If you were to think about addiction recovery without knowing anything about it, you would probably be picturing a 12-step meeting. Since the beginning of modern addiction treatment, 12-step programs have become the cornerstone of recovery programs, so much so that they have permeated the culture as the quintessential example of what people in recovery go through in pursuit of sobriety.
Twelve-step programs started in 1939, and since then they have spread throughout the country, growing in popularity. The program is incorporated into treatment centers and other treatment philosophies, but the original principles have remained intact over the years.
With the surge of addiction research in response to the drug crisis in the past few decades, 12-step programs continue to be a mainstay in the addiction recovery world. Could it be that our first attempt was the best option? How effective are 12-step programs? In this guide, we dive deep into the philosophy, challenges, and triumphs of this decades-old solution to a disease that continues to plague the United States and the world.
What is a 12-Step Program?
A 12-step program is a set of principles designed to guide a person through personal recovery. The program is a step-by-step program guided by The Twelve Traditions, which outline the basic principles and beliefs of the program and help facilitate unity among members. The original 12-steps and traditions were pioneered by Alcoholics Anonymous (AA) and were first published in a book called Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism (or the Big Book) by Bill W., the founder of AA. The 12-step program has been applied to hundreds of addictions and disorders, with people struggling with everything from eating disorders to “workaholism” going through the 12 steps.
While the 12-steps were originally conceived without much scientific research (except that it was co-founded with Bob Smith, a physician), they recognized that addiction treatment requires healthy interpersonal connection, a concept that is still being explored today. According to the Big Book, a sense of unity is a key factor in the 12-step program.
It says, “No society of men and women ever had a more urgent need for continuous effectiveness and permanent unity.”
The program also requires its participants to admit that their use of the substance has gotten out of control. This leads members to seek and accept help in their efforts to become sober. Recognizing a higher power (a term coined by AA) is another key tenet of the 12-step program. While the original program was founded on Christian beliefs as its base, the program only officially requires members to recognize a vague and undefined deity or higher power. Finally, the program has its members examine past errors, make amends for them, and help others do the same.
History of 12-Step Programs
The 12-step program began in 1939 as the guiding principles of Alcoholics Anonymous, which pioneered a more modern treatment of alcoholism and addiction as a whole. Before AA, the United States was coming out of the temperance movement and Prohibition. While the movement was initiated in order to cut down on domestic violence and public health issues, it also criminalized addiction, and alcoholism was seen as a moral failing.
Those that struggled with alcoholism would experience different societal reactions based on their economic status. The rich could seek medical help in hospitals. But even for them, treatment was rudimentary, often using belladonna, a poisonous plant that induced vomiting. Without financial resources, people would be thrown into “drunk tanks” to sober-up.
Meanwhile, in 1921, a Christian fellowship called the Oxford Group was founded by missionary Dr. Frank Buchman. It was an organization designed to help men who were seeking a change to turn away from sin. The Oxford Group’s main goal was to facilitate a change in sinners toward four common virtues, which were honesty, purity, unselfishness, and love.
Bill Wilson joined the Oxford Group as a way to address his own addiction to alcohol after his chance at a lucrative Wall Street career was ruined by drinking. During several of his hospitalizations for drinking, he was treated by Dr. William Silkworth, who told him that he believed alcoholism was a disease rather than a moral failing, an idea that would come to be widely accepted and studied in addiction treatment.
After attending an Oxford Group meeting, Wilson returned to drinking to the point of hospitalization where he was given a belladonna mixture that included hallucinogens. While under the influence of the medication, he had a dramatic spiritual conversion experience and later re-joined the Oxford Group.
While on a business trip, Wilson experienced alcohol cravings and wanted to speak to a local alcoholic who might understand, in order to avoid relapse. Local Oxford Group members connected him to Dr. Bob Smith, who Wilson would eventually help quit drinking. Together they resolved to help alcoholics with a new program within the Oxford Group. However, he eventually split away from the group when it’s members criticized and shunned Wilson for focusing too heavily on helping alcoholics. Wilson also disagreed with the Oxford Group’s publicity-seeking practices.
After separating from the Oxford Group in New York (the Akron branch still had members devoted to helping alcoholics), Wilson proposed implementing a wide scale project to treat including a book. He wrote Alcoholics Anonymous, or the Big Book, in 1939. The book outlined the basic principles of AA, talked about Wilson’s personal experiences with alcoholism, and also includes general advice to loved ones of alcoholics.
