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Section 15
Twelve-Step Programs as an Addiction

Question 15 | Test | Table of Contents

Because AA came into being at a time when modern methods of medical therapy, clinical psychology, clinical sociology, and professional counseling were all but nonexistent in the field of addictions treatment, AA filled a vacuum. The medical and psychological communities had failed to provide appropriate and adequate care for those addicted to alcohol, and so AA got the franchise. This meant that, for decades after AA's founding, expensive and lengthy addictions treatment programs adopted and offered essentially the same basic philosophy and methodologies as AA. In 1951, the organization known as Al-Anon was founded. It follows the same basic philosophy of AA, utilizing the twelve-step approach, but provides a support network for the recovering alcoholic's family and friends. In 1953 came Narcotics Anonymous, a twelve-step program and support network for recovering drug addicts. Then, through the 1970s and into the 1980s, there was an explosion of twelve step recovery programs. New organizations emerged until the self-help domain had expanded to include just about every compulsive or self-defeating behavior one could think of. It was like an evangelical movement: each program was a part of the larger AA religion, each one reframing reality to conform to the same monolithic culture and belief system. The growth was therefore lateral instead of vertical—a widening application of a single set of ideas rather than a progressive, research-oriented development of new ideas and improvements. With its one-size-fits-all approach, this larger AA movement was entirely formulaic; any self-defeating or compulsive behavior called for the same prescription, the formation of yet another twelve-step program. Though some of these groups offer their own minor variations on the twelve steps, all have the same spiritual-religious orientation. The general nature of all these groups is best seen in the pamphlet "Al-Anon Spoken Here", which I found so objectionable at my first Al-Anon meeting. In it, guidelines for the operation of the meetings are provided. The reader is told that, within meetings, only Al-Anon "conference approved" literature can be read and discussed; sources of information from outside the program are not to be used because they "dilute" the spiritual nature of the meetings. Therapy, therapists, and professional terminology are also taboo topics of discussion, as are other recovery or treatment programs.

Such limitations on freedom of inquiry and discussion are common throughout the wider movement. The twelve-step philosophy is essentially static and resistant to change. New ideas aren't readily embraced and new methodologies from outside any given program are viewed as a threat. The peculiar thing about this is an ironic relationship to the "denial" that is so often discussed within meetings. When AA-style programs discourage objective and critical thinking, as well as new
information, they essentially embrace a blatant and collective denial system of their own. Worse, if an individual in AA, for one reason or another, doesn't make adequate progress, the typical view is that he or she isn't adequately ''working the program." The usual prescription, then, is to attend more meetings. This is another form of denial: the program can never be the problem. 1n 1983, therapist Janet Geringer Woititz published a book entitled Adult Children of Alcoholics, which describes the syndrome associated with individuals raised in an alcoholic family. This book became a best seller. After its success, a number of other authors began publishing on adult children of alcoholics, as well as on codependence in general. Within the framework of the twelve steps, both the ACoA and codependence movements grew rapidly, gaining considerable media attention. Of course, true to form for any AA movement, acceptance of these new ideas was not easy or immediate, Within Al-Anon, for example, a large proportion of the membership banded together to resist incorporating ACoA groups into their program. Though this incorporation eventually occurred, it was only after the twelve steps had been safely imposed upon the membership within the newly formed meetings. The next development occurred in 1986 when therapist Anne Wilson Schaef, in her book "Codependence Mistreated/Misunderstood", expanded the concept of codependence from its original clinical application—involving the spouse of an alcoholic—to declare "that it includes the majority of the population of the United States." The next logical step was reported in an article entitled "Healing Ourselves and Our Planet" in the winter 1992 issue of Contemporary Drug Problems, in which Robin Room, vice president for research and development at the Addiction Research Foundation in Toronto, described the way in which many individuals within the growing twelve-step movement— particularly in Northern California—moved between programs for a variety of life problems. He then warned of the potential emergence of ''a generalized Twelve-Step consciousness" with a "sociopolitical agenda." The message was clear; if a majority of the world's population could be described as essentially codependent or dysfunctional, the global solution was simple and obvious: therapy for everyone in conjunction with the twelve steps.

