12 steps
Programs

TS philosophy. The original TS program was developed by Alcoholics Anonymous^® (AA)^®. AA was founded in 1935 by physician Bob Smith and businessman Bill Wilson, who were both addicted to alcohol and looking to maintain sobriety. The 12 steps used in the program appeared in print in 1939, when Wilson and Smith published Alcoholics Anonymous: The Story of How More than One Hundred Men Have Recovered from Alcoholism . Since then, other TS groups using similar principles have emerged to address other addictions, including Gamblers Anonymous^® (GA^®), Overeaters Anonymous^® (OA^®), Narcotics Anonymous^® (NA^®), and others.

The official AA position is that alcohol addiction is a progressive condition , characterized by “powerless[ness] over alcohol” . On this view, alcoholism cannot be “cured”—an alcoholic cannot expect to be able to drink moderately—but the illness can be arrested by abstaining from drinking alcohol . The essence of the method is that members help one another stay sober by “working the steps.” The steps are simple and can be summarized as follows : (a) acknowledgement that one has become “powerless” to control one’s drinking; (b) trust that “a Power greater than ourselves”  can help one stay sober; and (c) acceptance of responsibility for one’s behavior, including admission of character defects, making amends for past mistakes, and striving to be honest with self and others. Thus, on this view, alcoholics are powerless over alcohol but do have power to abstain, with help, one day at a time. While AA’s position is clear that alcoholism is not a moral failing, it is equally clear that recovery depends on alcoholics’ taking responsibility for living with their condition, much like asthmatics must take responsibility for maintaining treatment of their illness.

Although not a treatment per se , TS groups do have something important to offer people who are attempting to quit an addiction: they provide a social network that supports recovery; they emphasize both the powerfully compulsive nature of addiction and the importance of harnessing an individual addict’s personal responsibility; there are no dues or fees for members; there are no requirements, pledges, or oaths to become a member; meetings are available in many places and at many times of the day and night; and they are compatible with other measures.

Do 12-Step Groups “Work”? Ferri, Amato, and Davoli’s conclusion in a 2006 meta-analysis published in the Cochrane Review has been widely quoted: “No experimental studies unequivocally demonstrated the effectiveness of AA or [Twelve-Step Facilitation] TSF approaches for reducing alcohol dependence or problems”. Less widely quoted is the earlier discussion in which the authors say “there is no conclusive evidence to show that AA can help to achieve abstinence, nor is there any conclusive evidence to show that it cannot” [13]. To us, it appeared there was little difference among the treatments analyzed.

Several studies do support some efficacy of TS programs of recovery. AA participation is associated with fewer drinks and more abstinent days, and recent studies show that AA attendance improves sobriety even while controlling for self-selection bias. While these studies do not show unequivocal evidence of success—and are not evidence of sufficient effectiveness to recommend AA/TS programs for everyone—they do support inclusion of TS in the set of appropriate interventions.

Before turning to criticisms of TS, it is worth noting that TS groups (e.g., AA, GA, OA) are distinct from both professionally led treatment programs(inpatient or outpatient) that use TS as their foundation and the therapeutic technique grounded in the TS principles known as TSF [20].

Critiques of TS. Several features of TS programs make them a poor fit for some people who are seeking recovery. To begin with, some who eschew TS programs might find the emphasis on spirituality off-putting. AA maintains that the “Power greater than ourselves” can be construed as a non-theistic power, such as the power of the community, but this rings hollow for some recovery seekers. Additionally, TS programs promote the goal of abstinence, but moderation is a better goal for some people. Some people find that the emphasis on powerlessness erodes their confidence, and others dislike the group format inherent in TS. And some are bothered by the inconsistent, somewhat sloppy reasoning that runs through the TS philosophy. For example, AA’s position that alcoholism is an illness or malady (akin to an allergy) seems out of step with its view that it’s a spiritual problem; and the claim that alcoholism is not a moral failing seems at odds with phrases like make “a searching and fearless moral inventory of ourselves” and “remove all defects of character” found in Step 4 and Step 6.

Perhaps the most damning criticism of AA and other TS programs concerns the variability in adherence to core tenets from group to group. Since it is nonprofessional by design, quality control measures are minimal, and there is no way to ensure that every group adheres consistently to all of its principles. Thus, some criticisms of TS refer to beliefs and attitudes that can be found in some individual TS groups or members but that are inconsistent with the official position of AA. These include that it is a religious (specifically Christian) organization; that it shames addicts as being morally flawed; that members are not allowed to use medications to support sobriety; and that AA claims that it is the only way someone can get sober. Of course, variability of beliefs and attitudes among members of any organization is not uncommon and can lead to assumptions and misunderstandings about other members or the organization as a whole.

A related point is that some critiques of TS do not maintain a clear distinction between TS groups and rehabilitation programs and facilities that use TS groups, principles, or TSF. These criticisms take aim at the enormous expense of many inpatient rehabilitation units and the marketing used to encourage their use. They note that while hospitalization might provide a pleasant respite for those beginning recovery, the stressors of real life are waiting on the other side of discharge, which might account for these programs’ low rates of success despite the huge investment of money and time involved. It’s important to note that these are sound critiques of the rehabilitation industry, but not of TS programs as such. Moreover, some TS critics acknowledge that TS programs do help many people achieve recovery, but they are distressed about the lack of knowledge of and support for other addiction treatment modalities. Creating awareness of all the interventions that can help facilitate recovery is important, although the antagonistic tone of the addiction debate in popular media can, unfortunately, obscure points of agreement.

In sum, TS programs of recovery are a respectable modality to recommend to those seeking help with addiction; however, the effect is not sizeable enough for clinicians to insist on TS for everyone seeking treatment for addiction.