As AA began to grow in popularity, meetings began to open up across the country. Eventually, people struggling with other addictions began to attend meetings. General meetings are open to anyone who wants to attend; however, closed meetings are only for people who expressly want to quit drinking. By 1953, Narcotics Anonymous (NA) was founded to be a 12-step alternative for people struggling with drug addiction.
Today, the 12-step program has been applied to hundreds of addictions and mental health issues. A variety of programs and support groups employ the Twelve Principles with very little deviation from the original concept.
The 12-Step Program Philosophy
Twelve-step programs are designed to provide people struggling with addiction with a way to connect to and become part of a larger whole. The first of the Twelve Principles states that “personal recovery depends upon AA (or any other program) unity.” The Twelve Principles are essentially a set of values that connect individual groups to the larger organization. For instance, the Twelve Traditions of NA help people who start new groups within NA to maintain the standards of the group as a whole. The traditions speak to both philosophical and financial principles.
Anonymity is a key component of most 12-step programs. This principle allows people to come in confidence, knowing the things they share will be kept private. It also stops the group, or it’s members, from seeking prestige and notoriety, which was one of Bill Wilson’s main criticisms of the Oxford Group.
Here are the Twelve Traditions, paraphrased so as to include 12-step groups as a whole rather than a specific one:
- The group’s common welfare should come first; personal recovery depends on group unity.
- For our group purpose, there is but one ultimate authority— a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants; they do not govern.
- The only requirement for membership is a desire to stop using drugs or alcohol.
- Each group should be self-governed except in matters affecting other groups or the group as a whole.
- Each group has but one primary purpose—to carry the message to the person with Substance Use Disorder.
- The group ought never endorse, finance, or lend the group name to any related facility or outside enterprise, lest problems of money, property, or prestige divert us from our primary purpose.
- Every group ought to be fully self-supporting, declining outside contributions.
- The group should remain forever nonprofessional, but our service centers may employ special workers.
- The group should never be organized, but we may create service boards or committees directly responsible to those they serve.
- The group has no opinion on outside issues; hence the name ought never be drawn into public controversy.
- Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of media.
- Anonymity is the spiritual foundation of all the Traditions, ever reminding us to place principles before personalities.
The Twelve Traditions are seen to have tremendous importance in maintaining the group’s integrity and continued existence. Wilson initially wrote of the AA tradition, “We alcoholics see that we must work together and hang together, else most of us will die alone.” Wilson believed that many alcoholics would die without the program and he credited AA and the Oxford Group with having saved his life. Because of that, the group’s unity is held above everything else, and the 12 traditions are not negotiable.
What Are the 12 Steps?
While the Twelve Traditions are guidelines for groups operating under a 12-step organization, the Twelve Steps are guidelines for individuals within the program. These steps have several goals. First, they are designed to help individuals admit that they can’t control their addiction and that they need outside help. Twelve-step programs emphasize the spiritual needs of someone in recovery. Many programs express the need for a spiritual awakening, like the one Wilson experienced in the hospital.
The virtues of the Oxford Group inspire many of the core ideas of the 12-steps. Wilson points to self-centeredness as a major problem for a person in recovery. In the Big Book, he mentions that people are often disappointed when they see themselves as the “actor who wants to run the show.” When things don’t go their way, they become discouraged and ultimately turn to drinking. Even today, evidence-based addiction therapies (like cognitive behavioral therapy) exist that are all about addressing the issue of living life on life’s terms, and learning how to respond in healthy ways to stress and disappointment.
The steps also seek to reconcile an individual with the people that may have been affected by their addiction, which is why several of the twelve steps revolve around making amends for past mistakes. It also helps the individual look at outside perspectives, furthering the goal of selflessness.
It’s essential for 12-step group member who read the steps for the first time that they are not expected to check off each item perfectly. Wilson writes, “No one among us has been able to maintain anything like perfect adherence to these principles.” Instead, the steps exist to help members grow spiritually. Still, it’s emphasized to be willing to attempt each one, otherwise, progress may be stalled or stopped. Here are the paraphrased 12 steps and an explanation for each:
- ADMITTING POWERLESSNESS OVER THE ADDICTION. Addiction to drugs or alcohol is a brain-altering disease. Even in the 1930s, before the science of addiction, as we know it today was discovered, 12-step pioneers knew that it couldn’t be controlled. Wilson goes a step further, saying “probably no human power could have relieved our alcoholism.” Since 12-step programs often emphasize the spiritual, it’s important to recognize that no human means can force or maintain sobriety in someone who’s addicted.
