The Relevance of Twelve-Step Recovery in 21st Century Addiction Medicine

by By Michael Miller, MD, FASAM | February 13, 2015

ASAM defines addiction as a “primary, chronic disease of [the] brain … [with] characteristic biological, psychological, social and spiritual manifestations.” It isn’t just a social or criminal justice problem—it’s a medical and public health problem. Medical diagnosis and treatment are appropriate responses to addiction; ASAM’s definition points out that “without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.” So it is a serious, potentially fatal illness, but it is treatable: recovery is possible, and happens for millions of individuals with this disease every year.

Recovery is an interesting concept. It implies not only improvement, but potentially remission. The term describes a process as well as a destination. And the underlying premise of recovery is that of hope--hope that a person with a potentially fatal illness can avoid a catastrophic outcome. “Recovery activities” are not professional treatment, but can promote recovery just as professional treatment can. One of the most familiar “recovery activities” engaged in by persons with addiction is participation in the activities of Alcoholics Anonymous (AA).

ASAM’s definition of addiction document concludes that “treatment of addition saves lives,” and it points out that “in some cases of addiction, medication management can improve treatment outcomes,” and that “in most cases of addiction, the integration of psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provides the best results.” Much of “what’s new” in the professional treatment of addiction in the past two decades has involved new pharmacological therapies that have been brought into the marketplace. But psychosocial interventions, which are “not as new,” are the foundation of the treatment most persons receive when they seek assistance from an addiction treatment professional or agency.

Traditional addiction treatment in America is derived from multidisciplinary treatment of chronic mental disease and the peer-support program of Alcoholics Anonymous, founded in 1935 by two middle-aged men who leaned on each other for hope, and described in the eponymous book published in 1939. Its subtitle indicates it is a how-to description of the path of recovery. It describes twelve steps in the process of recovery outlined by the authors. One of the evidence-based practices of modern addiction treatment, as outlined by the federal Substance Abuse and Mental Health Services Administration’s registry of Evidence Based Programs and Practices, is Twelve Step Facilitation Therapy.

There are many kinds of counseling and psychotherapy that can be helpful for the person with addiction, beyond non-specific “supportive psychotherapy” that can be offered in any setting, along with medication management or apart from such an approach. Cognitive Behavioral Therapy is arguably the most widespread ‘evidence based practice’ offered to persons with addiction. This approach challenges irrational thoughts, understands automatic thoughts and thought chains, understands the thoughts and feelings that can lead to relapse behaviors and seeks to minimize relapse by specifying unhealthy cognitions and providing practice in decoupling an unhealthy thought (“stinking thinking,” as some people say) from an unhealthy action. Dialectical Behavioral Therapy and Mindfulness Meditation are two approaches that have enjoyed increased popularity in addiction treatment in this century.

But Twelve-Step Facilitation therapy is still a tried-and-true proven approach. It is far more than advising a patient to “go to AA” and providing them a list of meeting locations and times. In Twelve-Step Faciliation, the therapist actively probes and nudges, encouraging not only attendance, but participation, in meetings; it explains the potential benefits of working with a sponsor and promotes the individual developing a relationship with a sponsor; it explores problems or psychological resistances to attendance, participation, actual “working the steps,” and the development of a sponsor-sponsee relationship; and it opens the door to “AA-related activities” such as volunteer service to one’s AA “home group” or AA “clubhouse” and involvement with AA-related social events, retreats, and local and state conventions.

Is Twelve-Step Recovery an antiquated concept or intervention? Many addiction specialist physicians contend that while the majority of continuing medical education in addiction, aimed at sharing novel breakthroughs and improving practice and outcomes, addresses pharmacotherapies, it is the psychosocial therapies which warrant at least equal attention. Some addiction medicine physicians are concerned that not only do biological interventions predominate in continuing education curriculums, but they dominate graduate medical education in addiction, and some of these physicians are concerned that fellowship training programs in addiction as well as residency programs in primary care, psychiatry, and other medical specialties should include training about and in Twelve Step Facilitation and on Twelve-Step Recovery in order for the physician to have an appropriately well-rounded educational experience and a full skill and knowledge base in the rapidly-growing specialty of addiction medicine.

