Why some people trust Alcoholics Anonymous and others despise it (2023)

Rae Steward, a 33-year-old woman from California, has struggled with alcohol and drug addiction since she was 14. But it got much worse in his late teens and early 20s. "I barely remember those two years," he said. “I was practically passed out [drunk] the entire time.”

Steward then found a treatment program, which led her to attend Alcoholics Anonymous meetings and follow the guidelines.12 steps🇧🇷 Participants are encouraged to follow 12 guidelines, or "steps," that combine spiritualist ideals about addiction, along with the view that it is an illness, to help them overcome their illness. Among the steps: submitting to a higher power, addressing "character flaws" and correcting past issues.

Steward said that with the help of the program and AA meetings, she has been sober for 10 years. “When I started doing the steps, I didn't think they were going to work,” he said. “I still, 10 years later, don't understand why they worked. But I feel like I was given the design to live life. At this point, I just incorporate the steps into daily life.”

But for every Rae, there's a Roger, who asked me to use a pseudonym. He tried a 12-step treatment program in Indiana in 2012 and 2013 for alcohol and stimulant drug use.

It didn't stick. Within months, he had moved to Virginia and returned to drinking and drug use. “I spent a year and a half completely drunk every night,” he said. He was able to continue working and concealed his use of alcohol and stimulant drugs. But things got worse. In September 2014, he was hospitalized for alcohol and drug use. He left and drank again. At the end of November, he stopped working and cut off communication with friends and family.

Suddenly, in December 2014, Roger decided to stop drinking. "I really don't know why," he said. Two days later, the police did a welfare check, at his parents' request, and that's when he reconnected with his family. He moved to Michigan and started attending AA meetings, finding them helpful for a few months and even completing the 12 steps, but eventually giving up.

Roger, now 26, has managed to stay sober for the past three years. While he acknowledges that recent AA meetings have provided him with a support system, he has remained alcohol and drug free even after leaving meetings. Roger's big change seemed to stem not from the 12-step program but from the sudden realization that he was going in the wrong direction, although he admits he can't explain exactly why he came to that conclusion.

Then there's Betsy, who asked me to use her first name only. He had a particularly bad experience with affiliated AA and Al-Anon meetings. He stopped drinking after a DUI conviction prevented him from going to bars, but said the AA meetings he attended had little to do with it. She failed to get a sponsor (as recommended by AA), failed to complete steps, and at one point found herself in grave danger with a man from a meeting.

“I brought another man home,” said Betsy. “It really wasn't very stable. I ended up narrowly escaping being raped in his house. Looking back, I'm not sure how I got out of it. He was trying to be nice but he definitely assaulted me at his house." She added: "I was still sick at the time so I thought it was funny. And a friend pointed it out to me: 'You know that wasn't fun, right? what happened to you wasn't funny at all. And at that point, I started to realize that something was wrong."

Betsy found herself fundamentally at odds with AA's philosophies. As an atheist, she has always struggled to define her higher power. AA says people can set it however they want, even use a doorknob if necessary. Betsy tried to define her higher power as her cat, but it never worked. "I don't believe any of that," she said.

Betsy, who is 42 and lives in Texas, has been in recovery for 10 years, but not thanks to AA. After her struggles, she found a different secular mutual support group,life jacket— and that seemed to work much better in helping her deal not only with her drinking, but with the underlying issues that caused her to drink so much in the first place.

So Betsy shows that the 12 steps don't work? Steward shows do they work? Roger shows that the 12 steps can do something, but not quite?

Here's the problem: the results that Steward, Roger, and Betsy got from AA, while disparate, are not abnormal. They are representative of the combination of successes and failures of the 12 steps.

Over the past few months, I've spoken with experts who have researched 12-step facilitation treatment and AA, as well as people who have participated in the programs. My goal was to see if the 12 steps really helped people overcome alcohol addiction.

The answer: it's complicated.

The simplest explanation is that the 12-step treatment and AA meetings work for some people but not for others. J. Scott Tonigan, a researcher at the Center on Alcoholism, Substance Abuse and Addiction (CASAA) at the University of New Mexico, said the research supports a "rule of thirds": About one-third of people maintain recovery from alcoholism. to 12-step therapy, another third receive some treatment but not enough for full recovery, and another third receive none.

Getting to the bottom of this is crucial to tackling a huge public health issue. based onfederal data, more than 20 million people have a substance use disorder, and within that group, more than 15 million have an alcohol use disorder. Excessive alcohol consumption itself is associated with88,000 deaths per year🇧🇷 So if one of the most common types of treatment for this disease is actually effective, it could be a matter of life and death.