- BELIEVING THAT A HIGHER POWER (IN WHATEVER FORM) CAN HELP. AA originally points out that God “could and would” relieve alcoholism if he is sought. In other 12-step programs, spiritual help is less specific. But the goal is to open your mind to spirituality, which opens the door to hope. This step goes with the first, for a spiritual awakening in which you recognize powerlessness, it’s important to be able to trust in God’s power to initiate revival.
- DECIDING TO TURN CONTROL OVER TO THE HIGHER POWER. Here is where control of your life is moved away from self-centeredness and relinquished to God. The proverbial rubber of step two, meets the road. Wilson writes, “We must be convinced that any life run on self-will can hardly be a success.” He also asks people in the Big Book’s chapter called “We Agnostics” to remove prejudice toward spirituality and even organized religion. Ultimately, you don’t have to accept a particular religion to be a part of most 12-step groups, as long as you are open to spirituality.
- TAKING A PERSONAL MORAL INVENTORY. This is to take an honest, unfiltered look at yourself and your flaws. The purpose is to identify spiritual thorns to be removed. Resentment is a major example, which Wilson identifies as the “number one offender” that destroys the spirit. This inventory seeks to root out personal flaws, negative feelings, and their cause. Many of the pains and resentments you harbor may have their root in your resentments. Taking an honest look at them is crucial to avoid them returning to cause problems in your sobriety later down the road.
- ADMITTING TO THE HIGHER POWER, ONESELF, AND ANOTHER PERSON THE WRONGS DONE. Identifying flaws is one thing. Openly admitting them is another. Admitting them to yourself means acknowledging that your shortcomings are truly flaws that need to be addressed. Admitting them to God means letting them go and giving them up. Finally, admitting them to another person means being vulnerable and asking for accountability.
- BEING READY TO HAVE THE HIGHER POWER CORRECT ANY SHORTCOMINGS IN ONE’S CHARACTER. Sometimes a person can identify flaws without really being willing to give them up. You may find that you harbor resentment towards your spouse for the way they handled you during active addiction. But what if you have an opportunity to talk about it and forgive them? Would you be ready? This step is about willingness to no longer live in the shortcomings of you past.
- ASKING THE HIGHER POWER TO REMOVE THOSE SHORTCOMINGS. This is the spiritual element of the program continued and made deeper. God is instrumental as a source of strength in people seeking a spiritual change. This step also teaches the spiritual principle of humility. To give your hope for change over to God means letting go of trying to control your life, which was addressed in step one. Because we are not able to make this deep and meaningful change in our lives, we must look to a higher power to do it.
- MAKING A LIST OF WRONGS DONE TO OTHERS AND BEING WILLING TO MAKE AMENDS FOR THOSE WRONGS. Here, in Step 8, members will revisit the inventory list that was made in Step 4. Specifically, this is about looking at all of the people and institutions that you make have harmed in your past. In this step, you must mentally, emotionally, and spiritually prepare to make amends with everyone on the list. The task may seem daunting, but it’s essential. This step helps you to step outside of yourself and look at the people in your life in love, a key spiritual principle.
- CONTACTING THOSE WHO HAVE BEEN HURT, UNLESS DOING SO WOULD HARM YOU OR THE PERSON. Here is where your preparation in Step 8 comes to fruition. It’s often the most dreaded step of the 12 because it requires you to confront people who may be harboring grudges. But it can also mean opening up to loved ones in a way you never have. This step can take the form of apologies or even financial restitutions. Whether you fear the cost or the potential judgment, this step is crucial in leaving your past behind you.
- CONTINUING TO TAKE PERSONAL INVENTORY AND ADMITTING WHEN ONE IS WRONG. In Step 10, group members must acknowledge that spiritual growth and recovery is an ongoing process. By committing to vigilantly take stock of your inventory, you are committing to maintaining the spiritual principles you have learned in the first 9 steps.
