Quality & Science

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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    This article is 5 years old and still drawing comments. Hopefully that means that ASAM has NOT started a 12 Step Facilitator group. The 12 step programs are only 1 approach to helping those with addictions, yet professionals seem to forget that fact. Not everyone will respond to the religion of AA and yes, it has been legally deemed a religion. 

    PLEASE move into the 21st century and use the sciences of medicine and psychotherapy to help people with addictions.

  11. Bill Wolf (Bill W, lol) Sep 17, 2019 - 09:43 AM

    Very relevant and insightful article, thank you.  12 Step (AA and NA) groups retain a much larger presence in most communities than their more modern, and far more secular counterparts, such as SMART and Life Ring.  This is very significant, for a large number of people seeking recovery may not be currently involved with inpatient or outpatient programs.  And working one on one with a therapist, well, we're limited to an hour or two a week.  Peer support with AA or NA is potentially 24/7. This support can prove very critical to the first days and weeks sober. 

    The reluctance of traditional 12 Step governing bodies to secularize their official literature is not as yet a huge hindrance for the majority of folks seeking their help, and their is a rise in "unapproved" 12 Step literature (Staying Sober Without God; Twelve Secular Steps: An Addiction Recovery Guide; The Alternative 12 Steps) and "free thinker" meetings available to help meet the diversity and to evolve the 12 Step approach by incorporating evidence based concepts and methodologies that have come about since 12 Step's 1930's origins.

    The time seems right to promote the Twelve Step Facilitation model.  A team approach makes sense.  Many medical clinicians are likely seeing addiction related pathologies on a daily basis, and to remark to their patients "You should cut back or quit" during a 15 minute evaluation isn't going to cut it.  A team approach is needed between, for instance, primary care clinicians, mental health and addiction specialists, and community 12 Step resources.

  12. Debamalya Dey Aug 31, 2019 - 03:10 PM
    hi. there might not be a medicinal solution but can you give me some insight about the treatment for social media addiction or mobile addiction. I am dropping my email id
  13. Glenn Kulik Jun 07, 2019 - 04:27 PM
    this is the future
  14. John K. Jun 05, 2019 - 05:56 PM

    Timothy Edwards's post  Mar 17, 2019 is disingenuous to put it mildly, and a lie by omission to be frank. To claim "AA has no interest in outside issues and it is not affiliated itself with any institution, medical treatment or organization" is not true in the sense that most would commonly associate with "affiliate."


    Groups like the ASAM, NCADD and others are CERTAINLY affiliated with AA and other 12 Step groups.  That's WHY the ASAM has a such a quack definition of addiction! ONLY in 12 Step groups is "addiction" classified as a "spiritual malady."


    Anyone relying on criteria from the ASAM is playing with fire, legally speaking. 12 Step groups have never been found to be safe or effective treatment for compulsive behavioral syndromes.  The ASAM is basically one gigantic class action suit away from oblivion.

  15. Joseph Martin May 03, 2019 - 10:20 PM

    ASAM defines addiction as a “primary, chronic disease of [the] brain … [with] characteristic biological, psychological, social and spiritual manifestations.”

    This is not even a currently accepted definition of abuse disorder, completely made up pseudo-science.


    See: https://rationalwiki.org/wiki/Alcoholics_Anonymous

  16. Agni May 01, 2019 - 04:03 AM
    Addiction seen solely with an allopathic lens is wholly ignorant.  It is not correct metaphysics.  It's absent of mythology.  And it is Literalism 101.  And a rigid fundamentalism (literalism) does not replace a missing imagination.  The poetic motions of nature are not a disease.  We are nature.  Not separate, but distinct.
  17. Timothy Edwards Mar 17, 2019 - 03:46 PM
    This article, and the comments that follow, miss a critical point:  AA has no interest in outside issues and it is not affiliatrditself with any institution, medical treatment or organization.  Inexplicably, many (if not most) treatment centers have incorporated AA teachings into their treatment protocol, requiring their patients to attend AA and even holding meetings in their facilities.  Similarly, courts force people into AA, with complete disregard for the fact that is meant for people who have a desire to stop drinking.  As AA does not enforce its traditions, these practices are rarely challenged or exposed for what they are: flagrant, opportunistic violations of AA traditions with no regard whatsoever for the well being of the fellowship or the program.
  18. Ann Dec 28, 2018 - 10:00 AM