Twelve-Step Recovery addresses the psychology of the person with addiction as well as the individual’s spirituality--his/her values, his/her connectedness to others, and his/her willingness to engage with others and humbly ask for help. The process of change in Twelve-Step Recovery starts with an acceptance that when friends or loved ones point out that things are amiss in one’s life, they are likely correct, and things have likely become unmanageable. And while taking personal responsibility and accepting accountability for one’s actions are considered key steps, Twelve-Step Recovery outlines that excessive self-reliance and the firm stance that “I can get myself out of this,” and “I know what to do about this,” will be roadblocks to recovery from addiction. “Getting out of oneself” and recognizing that one doesn’t have all the answers, and humbly asking for help from another human being—from a health professional or from a lay person—are behaviors and behavioral styles that are promoted by Alcoholics Anonymous and related “Twelve-Step” programs of peer support.

The term “self-help” is often used to describe AA groups, but it is somewhat of a misnomer: it isn’t “professional help,” but it is more about listening and accepting guidance from a peer or mentor than it is about using “self” to move beyond active addiction. And while Twelve-Step approaches accept that addiction is a disease and isn’t simply a sign of “moral weakness,” there is a focus on values and morals in Twelve-Step Recovery, as the individual is encouraged to engage in a process of taking a “moral inventory” of one’s life and past actions in preparation for “making amends” to others, as indicated, possible, and appropriate.

The endpoint of “recovery” from addiction, if there is an endpoint, is to change one’s life for the better, to gain stability in one’s life, and to become more functional in one’s family and in one’s community. Being responsible, being reliable, being interested in others and not just in oneself, and being a loving being who cares about and is helpful to others, are all part of recovery.

There is a group of physicians within ASAM who are concerned that twelve-step recovery is not being taught to new physicians entering this field (most physicians currently enter addiction practice in mid-career, rather than straight out of residency training). Referring to themselves as “Like Minded Docs,” they communicate regularly among each other, leaning on each other via email for support and guidance, and occasionally reaching out to ASAM regarding policies of the Society. One of their stated concerns is that continuing education programs for physicians newly involved with addiction or considering a mid-career switch into addiction medicine have more content on pharmacotherapies and less content on psychosocial therapies, and that Twelve-Step Facilitation therapy and twelve-step recovery overall are at risk of becoming ‘dying arts.’

Michael M. Miller, MD, FASAM, FAPA, is the medical director of the Herrington Recovery Center at Rogers Memorial Hospital-Oconomowoc. He is a board-certified general psychiatrist and addiction psychiatrist. Dr. Miller has practiced addiction medicine for more than 30 years and is certified in addiction medicine by the American Board of Addiction Medicine. Dr. Miller is also an at-large director of the American Board of Addiction Medicine and The ABAM Foundation. He is a past president of ASAM.


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  1. ANDREW PARK Jul 20, 2016 - 02:51 PM

