The 12 Step model is dominant in the majority of addiction treatment programs in the United States. According to the National Survey of Substance Abuse Treatment Services, the 12 Step model is used in approximately 74% of treatment centers. Whether the primary model or one among several, the 12 Step model informs the potential recovery of millions of people.
The 12-Step model of addiction treatment is a direct descendant of the Alcoholics Anonymous (AA) program, with its attendant 12 Traditions. Thus, there is an undeniable, though far from fully articulated, connection between the majority of treatment centers and AA. This connection may cause some treatment professionals to be caught between competing and even mutually exclusive demands of anonymity and professional or organizational codes of ethics. These conflicting demands expose clients/patients to harm.
A History of the 12-Step Model
An important clarification: Alcoholics Anonymous does not describe itself as treatment; it is a program offering recommendations and traditions intended to help individuals achieve sobriety. There are no dues or fees to attend nor are there professionals facilitating meetings. Alcoholics Anonymous comprises the people who attend meetings or practice the program. There is no governing authority in AA.
While there is a General Services Office of AA, it does not function like a corporate office, nor are individual groups like franchises. The Steps and the Traditions maintain a continuity between different groups that helps to ensure the stability and viability of the program as a whole.
How did the 12 steps become part of treatment programs? A group of “professional men,” some of whom had benefited from AA formed Hazelden in 1949 in Center City, Minnesota to help other “professional men.” The cornerstone of this new venture was the 12 Steps. Relatively quickly, Hazelden provided the gold standard of treatment and spawned what is now called the “Minnesota Model” that has been incorporated into nearly every 12-Step based program.
The 12 Steps made the full transition into professional treatment, but the 12 Traditions only partially made the transition. This is part of the cause for clashing demands as they relate to anonymity.
Anonymity and AA
Tradition Twelve of Alcoholics Anonymous states, “Anonymity is the spiritual foundation of all of our traditions, ever reminding us to place principles before personalities.” As explained in the pamphlet under, “Understanding Anonymity,” (updated 2011), anonymity has two functions. On a personal level, anonymity functions as a safeguard; it protects members from identification as alcoholic. This is often important for newly sober people who may fear being “outed” and the stigma that follows from the application of that label. Anonymity allows people to have authority over who knows what about them.
On a public level, anonymity undergirds the equality of all members of the Fellowship by putting a constraint on those who might try to exploit the AA affiliation for recognition, power, or personal gain. On this level, anonymity protects against grandstanding or showboating, to which the early members of AA feared they could be prone. It is quite common for many AA meetings to end with the imperative, “Who you see here, what you hear here, when you leave here, let it stay here.”
As typically understood, this means not talking about who was at a meeting and who said what to anyone, including someone in the program who was not there. In its most stringent form, a meeting should be sealed shut at its close. If people are sharing information outside the meeting, this may make some people less willing to share in meetings or to attend meetings, which creates a serious obstacle to sobriety.
Breaking anonymity directly undermines the primary purpose of AA, which is staying sober and helping others achieve sobriety. When an individual breaks anonymity, he not only puts his own sobriety at risk but others’ as well. Furthermore, breaches of anonymity put the entire program at risk.
The Notoriously Ambiguous Term “Addiction Professional”
Treatment centers using the 12-Step model have multiple employees. Matters quickly become complicated because, as Anne Fletcher documents in her book, Inside Rehab, the world of addiction treatment is largely unregulated; there are no national licensure standards, no educational or degree requirements, no single governing body of addiction professionals, and no one governing code of ethics for addiction professionals.
Individual treatment centers may not even have their own code of conduct nor require its professionals to abide the codes of whatever associations to which they may belong. Further complicating the issue is the fact that the term, “addiction professional,” is ambiguous.
Physicians, psychotherapists, counselors, therapists, social workers, group facilitators, and managers of after-care and sober houses, for example, can all fit under that umbrella. Some of these professions (medicine, psychology, social work, e.g.) have professional codes of conduct while others do not.
One immediate problem is the lack of guidance to adjudicate conflicts between different codes or even within the same code. There’s also little guidance when a professional code of conduct conflicts with the code of a particular treatment center (though many treatment centers do not have their own codes). Where guidance is in short supply, bad decisions and mistakes may abound.
Dual Relationships in the Addiction Treatment Field
An additional complicating factor is a significant number of people working in the addiction treatment field are themselves in recovery. This means the world of addiction treatment, with a heavy reliance on the 12-Step model, is potentially rife with dual relationships. This is heightened when AA meetings are a component of a treatment plan.
The treatment center may itself offer AA meetings or it may send patients to AA meetings in the area. A treatment professional may find herself caught between responsibilities to her client, to her organization, to her profession, to AA, and to herself. How does one determine when one is acting in a professional capacity and when one is just a person in recovery? How is one supposed to place principles before personalities? And which set of principles should carry the day?
A few scenarios will help to illuminate the tricky dynamics of anonymity and conflicting responsibilities someone in recovery working in a treatment center may encounter and the harms to clients that might result.
A client discloses at an off-campus AA meeting that she and her psychologist are really bonding. She reports the psychologist is caring and considerate; they’re becoming friends. The psychologist even shares some of her own personal journey of recovery. Do you break anonymity and talk to the psychologist? Suss out more from the client outside of the meeting? Check with co-workers about what they know?
Variation: The client has finished treatment and you see her and the psychologist attending meetings together.
A person who has a reputation as a 13th stepper is paying extra attention to one of your clients at an off-campus AA meeting. Your center has no policy against involvements though AA recommends against getting involved in the first year of sobriety. Do you take your client aside and warn her? Do you tell her psychologist? Do you tell the 13th stepper to back off? Enlist someone else to tell the 13th stepper to back off?
Variation: It is your really good friend who has never 13th stepped paying attention to your client.
A Rock and a Hard Place
Negotiating competing demands leaves a treatment professional caught between a rock and a hard place. The consequences of those competing demands extend to the addiction professional for sure. But just as or more importantly, the consequences extend to the clients in terms of the quality of their care, opportunities for growth and recovery, and their overall wellbeing.
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