For some people, the 12 steps really work.

the 12 steps,first established in the 1930s by Bill Wilson, have now become a powerhouse in the world of addiction treatment, with millions of people worldwide attending AA meetings every year alone. AA has also spawned a network of affiliated groups such as Narcotics Anonymous, Marijuana Anonymous, Al-Anon (for family and friends of people with alcohol addiction), and many more.

Professional treatment organizations have taken advantage of AA's popularity, particularly in the United States. This led to the creation of the type of program Steward attended known as “12-step facilitation,” which encourages people to attend AA meetings and complete the 12 steps. An AA spokesperson said that the actual AA scholarship has nothing to do with professional treatment programs, telling me that "we do not operate, endorse or comment on treatment facilities." But the programs have become over the decades one of the most popular ways to treat addiction in professional settings, withfederal surveysshowing that more than 70% of addiction treatment facilities in the US implement it "sometimes" or "always or often".

Years of evidence show that the average 12 steps can really help treat alcohol addiction. But this comes with some important caveats.

On the one hand, studies generally focus on individual professional and outpatient settings. This is different from typical AA meetings in the basement of a church, which are free and therefore more accessible to people in recovery. It is also different from the residential treatment settings that dominate much of American alcohol addiction treatment today.

The best research also focuses solely on alcohol use disorder. So whether the 12 steps work for other types of addictions and whether non-AA programs like Narcotics Anonymous are effective remains an open research question. (As such, this article focuses on the research and experiences of people using the 12 Steps to Alcohol Addiction.)

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Over the decades, there has been much poor research on the 12 steps, plagued by methodological problems that make it difficult to assess whether the approach is effective. In the 1990s,MATCH projectoffered a better approach. The randomized controlled trial placed patients in a 12-step program of either cognitive-behavioral therapy or motivational enhancement therapy. The results were promising for the 12-step treatment: inEvaluationThree years after the initial study, the researchers concluded that there was little difference in effectiveness between these methods and, at the very least, the 12-step treatment showed "a small possible advantage" in reducing overall alcohol consumption.

Since then, other studies have returned similar results.A 2017 studyon adolescent alcohol use disorder found that the 12-step treatment worked similarly to cognitive behavioral therapy and motivational enhancement therapy.A 2009 studyfound that people facilitated for higher AA frequency also reported more days of abstinence.A 2006 studyLikewise, he found that intensive referrals to 12-step support groups such as the AA led to higher meeting attendance and better drug and alcohol use outcomes.

Ya 2006 review of existing researchby the respected organization Cochrane found that although no studies "unequivocally demonstrate the effectiveness of AA or [the 12-step facilitative treatment] in reducing dependence or alcohol problems", the 12-step treatment worked as well as other treatment programs.

However, these studies have a major flaw: they lack a control group. This makes it difficult to assess how effective 12-step treatment programs — or, in this case, cognitive behavioral therapy and motivational enhancement therapy — really are. It is possible that all of these treatments are equally effective, but the question is how effective is the overall treatment versus no treatment at all.

Still,a 2009 review of researchfound that cognitive-behavioral therapy produces "a small but statistically significant treatment effect" overall and a reasonably large effect compared with no treatment: "79% of people treated with CBT had rates of reduction in substance use above the median of those assigned to a waiting list or similar untreated control”.

Again, much of this research is focused on a limited type of program: 12-step facilitative treatment in an outpatient setting. He doesn't talk to someone who just goes to AA meetings, which in itself is not a professional business. It's not even referring to residential treatment, where someone stays in an institution for weeks or months to receive care.

John Kelly, an addiction researcher at Harvard Medical School, said residential treatment and community-based options such as AA meetings showed "compelling evidence." For example,some random clinical trialsshow that getting people to attend more AA meetings is associated with better drug and alcohol use outcomes. "But," he added, "I would say we need more studies." The question is whether the higher frequency itself or some other factor, such as an underlying motivation to stop drinking, is generating the best results.

But general research suggests that the 12 steps do work, at least for some people.

Why the 12 Steps Work for Some People

Official AA writings tend to attribute the success of the 12 steps to their spiritual elements, with the final step even invoking "a spiritual awakening."

While the spiritual element does notsomethingfor some people, this is not why the 12-step facilitation treatment and AA work for many others. Albert, the pseudonym of a 37-year-old man from Georgia who has been sober for more than half a year, said that, as an atheist, he finds the spiritual elements of the show very negative. But the 12-step treatment and AA meetings have still been very helpful.

“It wasn't a spiritual burning bush experience that changed my life,” he told me. “But it put me in touch with other people who were sober or trying to get sober. It helped me make some connections and make some friends." He added, "As a young adult, it can be difficult to socialize without alcohol, or so it seems to me."