    I am a friend of Bill W. And a  treatment professional for 35 years AA is not treatment it is not a counseling philosophy, one of the reasons why we get such a poor return for all our efforts is that there is a Dogmatic obstacle within the field we have not evolved from. 80 years ago there was a symbolic support that a new human support system and a brand ew profession needed each other to survive and develop. We do not utilize the wonderful research that has been accomplished if you look at 12-step facilitation groups, please go to  The training manual for project MATCH---in the informed consent no mention that othecrc self-help groups exist is present we missed a golden opportunity here it should have been self help facilitation not an explanation that 12 step groups are NOT TREATMENTare. OUR Job ethically is to provide athat Other forms exist and then provide an objective in accurate explanation of the different types of non 12 step. Self help support and being knowledgeable about them all as most rehabs have their staff knowledgeable about the fellowship there are many other issues here.I was a clinical director of detox/rehab in New York City for 20 years my recovering staff which included myself was the most difficult to train because  when you cannot separate your own recovery value system from  our ethical obligation is to Support our patients right to choose our profession get stuck and has been stuck for a diecade. All addiction professionals have to abide by ethical principles that we are not providing, again our responsibility is to provide informed consent to support the right to choose this is way too obvious a problem  that is not mentioned anywhere In NIDA or Samsa nobody is talking about it only one esteem professional in my opinion has the information and it is Dr. William White please go to his website and he has a list of all types of support entities our culture has  changed the Internet is here has anyone that's a professional gone to the Smart recovery site and looked at the tools and homework assignments that are CBT oriented I could not myself construct something more clinical IN it's EFFECIVENESS than that.I Could not construct CBT materials as effective as the Smart recovery site provides --our new generations will go to the Internet first Dr. White has a list of these meetings and sites of information and support 12-step non-12 step Internet for women secular they are all there  about 10 years ago Dr. White wrote a handout on self-help groups for Samsa please go toSAMHSA website and print out and use it it explains all the support available I cannot believe that we can't see it as a group why the rest of the psychiatric field is still laughing at us .

    PLEASE, TRY TO DEFEND THE ANTITHESIS OF MY (yes RANT) I welcome professionals who would openly reveal a biased belief system that is actually violating the constitution.


    Andrew Park LCSW-ATOD

  2. Steve Eckstein Jun 07, 2016 - 12:23 AM
    <p>I agree with Jann B.'s earlier comments that the resistance of <em>some </em>AA members to pharmacological assistance has helped to create the divide between 12 Step recovery and academic addiction medicine. In fact, resistance by active alcoholics to psychological assisstance - mostly by withholding the true nature of their addiction - &nbsp;was addressed in AA's original publication in 1939 of the text&nbsp;<em>Alcoholilcs Anonymous. </em>It acknowledged that the alcoholic him/herself was in part responsible for the skepticism many professionals felt when treating alcoholics. However, AA literature also is quite clear (in the text and via subsequent pamphlets) about the importance of seeking outside help and being open-minded to the advice of a helping professional.</p><p>That said, I believe the divide between 12 Step recovery and academic addiction medicine is largely a result of AA's non-scientific approach. The nature of addiction and subsequent recovery through 12 Step work is not easily measurable or definable. Academia can measure length of sobriety and certain facts, but is not able to tell us why this least not in a quantitative way. &nbsp;As a result, tends to avoid embracing 12 Step recovery because they cannot define it measurable scientific methods.</p><p>Fortunately to the suffering alchoholic who desires escape from the hell of alchoholism, 12 Step recovery doesn't <em>necessitate</em> understanding the process, it requires doing the process.<br /></p><p></p>The transformation to permanent sobriety results from taking action, not from taking thought. Study and debate it all you want, but his pragmatic approach continues to save lives, as it did mine, 31 years ago.
  3. Chris Weersing Apr 12, 2016 - 10:09 PM

    I am not why anyone find it necessary to say that "AA doesn't work", "AA has a low success rate" etc.  What I find even more interesting is what data they are using to support their claims, where are you finding the data to support your claims when the program is called Alcoholics ANONYMOUS

  4. Sophie Pride, RN, MSN Apr 21, 2015 - 03:54 PM

    I am appalled that a book written by two extremely disturbed privileged white males who lived in 1930s Jim Crow era America is still the "treatment " standard for addiction. AA has been ruled a religious organization by several federal circuit courts, and it is impossible to work the program without a belief in a God who magically answers prayers for the addict who prays hard enough. It is not possible to turn one's will and life over to the care of Nature, or a Doorknob, or the Group of Drunks. One is guided through the steps by someone who is only qualified by the amount of sober time they claim to have. 12 step groups are especially dangerous for survivors of rape, abuse, and other trauma when they are tasked to examine "their part" in the crimes committed against them, not to mention having to defend themselves against the unethical yet joked about 13th Step.