The first important challenge to this growing absurdity came from psychologist Stanton Peele in 1989. His book "Diseasing of America" questioned the efficacy of the proliferating twelve-step programs and described the movement within the addictions field as "out of control" He included an important quote from Donald Goodwin, pioneering researcher in the inheritance of alcoholism, who charged: "Therapists "invented" the concept that adult children of alcoholics have special problems that can be treated through therapy. They were able to sell this concept to the public and now they are eligible for reimbursement from insurance companies. In short, it was a way for therapists to tap into a new market and make money." And so, in the fall of 1991, at the national conference of the American Association for Marriage and Family Therapy, psychiatrist Steven J. Wolin, a keynote speaker, publicly denounced the ACoA and codependence movements, declaring that "the recovery movement and its lopsided counsel of damage has become dangerous." After this statement, he received a standing ovation from the five thousand members in attendance. When a ranking member of the ACoA movement was later asked by a reporter from USA Today to respond, he answered, "They're just jealous of all the money we're making." The paradox to all this is that one limited segment of the population to which these syndromes actually do apply has not been appropriately addressed or effectively handled. This population was identified by therapist Paul Curtin at both the 1986 and 1987 conferences of the National Association for Children of Alcoholics. Citing the work of Stephanie Brown—who had related the ACoA syndrome to the framework of eight stages of childhood development, as formulated by psychologist E. H. Erickson— Curtin applied the patterns of behavior encompassed within the syndromes to the actual professionals within the addictions field, saying: "Right now when we talk about an impaired professional in the alcoholism field, we mean a counselor who is a recovering alcoholic and who has relapsed. If her work is true, would we not have to say that the impaired professionals in the alcoholism field are also untreated adult children of alcoholics and untreated codependents. The implications of this are enormous."

About that time, other researchers were coming to the same conclusion. Addictions professional Susan Nobleman, conducting a survey on how addictions counselors enter the field, learned that 71 percent of the professionals she surveyed had entered as a result of a personal need for addictions treatment. Kern also noticed that many of the professionals within the addictions field were as psychologically unhealthy as their clients. In this context, it was no surprise that the response of most of Kern's staff to those staff members who didn't conform to the norms of the twelve-step belief system, or who attempted to expose and correct obvious flaws, was to engage in a variety of passive-aggressive behaviors, avoiding direct confrontation, until the nonconformers were "frozen out" and induced to resign. Criticism of the belief system wasn't tolerated; maintenance of the status quo was more important than efficacy.

Emil Chiauzzi and Steven Liljegren, in a 1993 article appearing in the journal Substance Abuse Treatment, took note of this problem, calling the treatment of addictions within the health care field an "anomaly." They named several topics of inquiry considered taboo among health care providers, one of the most predominant being to question either the efficacy or necessity of AA and the twelve steps. This is the nature of the "anomaly." The addictions field is one of the few areas of professional endeavor where the counselors and the patients are drawn from the same constituency, hence the twelve-step bias. It's not just what these individuals embrace in terms of a belief system that's important; it's how they believe it. Their faith in the twelve-step approach is quite literally as if their lives depended on it. True believers recruit other true believers, and the belief system perpetuates itself. This creates an obvious resistance to any other treatment possibilities that might be proposed. One could argue that just because the AA movement has a religious origin and nature, the features of which are significantly tied to the singularities of the founder's recovery experience; just because it is a one-size-fits-all dogma that is offered as a panacea for so broad a range of problems that nearly everyone in the world is thought to need it; and just because most of the people who administer its treatments are also among the treated, that doesn't logically prove that there's anything wrong with it. The AA method could be wonderfully effective nonetheless. But it is not. It suffers from two central problems: it scarcely works, and its cure is almost as bad as the malady. George E. Vaillant, in his 1983 landmark book The Natural History of Alcoholism, describes the natural healing process associated with individuals addicted to alcohol. Without AA, therapy, or any other outside intervention, a certain percentage of the population addicted to alcohol will reach a point when they will, of their own volition, choose to abstain from the drug. Vaillant's question was: does the AA modality improve on this percentage? Compiling forty years of clinical studies, including an eight-year longitudinal study of his own, he was able to determine that this treatment approach produces results no better than the natural history of the malady. Initially such programs do produce dramatic results, as the testimonials attest. However, over the long run, the "cured" population, through relapse, like water seeking its own level, asymptotically approaches the low water mark. With or without the AA approach, approximately 5 percent of the alcoholic population Vaillant surveyed managed to achieve abstinence. Subsequent studies have produced similar results. Therefore, to the extent that AA and other twelve-step programs work, they do so for only a tiny percentage of the addicted population.

