo’s of the ptp that claim a self help philosophy as professional!!!!!!!
    There are so many wrongs done behind this. First and last it is unethical to promote espouse and coerce people in rehab to 12 step. The ethical responsibility is for a counselor to accurately describe ALL self help groups and their resources. The rehab has 12 step posters everywhere, give a Big Book and other literature from AA, and that is unethical. If the higher court in New York ruled that rehabs cannot force an AA meeting on people un less they have an appropriate alternative at the same time. If that is a law, why doesn’t the program that states “we are based on 12 step philosophy”, allowed to to use it to cover all of treatment?
    Andy

    1. Thanks for your great comment Andrew,
      Hopefully you see that I fully agree with you. The 12 steps are only one of many options for self-help or even for professional help aftercare. As you pointed out, the 12 steps themselves are NOT the work of rehab, although 12 step facilitation has been shown to work for some people, it should always be part of multiple options. Like I say over and over: Doctors offer patients multiple treatment options if they exist, but in addiction we got so used to each provider offering only one kind of help we think it’s normal. It is most certainly not.

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