- SEEKING ENLIGHTENMENT AND CONNECTION WITH THE HIGHER POWER VIA PRAYER AND MEDITATION. Step 11 furthers your striving towards spiritual virtue. Still, this isn’t just freeform prayer as it is sometimes seen in media, as a person wishing for something, as upon a star. It can be easy to fall into a pattern of hoping and praying for gain, or for things to be easier. Instead, this is a humble prayer asking for God’s will to be revealed and for you to have the strength, courage, and desire to carry out that will.
- CARRYING THE MESSAGE OF THE 12 STEPS TO OTHERS IN NEED. Finally, the steps, lessons, and people that got you to spiritual growth and sobriety should be taken to others. Since the process is designed to remove a selfish focus, foster humility, and encourage love, it’s only natural that your focus would shift to helping other in this last step. Still, Steps 10 and 11 continue to be relevant as you pursue helping others.
Other Important Facets of 12-Step Programs
There are several other important factors that go into most 12-step programs that help people through the steps. Here are some important things to know about the 12 step models:
Sponsorship is the cornerstone of the 12-step model. Wilson believed that an alcoholic’s best chance at sobriety was to have other recovering alcoholics come alongside them. A sponsor is an experienced member that has already completed the 12 steps and is committed to helping other people do the same.
They can help offer spiritual guidance and practical advice in going through the steps in their own life. However, sponsors aren’t limited to guiding members through the steps. They often help people in other areas of life as well. From handling challenges at work to pursuing balanced finances, a sponsor can help you overcome challenges and pursue positive goals in sobriety. As daily communication is sometimes necessary, it’s important to choose someone who is willing to commit.
Conversely, the sponsor might reach out to you every day and it’s important to be open to honest and frequent accountability and communication. If you choose a sponsor and for whatever reason, it doesn’t work out (i.e., you feel like you can’t open up to them, they don’t answer their phone, they live too far away) you can switch at any time.
Meetings are when groups come together to discuss challenges, share triumphs, and generally discuss sobriety and the program. Meetings are never mandatory, but they are strongly encouraged. Meetings allow you to get connected to other people that share your goals, learn ways to manage sobriety in your daily life, and vent frustrations you might be having. Meetings are also a safe place to go if you ever find yourself in a crisis.
Meetings can follow different formats and serve different purposes. For instance, some meetings may be gender specific; others may for the purpose of going through specific steps. No matter the format, meetings all share the common goal of offering support to people in the program and help through the steps.
Meetings that a member regularly attends (often several times on a weekly basis) are called homegroups. Attending a homegroup is important for sobriety maintenance and maintaining Steps 10, 11, and 12. You may also be given tasks to complete in preparing or managing a homegroup. This can mean anything from setting up chairs to corresponding with the group for announcements and scheduling.
The term fellowship refers to the members of the program as a body. More specifically, fellowship is defined as the members of the program coming together to connect and support one another. Since alcoholics and people with Substance Use Disorder helping one another was a key component of the 12-step program as Bill Wilson envisioned, fellowship is the key to a successful 12-step program and ensuring long-lasting recovery.
The fellowship you are a part of also helps you forge connections with people who are sober. It can be dangerous to socialize with old friends who are still using and difficult to exclusively have friends who can’t empathize with someone in recovery. Having a family who understands addiction and recovery is a tremendous help in your pursuit of recovery and relapse prevention.
However, it is important to note that the fellowships you encounter are not the program itself. If you find people that are, at times, unsupportive, they may not reflect what the program is all about. Remember that people are fallible and don’t be discouraged if you meet unsavory characters. Besides, they are going through their own struggles and challenges.
Spirituality Apart From Religion
AA, and subsequent support groups, are careful to avoid specific political and religious ideologies. The purpose of 12-step programs is to welcome anyone that is looking to abstain from alcohol or drugs. Therefore, spirituality is stressed over any specific religion. It’s true that some of the parallels are obvious. Twelve-step group meetings are a place where people gather to grow spiritually; to some, that may seem like a religion.
Plus, the program’s roots in the Oxford Group causes it to have some similarities to the practice of Christianity, especially the first-century church. However, the recognition of a specific deity (especially in today’s 12-step programs) or merely a nondescript higher power is left up to the individual. There are variations on the 12-step model (see section on variations) that either reject spirituality altogether or embrace the God of Christianity specifically.