    Only because someone mentioned it, and the comment is old - I'd still like to offer my two cents. I am an extremely active member of Narcotics Anonymous (NA). Regarding medication - never, ever have I heard of anyone telling someone not to take medication PRESCRIBED BY A DOCTOR to treat mental and health issues. We consider an addicts relationship with their doctor "an outside issue." I suffer from Panic Disorder and GAD. I will be on meds for the rest of my life. Yes, I have to be perfectly transparent and open with my doctor. He knows my background, and will never give me a medication that might alter my mind unless it is absolutely necessary (surgery, terminal illness, etc.). 

    The program of NA works...like many said above, if you actually live and work the program. I tried many other avenues before arriving here, and I can't imagine another way, FOR ME. 

  19. Tamara Brereton Nov 11, 2018 - 08:55 AM

    Wow.  Does the medical field take into account the intangiable life that’s in us—the “life” that moves around our bodies?  What we call our spirit or soul.  What pill can fix that?  What pill do they have that will make us put down our useless thoughts?  To move a muscle or change a thought?  Nothings so bad a drink/drug wont make worse, we’re only as sick as our secrets, be part of the solution, not the problem,before you say i can’t...say i’ll try, remember that alcoholism/addiction is incurable, progressive and fatal.   Ive been living with an addict for 30 years whos now so digressed that he can only not smoke crack unless hes living in a rehab.  As soon as he gets out, he picks up.  The last 15 years he’s  have had short periods of sobriety because he wanted to have a life, and AA and church provided that way of life.  The medical field said he needed anti depressents, anti anxiety, mood stabalizers and some reccommended cognative therapy.  The anti anxiety are benzoids😳- hes an addict. What an incredibly insane time that was for my children and I. Here he was now fighting one more drug he got addicted to. The doctors thought of me as uneducated,  and so decided I really didnt know what I was talking about,  While we got to deal with those years  of chaos his prescription brought to our lives.  The mood stabalizers and anti depressents made him just as doped up as the crack. The cognative therapy dove into reasonable connections - a chance for some truth to come into him.    Hes now been in their facility for over a year with constant care, drugs and AA/NA  meetings, came out and picked up a drink right away and then crack.  Theres not a pill in the world that will make his brain live life on lifes terms.  And as long as the medical community is giving him drugs —what else can he be? Giving them drugs and AA meetings is stupid.   AA doesnt consider that sober- so why does the medical field insist on saying they have the answers?  Naltrexone helps with cravings for alcohol- what about the part of them that doesnt want to take anything that’ll disrupt the craving?  What about the sick part of their minds that insists on being able to drink/use and nothing bad will happen— their refusal to accept that it is the way it is? All the medicine does for an addict is keep them in a mindset where they need drugs to live.  All of the alcohol and drugs change his chemical make up.  If they don’t really want to face how horrible their use is and how destructive their use is to everyone and themselves, there is no chance of any recovery.  AA works if you work it.  You get paid if you have a job.  You have a house if you pay your mortgage (and taxes🙄). You have friends if you can be a friend. You get saved from your sins if you give them up— not bury someone else with them. They have to really want to live differently and their best chance is to go through life like the rest of us.  That whole world— alcohol and drugs is spiritual.  “Wine and spirits”.  AA’s tough love is real- my husbands been dead inside for years and his life is strangling the rest of us.  So now, he’ll be left in a facility that gives him all kinds of meds, and thinks AA doesnt work for everyone- never acknowledging he wont pick up the programs tools and never acknowledging he’s a zombie. He will be left thinking about how his family and friends abbandond him without a thought of any responsibilty on his part and the ruin he caused for his family.  AA calls his condition “self will run riot”.  I know many sober and clean people and its because they have taken inside their hearts the 12 steps AA lives. It focuses on getting away from your own self-obssession and serve another person.  These principles come from an original book that said God spoke a Word to create life— and that Word can hold fast and keep any alocoholic or addict if they would be willing to give their hope to Him.  May we all find Him now.     