    AA is not treatment. 12 step facilitation centers count on repeat business as they push this "abstinence by the grace of God" model without offering evidence-based practice, without even offering a choice of support groups. Other groups have existed for decades and include Women for Sobriety, SMART Recovery, LifeRing, and SOS.

    Science, medicine, and society itself have evolved since the 1930s. The 12-Step model has not. AA has lost as many "millions" as it claims to have saved. All addicts deserve treatment that fits, even those "constitutionally incapable" of accepting faith healing. It is our responsibility as medical professionals to help them.


  5. Jonathan C. Lee, MD Apr 17, 2015 - 02:34 AM

    Thanks Mike for your excellent article! I certainly have seen the benefits of a 12 step recovery program for people who suffer from the disease of addiction.

  6. Jack Verdon MD Apr 15, 2015 - 02:45 PM

    Mike Superb per usual Excellent elucidation of Twelve Step Facillitation and the Principles of AA unfortunately prior posters critical of AA don't share my Experience with that Fellowship AA recommends that members seek out Docs with understanding of the Disease of Addiction It cautions about the use of benzos  hypnotics and MJ Maintenance AA does not oppose ANY OF THE MEDICATIONS that you have described  I have encountered some problem in that regard with NA 






  7. Mary McMasters, MD, FASAM Apr 15, 2015 - 08:56 AM
    Another important point about 12 Step programs is their cost and accessibility.  What other chronic lifelong disease has an equally accessible and cost effective (free) intervention?    Like any disease, part of our job as physicians is to recommend effective treatment which our patients can both access and afford.  I'd like for my patients to be able to access and afford all useful modalities of addiction treatment, but here at least is one they can all use.   
  8. michael white Apr 10, 2015 - 06:14 AM

    Important to note that as soon as medicine is introduced to AA members it is abused, the clue is addiction, one could condone an inhibitor, a drug that stops the effects of alcohol after it is induced, this however will not cure the isms associated with addiction.  Abstinence plus meetings has kept me sober ten years, without drugs

  9. Paul Bowman Feb 28, 2015 - 12:11 AM
  10. PB Feb 28, 2015 - 12:07 AM

    Great article

  11. Paul Feb 28, 2015 - 12:04 AM

    Read that Bill W asked Vincent Dole to work on a medication to treat alcoholism. They were friends and this publication is about the close relationship of Dole/Nyswander and how they all believed in science. All Bill W had was his 12 steps but hoped for a medical treatment.


  12. Paul Feb 27, 2015 - 11:53 PM
    by Vincent P. Dole
    Alcohol Clinical and Experimental Research 1991: Vol. 15, No. 5: 749-752.

    Download article
  13. Lena Sheffield Feb 26, 2015 - 09:16 PM

    I am still surprised and disappointed by professionals who focus on the all or nothing, right vs wrong approach to treatment.  I think we owe to all our lie RS and the treatment community to learn about the different options our clients may encounter and professionally guide them to the best match for them on the present.  Why do some addicts have years of solid recovery with one approach over another probably won't have definitive explanation other than every addict is unique. We support them. We I still response single hope and help them explore options.  We do not decide or judge.  They have family friends and society doing enough.   I regret how judgmental I've been trying to push a client and may have created more resistance and fear. 

  14. Sam Snodgrass, PhD Feb 24, 2015 - 03:54 PM

    I disagree. The underlying premise of "recovery" is not hope, but wellness. Becoming well. Staying well. By AA's own statistics, only 10.4% of participants continue with the program after the first year. What about the 89.6% that don't continue? According to AA, they failed. It's their fault. They weren't "working" the program. Or, they're "constitutionally incapable of being honest." If one defines normality as what the vast majority of people do in a given situation, then it is "normal" for people to fail in AA.

