Twelve-step program

A twelve-step program is a set of guiding principles outlining a course of action for tackling problems including alcoholism, drug addiction and compulsion. Originally proposed by Alcoholics Anonymous (AA) as a method of recovery from alcoholism,^[1] the original Twelve Steps were first published in the 1939 book Alcoholics Anonymous: The Story of How More Than One Hundred Men Have Recovered from Alcoholism.^[2] The method was adapted and became the foundation of other twelve-step programs.

As summarized by the American Psychological Association, the initial steps were six as follows:^[1]

• admitting that one cannot control one's alcoholism, addiction or compulsion;
• recognizing a higher power that can restore sanity;
• examining past errors with the help of a sponsor (experienced member);
• making amends for these errors;
• learning to live a new life with a new code of behavior;
• helping others who suffer from the same alcoholism, addictions or compulsions.

Overview

Twelve-step methods have been adapted to address a wide range of alcoholism, substance-abuse and dependency problems. Over 200 self-help organizations—often known as fellowships—with a worldwide membership of millions—now employ twelve-step principles for recovery. Narcotics Anonymous was formed by addicts who did not relate to the specifics of alcohol dependency.^[3]

Demographic preferences related to the addicts' drug of choice has led to the creation of Cocaine Anonymous, Crystal Meth Anonymous, Pills Anonymous, Marijuana Anonymous and Nicotine Anonymous. Behavioral issues such as compulsion for, and/or addiction to, gambling, crime, food, sex, hoarding, debting and work are addressed in fellowships such as Celebrate Recovery, Gamblers Anonymous, Overeaters Anonymous, Food Addicts in Recovery Anonymous, Sexual Compulsives Anonymous, Sex and Love Addicts Anonymous, Sexaholics Anonymous, Sex Addicts Anonymous, Emotions Anonymous, Clutterers Anonymous, Debtors Anonymous and Workaholics Anonymous.

Auxiliary groups such as Al-Anon and Nar-Anon, for friends and family members of alcoholics and addicts, respectively, are part of a response to treating addiction as a disease that is enabled by family systems.^[4] Co-Dependents Anonymous (CoDA) addresses compulsions related to relationships, referred to as codependency.

History

Alcoholics Anonymous (AA), the first twelve-step fellowship, was founded in Akron, Ohio on August 11, 1938 (although some speculate the date as being June 10, 1935, the date on which Dr. Bob had his last drink) by Bill Wilson and Dr. Bob Smith, known to AA members as "Bill W." and "Dr. Bob". They established the tradition within the "anonymous" twelve-step programs of using only first names "at the level of press, radio and film".^[5]

As AA chapters were increasing in number during the 1930s and 1940s, the guiding principles were gradually defined as the Twelve Traditions. A singleness of purpose emerged as Tradition Five: "Each group has but one primary purpose—to carry its message to the alcoholic who still suffers".^[6] Consequently, drug addicts who do not suffer from the specifics of alcoholism involved in AA hoping for recovery technically are not welcome in "closed" meetings unless they have a desire to stop drinking alcohol.^[7] The reason for such emphasis on alcoholism as the problem is to overcome denial and distraction.

The principles of AA have been used to form many numbers of other fellowships specifically designed for those recovering from various pathologies; each emphasizes recovery from the specific malady which brought the sufferer into the fellowship.^[8]

In 1953 AA gave permission for Narcotics Anonymous to use its Steps and Traditions.^[9]

Twelve Steps

The following are the original twelve steps as published by Alcoholics Anonymous:^[10]

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory, and when we were wrong, promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual experience^[11] as the result of these steps, we tried to carry this message to other alcoholics, and to practice these principles in all our affairs.

In some cases, where other twelve-step groups have adapted the AA steps as guiding principles, these have been altered to emphasize principles important to those particular fellowships, and to remove gender-biased language.^{[12][13][14][15]}

Most of the alternate wordings are in Step 1 and Step 12. Secular groups omit references to a deity or deities. See List of Twelve Step alternate wordings.