Popular 12-Step Programs For Chemical Addiction
After Alcoholics Anonymous started to grow in popularity, the 12-step model began to be applied to more and more forms of addiction and mental health issues. AA is still a strong presence in the recovery community but now they share the stage with many other 12-step groups. Several groups exist that are centered on treating people with addiction and their families. Here are some of the biggest programs open to people who have been affected by addiction:
- Narcotics Anonymous (NA) – The first group to adapt the 12-step model after AA. NA is designed to help those who are looking to recovery from drugs, specifically narcotics. Their principles and steps are nearly identical to AA.
- Cocaine Anonymous (CA) – In the top three largest 12-step programs, CA is a mirror of the original 12 steps directed at cocaine users specifically.
- Crystal Meth Anonymous (CMA) – A fellowship 12-step program specifically geared toward recovery from methamphetamine. They have their own literature, similar to the Big Book. However, their traditions and steps are very similar to AA.
- Nar-Anon and Al-Anon recognize the now common phrase, “addiction is a family disease.” The two programs are support groups for families of people in narcotics and alcohol addiction, respectively. Though the language is modified for friends and families of addicts and alcoholics, the 12-steps and traditions are the same as AA.
Variations on 12-Step Programs
While many 12-step programs are similar, if not identical, to the original traditions and steps of AA, there are a few variations that have taken the basic ideas of 12 step programs and changed some of the core principles. This is usually to cater to a specific group of people. Here are two of the biggest examples of 12-step variations:
- SMART Recovery – SMART Recovery rejects the idea that spirituality and spiritual growth are essential components in addiction recovery. Instead, they take a cognitive behavioral approach which examines your thinking. Instead of acknowledging powerlessness, they seek to empower members by enhancing motivation to abstain, resisting urges to use, managing life’s problems in effective ways, and developing a healthy lifestyle.
- Celebrate Recovery – Celebrate Recovery’s core tenets are closer to the original 12-step program except it fully embraces a Christ-centered approach to recovery. The 12 steps are very similar to AA’s 12 steps but are more specific when it comes to the acknowledgment of a higher power. Plus, each of the 12 steps is backed up by a supporting Bible verse. For instance, the second step is, “We came to believe that a power greater than ourselves could restore us to sanity” and it’s supported by Philippians 2:13 which says, “For it is God who works in you to will and to act according to his good purpose.”
Do 12-Step Programs Work?
Since the 12-step model is all over the world and in addiction treatment facilities across the U.S., it’s critical to ask one of the most questions in addiction treatment: Does the program work? Many of the largest programs keep track of progress with member surveys. However, their technique and accuracy are called into question because of problems with methodology. One Health and Human Services study said that reporting from organizations like AA, NA, and CA is “viewed as not being scientifically rigorous and as based on self-selected convenience samples.” Still, the reports provide some insight, especially when it comes to attendance and the average length of stay.
Reports show that the majority of people attend more than one meeting per week and close to or more than half of people who attend AA and NA meetings have been sober for more than five years. Other studies have confirmed the value of 12-step meetings on a clinical level. One study showed that people that participated in AA fellowship for 27 weeks or more had longer periods of abstinence than people who weren’t treated. Meeting attendance has also been associated with improved psychosocial functioning and self-efficacy (belief that you are capable of resisting drug cravings).
When 12-Step Programs Fail
In some circumstances, 12-step programs are not enough to facilitate recovery. A major example of this is in cases of dual diagnosis, or a co-occurring mental disorder. Since the 12-step model elevates spiritual needs and change, other areas may not be addressed. A person with a dual diagnosis needs to have psychological issues addressed that a 12-step program wouldn’t be equipped for. However, a 12-step program may be useful as complementary to another form of treatment.
12-Step Programs With Other Treatment Options
The most effective use of a 12-step program might be in conjunction with other treatment options and as part of the continuum of care. For instance, people who go through detox, intensive outpatient treatment, and then outpatient treatment can also attend 12-step meetings during and after treatment.
This does two things. According to the National Institute on Drug Abuse (NIDA), groups can offer an additional layer to treatment that connects you to the community level, allowing you to gain more support. Second, 12-step groups are an excellent form of aftercare. Once you’ve completed treatment, you can continue to attend meetings indefinitely to maintain your sobriety and prevent relapse.