People who know me well will be surprised to find that I’m writing in defense of Alcoholics Anonymous (AA).
After all, more than a decade ago, I wrote a book (Sober for Good) with chapter headings including, “There’s Not Just One Way;” “You Don’t Have to Hit Bottom;” “It’s Not Necessarily One Day at a Time;” and “With or Without a Higher Power” – all of which could be seen as an affront to AA. And my latest book, Inside Rehab, “takes on” the traditional addiction treatment industry for its one-size-fits all approaches – often weighted with principles from AA and its 12 steps – for failing to tell clients about AA alternatives, and then offering the very same treatment time and again instead of changing it up when clients have a recurrence of their substance use disorders.
Yet I can’t deny that countless people have been helped by AA.-Anne Fletcher
I continue to stand by all of this, and over the course of the near-decade I spent researching and writing both books, I’ve received and continue to receive numerous personal accounts of individuals harmed by experiences at AA or 12-step-based treatment.
Yet I can’t deny that countless people have been helped by AA. When recruiting Sober for Good participants (individuals who had at least five years of sobriety, achieved by any means whatsoever) AA recoverees came out of the woodwork – more than I could begin to include in the book. I recruited them by leaving flyers in such public places as airports, salons, and on public bulletin boards, as well as through the Internet, the book review section of The New York Times, and approaching AA alternative recovery groups. In my work now, I frequently encourage individuals to give AA (or Narcotics Anonymous [NA]) a try, urging them to shop around at different groups, as well as to try alternative groups such as SMART Recovery, Women for Sobriety, Secular Organizations for Sobriety, and LifeRing.
Moreover, as a scientist at heart (and through my training), I really can’t discount research that runs contrary to much of the negative information I keep seeing in the media about AA. I’m referring to unfounded single-digit estimates of AA’s success rate and exaggerated statements about its harms, as well as misunderstanding about research involving AA, how it’s used in various settings, and who’s responsible for the problems attributed to AA as an organization.
…Alcoholics Anonymous has become the proverbial elephant described by unsighted examiners.-William Miller and Ernest Kurtz, 1994
Back in 1994, scholars William Miller, Ph.D. (co-author of Controlling Your Drinking and Motivational Interviewing) and the late Ernest Kurtz, Ph.D. (author of Not God: A History of Alcoholics Anonymous) said in a Journal of Studies on Alcohol article comparing AA with other models, “Perhaps more than any other reality born in modern times, Alcoholics Anonymous has become the proverbial elephant described by unsighted examiners.” Miller said in a recent email, “This is still largely true two decades later, and some recent commentators have been standing behind the elephant and missing the larger picture.”
AA Is Not Treatment
A widely publicized Atlantic Monthly article titled, “The Irrationality of Alcoholics Anonymous,” rightly opens with, “Its faith-based 12-step program dominates treatment in the United States.” Author Gabrielle Glaser’s article graciously cites Inside Rehab’s finding that about three-quarters of U.S. treatment facilities involve the 12 steps. (See the next section for details.) However, like so many articles pointing to research challenging AA’s efficacy, important distinctions are unclear concerning AA as it exists in lay community support groups, AA as it’s used in addiction treatment programs, and AA as tested in research settings in a form called “12-step facilitation.” Here are the differences:
- AA support groups are held in such places as churches, hospitals, public libraries, senior centers, and AA clubhouses. Participation in this network of non-professional support groups is not considered addiction treatment. Miller stated, “AA was never meant to be a treatment. It is a fellowship and a program for living. The treatment industry appropriated ‘Twelve Step’ and turned it into something very different from the original AA.”
- 12-step treatment typically refers to addiction programs in which clients receive a variety of interventions, including education about AA and the 12 steps. Clients often formally “work through” some of the steps, learn about the “disease model” of addiction (much of which did not originate from AA), attend AA meetings as part of treatment, and are strongly encouraged to continue in AA when the program ends. (Although members of various AA support groups often speak at treatment programs, AA itself is not affiliated with any professional entity or organization.)
- 12-step facilitation (TSF) is a professional approach to treatment that has been tested in many studies, usually done with the guidance of a manual and designed to facilitate, not pressure or compel, client involvement in AA. TSF helps clients understand AA’s main concepts, expectations, and etiquette; learn how to use its resources for support and advice; links clients with current 12-step members and groups; dispels misconceptions about 12-step organizations; and helps them overcome barriers and challenges related to their experiences with AA.
The Ubiquity of 12-Step Treatment
If you’re looking for treatment sans the 12 steps, your choices will be limited, although 12-step treatment is not quite as ubiquitous as it was when Sober for Good was published in 2001. Back then, more than 90 percent of treatment facilities were 12-step based. In writing Inside Rehab, the most recent statistics I could find were from the University of Georgia’s National Treatment Center Study (NTCS), which conducts periodic surveys of nationally representative groups of addiction treatment programs.
