Twelve Steps Reconsidered

Last updated on November 4th, 2019

Recently, I had dinner with several psychologists who are active in the addiction treatment field. I spoke of the use of the Twelve-Step fellowship in my work; this was quickly dismissed by several of the participants. One of them remarked that she “knew all about the Twelve Steps and the Twelve Principles,” an obvious mistake for anyone with any familiarity with the AA program (it’s the “Twelve Steps and Twelve Traditions”). Another mentioned that she had never looked at the Big Book, but thought that she might someday read it.

A recent book, released with great fanfare, purports to dismiss the entire body of work based on Twelve-Step principles. The author cites pieces of various studies, the implementation of the program in professional treatment, and the philosophical premises of the program. Whether you agree with this analysis or not (and I don’t, finding the review to be selective and distorted), there is something disturbing to me about the level of attack on any treatment modality.

What therapy works, for whom, under what circumstances, for what problem?-Mark Schenker

When I started graduate school way back in the disco era, the pressing question in some of our minds was, “Which is correct: psychoanalysis or behavior therapy?” It didn’t take long to recognize the naiveté of this question. Besides the intense proliferation of new approaches in the years to come (most significantly Cognitive-Behavioral Therapy), the more relevant question became, “What therapy works, for whom, under what circumstances, for what problem?”

The Tone of Addiction Treatment Has Changed

However, the field has become fractured and contentious. It has become important not only to demonstrate the superiority of one approach, but to demolish the merits of competitors.-Mark Schenker

However, the field has become fractured and contentious. It has become important not only to demonstrate the superiority of one approach, but to demolish the merits of competitors. When I taught a survey course on psychotherapy at a cognitively oriented graduate program a few years ago, I was discouraged from including a book with the word “Psychoanalysis” in the title (actually a balanced appraisal of this approach). As a speaker at a recent conference on psychotherapy integration remarked that the state of therapy research has come to resemble “ethnic cleansing.”

This state of affairs has polluted the addiction treatment industry, and is reflected in a recent tendency to dismiss or denigrate the Twelve-Step approach to recovery. For the record, I do believe that this fellowship requires rigorous examination, not only as to efficacy, but to identify any components which may be specifically helpful to patients. I do not endorse an unwavering and uncritical loyalty to the program, nor do I feel that this is the only route to recovery. In my practice, I utilize an array of interventions, based primarily on my assessment of the problem and the patient’s resources. However, I do feel that it behooves anyone working in this field to have more than a passing knowledge of it.

A Call to Reconsider the Twelve Steps

Alcoholics Anonymous occupies a unique role in the history of the development of treatment and research in this previously neglected area, and if for no other reason, those working in the field should be aware of this history and this tradition. (A reading of “Slaying the Dragon” by William White should be required reading for anyone working with addicts, placing the entire enterprise, including AA, into context).

Alcoholics Anonymous occupies a unique role in the history of the development of treatment and research in this previously neglected area, and if for no other reason, those working in the field should be aware of this history and this tradition.-Mark Schenker

Even when working within a different modality (as I did for years) clinicians will encounter patients who have had some involvement in Twelve-Step programs. One of the first things I learned is that it is essential to “speak the patient’s language.” A therapist who doesn’t grasp the role of a sponsor, or the significance of the Steps, or the distinction between the Twelve Traditions and the “Twelve Principles” (whatever they may be) will undermine his/her credibility and will miss out on understanding the patient’s own view of his/her problem. Furthermore, the therapist loses the opportunity for the patient to avail themselves of support for recovery, regardless of their acceptance of a “Higher Power” or going through a personal inventory.

It is obvious to someone who has spent some time working within this tradition that many of the critiques of the fellowship display an ignorance of the true inner workings of the program. Those who decry the disease concept as promoting irresponsibility about one’s behavior have never heard an AA speaker describe his own responsibility to work his program. Those who dismiss a “spiritual solution” as irrelevant to recovery might otherwise endorse an approach stressing humility, honesty and social connectedness.

What should be the role of AA and other such fellowships in the recovery enterprise? In my view, a clinician facing the devastating impact of addiction on patients and their families would be irresponsible to write off any potential resource for recovery. Just as we have a continuum of levels of care within the treatment industry, we should have an array of options available for supporting our patients in their journey. Thankfully, we now have many approaches which are useful in helping patients achieve and maintain recovery, which itself may take many forms, including moderation and abstinence.

A categorical rejection of AA is a theoretical and pragmatic mistake, which most often represents, in the words of Herbert Spencer (as quoted in the Big Book) “contempt prior to investigation.”

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