Twelve Traditions

The Twelve Traditions accompany the Twelve Steps. The Traditions provide guidelines for group governance. They were developed in AA in order to help resolve conflicts in the areas of publicity, religion and finances.^[16] Most twelve-step fellowships have adopted these principles for their structural governance.^[17] The Twelve Traditions of Alcoholics Anonymous are as follows.^[5]

1. Our common welfare should come first; personal recovery depends upon AA unity.
2. 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.
3. The only requirement for AA membership is a desire to stop drinking.
4. Each group should be autonomous except in matters affecting other groups or AA as a whole.
5. Each group has but one primary purpose—to carry its message to the alcoholic who still suffers.
6. An AA group ought never endorse, finance, or lend the AA name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose.
7. Every AA group ought to be fully self-supporting, declining outside contributions.
8. Alcoholics Anonymous should remain forever non-professional, but our service centers may employ special workers.
9. AA, as such, ought never be organized; but we may create service boards or committees directly responsible to those they serve.
10. Alcoholics Anonymous has no opinion on outside issues; hence the AA name ought never be drawn into public controversy.
11. Our public relations policy is based on attraction rather than promotion; we need always to maintain personal anonymity at the level of press, radio, and films.
12. Anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities.

Process

Recovery is sought in several areas, which may include physical, mental, emotional, and spiritual.^[18][19][20]

For addicts and alcoholics, the physical dimension is best described by the allergy-like bodily reaction, which results in the compulsion to continue using substances after the initial use. For groups not related to substance abuse, this physical manifestation could be more varied including, but not limited to: compulsive hoarding, distractibility, eating disorders, dysfunctional enabling, hyperactivity, hypomania, insomnia, irritability, lack of motivation, laziness, mania, panic attacks, psychosomatic illnesses, poor impulse control, procrastination, self-injury and suicide attempts.^[21][22]

The statement in the First Step that the individual is "powerless" over the substance-abuse related behavior at issue refers to the lack of control over this compulsion, which persists despite any negative consequences that the person may endure as a result.^[23]

The emotional obsession is described as the cognitive processes that cause the individual to repeat the compulsive behavior after some period of abstinence, either knowing that the result will be an inability to stop or operating under the delusion that the result will be different. The description in the First Step of the life of the alcoholic or addict as "unmanageable" refers to the lack of choice that the mind of the addict or alcoholic affords concerning whether to drink or use again.^[24]

The illness of the spiritual dimension, or "spiritual malady", is considered by many twelve-step groups to be self-centeredness. This model is not intended to be a scientific explanation, it is only a perspective that twelve-step organizations have found useful.^[21][22] The process of working the steps is intended to replace self-centeredness with a growing moral consciousness and a willingness for self-sacrifice and unselfish constructive action.^[22] In twelve-step groups, this is known as a spiritual awakening or religious experience.^[25] This should not be confused with abreaction, which produces dramatic, but ephemeral, changes.^[26]

In accordance with the First Step, twelve-step groups emphasize self-admission by members of the problem they are recovering from. It is in this spirit that members often identify themselves along with an admission of their problem, often as "Hi, I’m [first name only], and I’m an alcoholic".^[27] Such catchphrases are now widely associated with support groups. Some meetings are known as dual-identity groups which encourage attendance from certain demographics. Some areas have, for example, groups limited to women members; men's groups; and groups for gay, lesbian, and transgender individuals. Some areas also have beginner's groups as well as "old-timer" groups that limit who can share, or speak during the meeting, by the length of time the members have in that fellowship.