    In one section, Dr. Miller discusses the importance of pharmacological therapy for the treatment of addiction. In another section he discusses the importance of AA in recovery, knowing full well that AA, with their definition of  "abstinence" does not welcome those receiving medication into their program. This is not only disingenuous, it is hypocritical. And AA's definition of abstinence, it is killing people. Those who have an addiction to opioids, when they relapse, too many of them, they die. They need to be on medication, and they need to stay on medication. Medication to treat this brain disorder of structure and function that we call addiction. They need to get their life back. And keep it. And if those still wedded to the ideology of AA, to the beliefs of the 1930's, when there were no medications for the treatment of addiction, don't like it, then oh well. Too bad.

  15. Cam McCannell Feb 19, 2015 - 11:07 AM
    The twelve steps of alcoholics anonymous do not come from the Oxford Groups because there were twelve apostles the  Oxford Groups practised six steps all of which AA adopted but also added six which had to do specifically with a non denominational or religious numinous power and the specific effects of alcohol addiction on the character on the afflicted.  As many addicts -- probably many more -- have been harmed by the ignorant prescription or pharmaceuticals to people in recovery for AA as have been harmed by a lay AA sponsor telling a member that all prescriptions are bad. .   
  16. Joseph Mott, M.D., J.D. Feb 19, 2015 - 02:19 AM

    I agree with many of the earlier comments highlighting the drawbacks of 12-Step for many folks seeking recovery.  Although the program claims to be "spiritual" and "not religious," it's roots are in the Oxford Group, an early evangelical Protestant organization, and the 12 Steps (12, because there were 12 apostles) are taken directly from Oxford Group, which maintained that people were "powerless over sin."  Bill W. simply replaced "sin" with "alcohol" and kept the rest unchanged.

     In addition, every federal court in the land that has examined the issue has held that 12-Step programs -- despite their claims to the contrary -- are sufficiently religious that coerced attendance (for example, when a court or probation officer orders mandatory attendance at AA meetings) violates the Establishment Clause of the First Amendment of the U.S. Constitution.  This is explicitly the law in the 2nd, 7th, and 9th federal circuits, as well as the states of New York and Tennessee.

    12-Step has also been criticized for putting vulnerable folks new to recovery into the hands of untrained "sponsors" who often give unsound advice and make unduly onerous demands.  Meetings have also recently been criticized for sometimes being unsafe; with no organizational supervision (every meeting is "autonomous"), there have been numerous reports in the news of sexual harassment, and even assault, occurring in the program.

    There are a number of secular (non-religious) self-help organizations besides SMART recovery, like LifeRing Secular Recovery and Women for Sobriety.  I serve on the Board of Directors for LifeRing.  Women for Sobriety is a women's only group that keeps its meeting times and locations private to ensure the safety of its participants, some of whom are the victims of domestic violence and stalking.

    At secular meetings there is generally much more acceptance of medication-assisted recovery, much less emphasis on deficits in "moral character," and no prayer.  The focus is present-centered, avoiding "war stories," and pragmatic:  "how am I staying sober today?  What tools am I using?" Participants are also generally not required to label themselves as addicts or alcoholics, which can be refreshing for many people new to recovery.  In LifeRing, "crosstalk" is a key element of meetings, so folks in recovery are sharing their strategies for success.

     I encourage everyone to learn more about alternatives to 12-Step programs, because our society is quickly becoming increasingly secular, with more and more young people identifying as agnostic, atheist, or "other" when it comes to religion.