Overall, the best hard research evidence available indicates that the most commonly employed addiction treatment modalities in the United States and Canada have questionable efficacy and consistently produce negative treatment outcomes. Extensive research in a comparative analysis of treatment outcomes, conducted and compiled by Reid K. Hester and William R. Miller at the Center on Alcoholism, Substance Abuse, and Addictions—places Alcoholics Anonymous, educational lectures and films, general alcoholism counseling, and psychotherapy at the very bottom of the list in terms of effectiveness. On the other hand, modalities which include brief intervention, coping and social skills training, motivational enhancement, community reinforcement, relapse prevention, and cognitive therapy—when employed within the context of a client-to-program matching system typically found in Europe— consistently produce positive treatment outcomes. A statement by Miller in the September/October 1994 issue of Psychology Today puts it best: "The drug treatment community has been curiously resistant to using what works." In fact, it has been curiously attached to that which is harmful. Twelve-step groups offer what is, in reality, the antithesis of therapy. There is no cure; the solution provided by such programs entails an endless attendance at meetings. An old slogan says It best: "You never graduate from Al-Anon." And you don't; you become addicted to it, desperately hanging on to the program like a spiritual lifeline in a sea of sin and death. Somewhere within the quagmire of the AA movement and all of the twelve-step programs associated within it, the meaning of recovery was lost. By definition, recovery is a retrieval and reclamation process, not a surrender and abdication. The process of recovery or emotional balance and psychological wellbeing entails independence from addictive chemicals, compulsive behaviors, therapists, and recovery groups. To transfer dependence on chemically addictive substances to emotional or psychological dependence on a group or recovery program is not recovery in the true sense of the word.

Prior to having been expanded, convoluted, and rendered empty, the term ‘codependent’ had meaning in a limited clinical setting for a specific population. In her book Choice'-making, Sharon Wegscheider-Cruse quotes Robert Subby, director of Family Systems, Inc., of Minneapolis, who defined codependency as ''an emotional, psychological, and behavioral condition that develops as a result of an individual's prolonged exposure to, and practice of, a set of oppressive rules—rules which prevent the open expression of feelings, as well as the direct discussion of personal and interpersonal problems." Using this as a base, Wegscheider-Cruse expands her own definition: "Codependency is a specific condition that is characterised by preoccupation and extreme dependence (emotionally, socially. and sometimes physically) on a person or object. Eventually, this dependence on another person becomes a pathological condition that affects the codependent in all other relationships." These definitions are significant in that they describe so well both the nature of twelve-step programs and the relationship of the participants in these programs to their groups.
- Lemanski, M. J. (May-June 1997). The Tenacity of Error in the Treatment of Addiction. The Humanist, 57(3), 1-15. doi:10.1002/9781118316474.ch1

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 250 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about how twelve-step programs become and addiction for participants. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Peer-Reviewed Journal Article References:
Field, M., Heather, N., Murphy, J. G., Stafford, T., Tucker, J. A., & Witkiewitz, K. (2020). Recovery from addiction: Behavioral economics and value-based decision making. Psychology of Addictive Behaviors, 34(1), 182–193.

Kang, D., Fairbairn, C. E., & Ariss, T. A. (2019). A meta-analysis of the effect of substance use interventions on emotion outcomes. Journal of Consulting and Clinical Psychology, 87(12), 1106–1123.

Piper, M. E., Baker, T. B., Mermelstein, R., Benowitz, N., & Jorenby, D. E. (2020). Relations among cigarette dependence, e-cigarette dependence, and key dependence criteria among dual users of combustible and e-cigarettes. Psychology of Addictive Behaviors. Advance online publication.

QUESTION 15
What percent of alcoholics achieve life-long abstinence with or without the AA approach? To select and enter your answer go to Test.