Sponsorship

A sponsor is a more experienced person in recovery who guides the less-experienced aspirant ("sponsee") through the program. New members in twelve-step programs are encouraged to secure a relationship with at least one sponsor.^[28] Publications from twelve-step fellowships emphasize that sponsorship is a "one on one" relationship of shared experiences focused on working the Twelve Steps.^[29][30][31] According to Narcotics Anonymous:

Sponsors share their experience, strength, and hope with their sponsees... A sponsor's role is not that of a legal adviser, a banker, a parent, a marriage counselor, or a social worker. Nor is a sponsor a therapist offering some sort of professional advice. A sponsor is simply another addict in recovery who is willing to share his or her journey through the Twelve Steps.^[32]

Sponsors and sponsees participate in activities that lead to spiritual growth. These may include practices such as literature discussion and study, meditation, and writing. Completing the Twelve Steps implies being competent to sponsor newcomers in recovery.^[28] Sponsees typically do their Fifth Step, review their moral inventory written as part of the Fourth Step, with their sponsor. The Fifth Step, as well as the Ninth Step, have been compared to confession and penitence.^[33] Michel Foucault, a French philosopher, noted such practices produce intrinsic modifications in the person—exonerating, redeeming and purifying them; relieves them of their burden of wrong, liberating them and promising salvation.^[33][34]

The personal nature of the behavioral issues that lead to seeking help in twelve-step fellowships results in a strong relationship between sponsee and sponsor. As the relationship is based on spiritual principles, it is unique and not generally characterized as "friendship". Fundamentally, the sponsor has the single purpose of helping the sponsee recover from the behavioral problem that brought the sufferer into twelve-step work, which reflexively helps the sponsor recover.^[28]

A study of sponsorship as practiced in Alcoholics Anonymous and Narcotics Anonymous found that providing direction and support to other alcoholics and addicts is associated with sustained abstinence for the sponsor, but suggested that there were few short-term benefits for the sponsee's one-year sustained abstinence rate.^[35][36]

Effectiveness

Alcoholics Anonymous is the largest of all the twelve-step programs (from which all other twelve-steps programs are derived), followed by Narcotics Anonymous; the majority of twelve-step members are recovering from addiction to alcohol or other drugs. The majority of twelve-step programs, however, address illnesses other than addiction. About twenty percent of twelve-step programs are for addiction recovery, the other eighty percent address a variety of problems from debt to depression.^[37] It would be an error to assume the effectiveness of twelve-step methods at treating problems in one domain translates to all or to another domain,^[38] therefore readers are directed to relevant sections in each group's article.

Traditional 12-step programs have been criticized for suggesting a belief in some deity or higher power, reducing their applicability and efficacy.^[39]

In one study, about 3% of people suffering from alcoholism and attending Alcoholic Anonymous were able to abstain without relapse after 12-step treatment^[40] Another study reported a 31% continuance rate after the first year.^[41]

Confidentiality

The Twelve Traditions encourage members to practice anonymity in the public media and members are also asked to respect each other's confidentiality.^[42] However, in most jurisdictions there are no laws preventing 12-step attendees from revealing information disclosed during meetings.^[43] In the United States, statutes on group therapy do not encompass those associations that lack a professional therapist or clergyman to whom confidentiality and privilege might apply. US professionals and paraprofessionals who refer patients to these groups, to avoid both civil liability and licensure problems, have been advised that they should alert their patients that statements they make in meetings may later be publicly disclosed.^[43]

Cultural identity

One review warned of detrimental iatrogenic effects of twelve-step philosophy and labeled the organizations as cults,^[44] while another review asserts that these programs bore little semblance to religious cults and that the techniques used appeared beneficial to some.^[45] Another study found that a twelve-step program's focus on self-admission of having a problem increases deviant stigma and strips members of their previous cultural identity, replacing it with the deviant identity.^[46] Another study asserts that the prior cultural identity may not be replaced entirely, but rather members found adapted a bicultural identity.^[47]

See also

• Addiction recovery groups
• Al-Anon/Alateen
• Calix Society
• Community Reinforcement Approach and Family Training (CRAFT)
• Drug rehabilitation
• Effectiveness of Alcoholics Anonymous
• Group psychotherapy
• Intervention Counseling
• List of twelve-step groups
• Recovery model
• Self-help groups for mental health
• Substance abuse

References

Bibliography