  17. Joseph Gerstein, MD, FACP Feb 18, 2015 - 08:55 PM
    I am surprised that along with the detailed description of the utility of CBT in aiding recovery from addictions that no mention was made of the SMART Recovery Self-Help Network. The SMART Recovery Program (Self-Management And Recovery Training) which is grounded in CBT along with several other evidence-based tools. There are about 1,500 free SMART Recovery meetings available in communities & prisons around the world. is an interactive website which receives about 120,000 unique visitors per month and has over 135,000 registrants. 30 online SMART Recovery meetings per week are available online. 160 SMART facilitators per month are being trained via an interactive online program; many are professionals. About 1/3 of regular SMART Recovery participants also attend 12-Step meetings, at least occasionally, There have been >25,000 SMART meetings in MA where 2/3 of participants are professionally referred and the majority of meetings occur in hospitals. SMART Recovery has no objection to appropriate, medically-prescribed pharmaceuticals being used in the course of recovery from an addiction.
  18. Greg Feb 18, 2015 - 08:46 PM
    In my 30 years as an addiction counselor I've been amazed by the practically obsessive attempts to push the 12-step philosophy to the forefront of treatment methodology, and to ignore research.  Does anyone remember that Bill W. once remarked that he never considered AA to be a panacea for addiction?  In fact, few people know he considered the nutritional therapy of Vitamin B3 to be perhaps the most effective means of treating symptoms of depression he found closely linked to alcoholism.  He wanted to be remembered more for promoting B3 therapy than AA itself.  The point is, support is support, and science is science.  I've never had any qualms whatsoever about my clients attending AA or NA meetings. It's their free time; they can attend or not.  If my role is to teach or persuade them to go, why do I need a clinical license and a Master's Degree?  Why did I need to take exams? (Which, by the way, never 'assessed' my ability as AA promoter.) I take my work more seriously than just encouraging support group concepts or involvement.  I see my role alternately as providing up-to-date information about behavioral therapies, relapse prevention approaches, and being a force for connection and inspiration.  We should be appalled by the slow transfer of research to practice.  There's a lot more we can do for our clients, and we're not doing it.  I think it's high time for the traditionalists in our field to recognize that our clients need the benefits of science, not more AA instruction and orientation.  
  19. Jerry Shulman Feb 18, 2015 - 08:28 PM

    Way to go Mike. 

  20. Gregory Acampora Feb 18, 2015 - 07:49 PM
    Mike, I applaud you for this excellent treatise supporting the relevance of 12-Step recovery in modern addiction treatment.  Upon careful study, the goal is to achieve "A A" = autonomy and agency.  That this method is unwaveringly spelled out, is freely and widely available, requires no Prior Auth or co-pay, has no drug-drug interactions or side effects and enjoys a success rate commensurate with all other offerings is compelling.  For some validated evidence of things that work in recovery (including 12-Step) I invite you to visit our (RRI) website.
  21. Alan Wartenberg Feb 18, 2015 - 07:39 PM

    Michael, while one of the above posters felt that the anti-medication bias of many AA members (as well as its entire leadership) is receding, I have not seen that at all. Patients on methadone, buprenorphine and even (very recently) Vivitrol, are told that they are not "clean," cannot speak at the meeting, cannot receive sobriety tokens, cannot join in on committments and in fact are still using.  They are urged routinely to stop their medications.  While it has perhaps receded with some psychiatric medications, it has NOT with many other medications, including Disulfiram, Campral and Naltrexone.

     For a physician to advise a patient on any medication-assisted treatment to go to 12 step meetings without informing them about this is very poor practice, and for many patients, it is completely inappropriate.


  22. Jann Becker Feb 18, 2015 - 06:18 PM

    Some of the divide between 12-Step recovery and academic addiction medicine came about because of resistance by some AA members to the use of any pharmaceuticals whatsoever. Newcomers were told to abandon any and all medications. While this attitude is receding, stories of members with advanced cancer refusing opiates are still told with admiration in meetings. 

  23. Valgerdur Runarsdottir Feb 18, 2015 - 05:40 PM

    Thank you dr Miller, very important part of recovery of addiction and important tool for our patients that should not be "a dying art". I have heard international lecturer and professional in addiction treatment, state that "Minnesota Model" is one treatment that has been shown ineffective (evidence based medicine... Many correlate that with Twelve step facilitation. Can you help with references to support or counteract that?

    How can one participate as Like minded docs ?  ... 


  24. Laurie Lorino Feb 15, 2015 - 05:59 PM

    Dr. Miller,

    Outstanding article on the relevance of 12 Step Recovery program for substance abuse. In a nut shell the 12 steps have taught me to :

    1.Give up

    2.Clean up

    3.Make up

    4.Grow up

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