This speaks to one of the big non-spiritual reasons why the 12-step treatment and AA work for some people: They help to bring about change in a person's social network.

After months, years, or decades of drug or alcohol use, people with addiction often surround themselves with peers and friends who also use drugs. This becomes, as Kelly of Harvard Medical School put it, "one of the greatest threats to sobriety."

By attending the meetings, participants can connect with others who want to stop using drugs. This new social network supports sobriety and creates a drug-free way to socialize.

David Sanderson, a 55-year-old man from Prince Edward Island, Canada, said this was consistent with his experience. “Immediately for me, it was that connection with the people thathe knewSanderson said, describing their first encounter. He talked about the importance of "meeting after meeting" to help you connect with others and how it helped add people to your social network who weren't as into drinking. At the same time, he didn't see much value in the spiritual aspects of the 12 steps.

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Stories like Albert and Sanderson's are supported byof several studies, which found that changing a person's social network can facilitate drug withdrawal. “It's the social support that makes the difference,” Christine Timko, an addiction researcher at Stanford, told me. “When people have less people who use drugs and drink in their social network, and have more people in their social network who don't use drugs and drink, then they are better off in terms of being able to not drink and use. 🇧🇷

The Twelve-Step Treatment and attending AA meetings, Kelly said, also "increase your ability to cope with the demands of recovery."

This is the kind of thing cognitive behavioral therapy tries to do: it teaches a person how to resist alcohol and drugs when offered, how to deal with difficult life events without using drugs, how to copestigma of addiction, and so on. Essentially, it teaches the patient to develop the attitudes and behaviors that may be necessary to resist relapse.

“You could be forgiven for viewing AA as a quasi-religious spiritual entity,” Kelly said. “But if you went to 10 AA meetings and listened, you would basically listen to cognitive behavioral therapy.”

The 12-step treatment patients and AA assistants I spoke with corroborated this. Hearing other people's stories helped them find coping mechanisms to overcome drinking triggers, from exercising to being in close contact with other participants or simply drinking too much soda at social drinking events. They learned to deal with environmental stimuli and social stress without resorting to alcohol and other drugs.

Even Steward, who attributed some of his success to the spiritual elements of AA, said that the biggest change, at the end of the day, came from other elements of the 12 steps that gave him a sense of support and structure that he could draw on throughout the years. of his life. . “Really,” he said, “what I have is the ability not to be an idiot.”

Why the 12 Steps Don't Work for Others

For all the 12-step success stories, there are also many disappointments.

The biggest bone of contention seems to be the spiritual element of the 12 steps. Critics like Maia Szalavitz, addictive journalist and author ofNonstop Brain: A Revolutionary New Way to Understand Addiction, focused on this part of the program to argue that the 12 steps really shouldn't be considered treatment.

“Say you go to a doctor to get your depression treated,” Szalavitz said. "If you were told that you had to surrender to a higher power, work out your character flaws, take a moral inventory [and] pray, you'd probably think you'd run off with a charlatan." He added, “If we are to argue, as the 12-Step people vigorously do, that addiction is a disease, it cannot be the only disease for which the treatment is confession and prayer. This is not acceptable."

That's why Roger was on and off the show. Although he is agnostic, he has tried to make it work, following AA's recommendation to, if necessary, turn his higher power into a doorknob. "But it's very strange to pray to a doorknob," said Roger. "That's a weird thing to do."

This is something critics of the 12 Steps have mentioned again and again: when fanaticism, spirituality, and religion enter the picture, people can be judgmental. Betsy, for example, said other participants mocked her and berated her for making the cat her spiritual power, even though it's the kind of thing AA recommends.

What further complicates this is that different AA meetings and communities work differently. Albert said his current AA group is LGBTQ-friendly and includes many atheists and agnostics. But depending on where a person lives and attends meetings, the experience can be different and much more negative.

Gerald Zeigler, a 44-year-old man from Montana, said he is religious, but the 12 steps still haven't worked for him in dealing with his alcohol addiction. Although he found some value in the group support provided by AA meetings, he felt "shamed" by the program, as if his struggles in recovery reflected some kind of character flaw.

"Everyone has character flaws, but I don't think that's what alcoholism is all about," Zeigler said, arguing that addiction should be treated as a medical condition, not a moral, spiritual or religious problem. "It was a real turnoff for me."

In some cases, rigid interpretations of the 12 steps can even lead people todeclinetreatments or approaches that work for some people.

An article from 2015Gabrielle Glaser's in the Atlantic, which came up in my conversations, emphasized the potential of naltrexone and other medications to help people stop drinking. Theevidenceshows that these drugs can help maintain abstinence and reduce binge drinking, but they don't work for everyone and their success can vary depending on how they are used. Among the people I spoke with who used naltrexone, its effectiveness varied.