Researchers at NTCS (personal communication) compiled 2007–8 data on 12-step programming for private programs and found that nearly 8 out of 10 facilities offered 12-step-based treatment or included the 12 steps as part of programming. Two-thirds of them required 12-step meeting attendance, and nearly as many held on-site meetings. NTCS surveyed public programs in 2009–10, determining that almost 7 out of 10 were either based primarily on a 12-step model or included a 12-step component. (Public programs weren’t asked about meeting attendance requirements or meetings on-site.)
Did Treatment Misappropriate AA and Its 12 Steps?
More than once while writing this book, I heard people talk about “what treatment has done to AA.” Salina S., a woman who had been to several 12-step rehabs before finding one that used a different philosophy, said, “There are parts of the 12 In truth, much of the cynicism about AA really should be directed at the treatment industry and other systems external to AA.-Psychologist, Anonymoussteps that are a beautiful concept, but I think that the creators of them would roll over in their graves if they knew what treatment programs were doing with it.” A psychologist who worked at a 12-step residential rehab even stated, “In truth, much of the cynicism about AA really should be directed at the treatment industry and other systems external to AA. One-size-fits-all is insane. Much of the treatment industry perpetuates this, but this should not be an indictment of AA itself.”
In their 1994 article Miller and Kurtz stated, “AA, as reflected in its own literature, differs in several important respects from the moral, volitional, and dispositional disease models with which it has been commonly confused in public and professional conceptions of alcoholism… Assumptions derived from these other models have been grafted onto AA concepts to form opinions that have guided the treatment of alcoholism in the United States.” An example is the concept of “denial,” which refers to the notion that people with addictions commonly don’t recognize or accept their “disease” and, therefore have to be confronted about it. However, Miller and Kurtz note that nowhere in the major writings of AA’s founder, Bill Wilson, does the concept of denial appear.
Note, too, that even though many programs say they use 12-step facilitation, a non-coercive approach, it’s seldom done in the way it’s intended in research studies showing TSF to be effective. That is, at traditional 12-step-based programs the 12 steps are commonly presented in a “do or die” way – if you don’t accept the steps and “get with the program,” clients are led to believe you won’t get sober and may die. While researching my book, I observed full days of residential treatment that seemed to revolve around getting patients to buy into the 12 steps and the “disease concept” of addiction.
If you read the Big Book carefully, you will see that AA as originally conceived, but now sorely corrupted by the treatment industry, was purely a self-directed, self-elected program—no pressure to attend, no pressure to admit being an alcoholic.-Fred Rotgers
Psychologist Fred Rotgers, Psy.D., past president of the American Psychological Association’s Society of Addiction Psychology, said, “If you read the Big Book carefully, you will see that AA as originally conceived, but now sorely corrupted by the treatment industry, was purely a self-directed, self-elected program—no pressure to attend, no pressure to admit being an alcoholic. The only approach was an invitation, not a prescription. All the prescriptive stuff came from treatment providers who decided that if something was good, it should be required as a part of treatment. And, of course, they ‘knew’ it was good because they got sober while they were doing it. And if it worked for them, it would work for everyone. But AA makes no prescriptions about how it should be used, or even that it should be used.”
How the “Culture of AA” Has Fostered Misconceptions
In a recent article on “Alternet,” Maria Alexander reminds us, too, that the “12-step culture” has developed practices that deviate from AA’s own teachings. She wrote, “As a woman in recovery since 2002, who has survived multiple overdoses requiring emergency medical attention, I find it very disappointing that when I bring up overdose prevention education efforts to many of my comrades in 12-step programs, I am met with resistance.” (She is referring to naloxone, a life-saving medication that reverses opioid overdoses.)
Previously, I’ve written about rehabs that reject the science-based practice of using long-term treatment of opioid addiction with Suboxone and methadone, as well as sober living facilities that won’t admit people on such medications. At 12-step meetings, people on these medications are often not accepted as truly being “in recovery.”
However, such policies seem contrary to AA’s own writings in, “The AA Member – Medications and Other Drugs,” which discusses how AA members are sometimes discouraged by other members from taking psychiatric medications.
- It reads, “A.A. members and many of their physicians have described situations in which depressed patients have been told by A.A.s to throw away the pills, only to have depression return with all its difficulties, sometimes resulting in suicide…. Unfortunately, by following a layperson’s advice, the sufferers find that their conditions can return with all their previous intensity. On top of that, they feel guilty because they are convinced that ‘A.A. is against pills.’ It becomes clear that just as it is wrong to enable or support any alcoholic to become readdicted to any drug [referring to misuse of drugs], it’s equally wrong to deprive any alcoholic of medication, which can alleviate or control other disabling physical and/or emotional problems.”
It seems apparent that any medication capable of preventing people from returning to a disabling substance use disorder would fall into this category.
What’s Next: Part 2 will address myths and facts about AA.
- Parts of this article were adapted from Inside Rehab by Anne M. Fletcher, published on December 31, 2013 by Penguin Books, an imprint of Penguin Publishing Group, a division of Penguin Random House LLC. Copyright by Anne M. Fletcher Communications, Inc., 2013.