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But some 12-step treatment programs and AA participants are actively hostile to the idea of ​​using drugs to treat addiction. They interpret sobriety as giving up all drugs completely, and using naltrexone to stop drinking doesn't quite do that. (This stigma extends to opioid addiction, for which the drugs arewidely considered the gold standard for the treatment, and even other mental health issues such asdepression and anxiety.)

This does not apply to all 12-step treatment programs or AA groups. A spokesman told me that AAdoes not take an official stand against drugs, leaving these questions to individuals and their physicians. And the Hazelden Betty Ford Foundation, a major provider of the 12-step treatment,using medications to treat addiction, as well as many other treatment providers. But not everyone is on board.

Likewise, 12-step treatment programs almost unanimously reject moderate alcohol consumption as a possible outcome for participants. But some people can succeed with moderate alcohol consumption. Betsy, for one, still drinks "maybe twice a year," she said. And from her perspective, he's doing well now.

All of this leads to a fundamental conflict at the heart of the 12 Steps: the same rigidity that gives people like Butlers a structured guide to life also alienates others. As Betsy told me, "I don't like having to fit into their framework."

Some 12-step treatment programs have also been associated with a confrontational approach. This has been popularized in many media such asasopranocenawhich starts with a well-intentioned intervention and ends with several characters beating up the person they think needs help. It also led to some weird AA effects, like the Synanon movement, which turned out to be what journalist Zachary Siegeldescribedas a "violent cult".

The reality, CASAA's Tonigan told me, is that the adversarial approach "is terribly ineffective."the best researchshows thatpositiveReinforcements, such as motivational training and life enrichment, are much more effective ways of getting people to stop drinking. (This is also true for encouraging changes that can combat problemsbeyond addiction.)

But just as the emphasis on spirituality and acceptance of medication varies from one 12-step group to another, so does each group's focus on compassion versus confrontation. And that can create some really bad experiences for some people, which can cause them to relapse and potentially put their lives in danger again.

For addiction we need as many options as possible

Everyone I spoke with, regardless of whether the 12 steps worked for them, had one point of agreement: the 12 steps and AA should be available, but they shouldn't be the ones.onlyoption.

“There are a lot of good people in AA, and there's a lot of support there, a lot of compassion there,” Zeigler said. “I find it so strange that it is treated as an option for everyone.”

"AA worked," said Sanderson, who has been sober for more than two decades, "and I didn't feel any reason to try other programs." But, he added, "if anyone struggles with any of the AA concepts, stick with whatever works."

This echoes what the researchers also told me. As Stanford's Keith Humphreys said, “We don't have one thing that works for everyone. There are very few places in medicine where you do that." So there should be as many alternatives as possible.

However, the reality, researchers said, is that most treatment centers in the United States are based on the 12 steps, making them theonlyoption for many people. While alternatives likeSMART recoveryolife jacketThey exist, they are not as widely available as AA, and they are certainly not integrated into professional treatment programs the way the 12 steps are.

Not because other self-help groups are expected to be worse. Kelly of Harvard told me that “I would bet that SMART Recovery, LifeRing [and] these other self-help groups, if they were readily available and accessible, would produce a similar benefit for AA. I don't think it's the unique and specific aspects of AA that make the difference; it is rather these common therapeutic factors that are incorporated into all these mutual help groups”.

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However, in the real world, these non-AA options for support groups can be rare, to the point where it is difficult to study them, facilitate participation in them, or simply sign up for them.

Albert has experienced this problem firsthand: the hundreds of AA meetings that take place in his town each week make it easy for him to find a convenient time and place. Not so with other programs, which tend to have maybe a handful of meetings a week. “It just doesn't work in practice,” Albert said.

The problem is further complicated by poor access to treatment facilities, even from 12 steps onwards. Health insurers may be reluctant to pay for substance abuse care, even when they arerequired by federal law– forcing patients to pay up to thousands of dollars a month out of pocket. Waiting periods for treatment can also last for weeks or months, making it difficult for people to receive care during limited windows of opportunity.

As a result,a 2016 reportby the general surgeon found that only 10 percent of people with a substance use disorder receive specialist treatment. (Although, in particular,some researchsuggests that more than half of people successfully cope with their substance use disorderswhichtreatment.)

Government policies and health care providers could change all that by putting more resources into greater access to treatment and alternative groups. More people could try starting local offshoots of the alternatives. New technologies can be used to hold meetings online instead of in person.

The aim should be to obtain a wide range of options for a disease marked by individualized features that require individualized approaches. But the reality is far from that.

“There just aren't many widely publicized options available,” Albert said. AA and the 12-step treatment are "the most popular and recommended option, so you tend to go there."