  20. Michelle Oct 28, 2018 - 10:31 PM
    Hello. I am doing  research paper on what is long term recovery and how long does one take to recover. I strongly believe that twelve step programs is an important aspect of long term recovery and want to know your opinion on that.
  21. Mark Hufford, CADC-II Aug 29, 2018 - 07:51 PM

    As an addiction professional who has worked in the field for 21 years I would be negligent in my duties if I did not inform my clients about the availability of AA as a potential avenue for recovery. I also let them know of other options such as SMART, rational recovery, etc. They invariable return to me saying "all I can find around town is AA". I encourage them to use what is available if they choose to do so. I educate them about the program of AA, the fellowship (which is not the program) and what AA's official stance is on medications (there is none other than it's between the alcoholic and their doctor). I educate and encourage them on all of these things so they are not at the mercy of any uninformed alcoholic in AA.

    It's interesting to read the comments, pro and con about AA and other 12 step programs. Much of which I agree with. What I did not see mentioned is that AA doesn't enter into this debate about how 'successful or effective' their program is; because they aren't selling or promoting anything. Period. AA offers a spiritually based program to help one find a connection with a higher power that many have found helpful in staying sober. Period. All this other chatter and debate is not what AA is about or even pretends to offer. This debate about the success of a program that is a voluntary offering of a chance to live sober is, frankly, ridiculous. It's truly a take it or leave it kind of deal. If the court orders you to go to AA and you feel you're rights are being violated then you might be better served taking that up with the court then blaming AA. There are three facts that are not legitimately debatable: 1) Many people have gone to AA, got sober and remain that way. 2) Many people have gone to AA and decided they didn't want to go back. 3) Addiction will kill some people who are afflicted regardless of the best efforts of the best of us.

    Maybe our energies would be better focused on a debate that isn't pointless.

  22. Alan Jul 02, 2018 - 02:21 AM
    Thank you. Twelve Steps and AA culture is a great bridge to extended self help. It works great when most of those working together come from diverse backgrounds. In my humble opinion, it gets difficult when the professional treatment world extends so deep into self help that they begin to set the standards for CBT in terms of acceptable attitudes. I am disheartened by the almost organized labor or mob influence on the traditional meetings.
  23. James Jun 29, 2018 - 03:03 PM
    It is gratifying to learn that not everyone at ASAM is being bamboozled by the Pharmaceutical Industry.
  24. Rich May 01, 2018 - 02:48 PM
    I forgot... the Surgeon General of USA published a very important report in 2016. All his commenst about AA are very positive. And they were maybe 300 Ph.Ds that help him dressed that report: https://addiction.surgeongeneral.gov/. So if you care about science it's a nice place to start.
  25. Rich May 01, 2018 - 02:37 PM

    I'm sober since 1999, with AA and by the grace of my Higher Power. No religion for me. Meetings, sponsor, litterature and 12 steps every day if possible. I live a wonderful life, quiet and stable. My only enemy is my ego. He often try to bring me back to the "Old Me"... but AA, my sponsor, my sponsees and other members are always there to help me. And I'm there for them.

    The rest is just BS. But some people like BS, it makes them feel. No my case anymore. Wish you the best.

  26. Kyle nelson Apr 03, 2018 - 04:28 PM
    Dr.Miller, if it were that simple, we wouldn't be discussing the issue at all. I have experienced both sides of the fence so to speak. I've been the guy in the back of the room who couldn't put 24 hours of sobriety together, life in shambles, family gone, and without the ability to function in society.   On the other hand I have worked in the treatment field, worked the program in every aspect of my life, as well as sponsored countless people.  The sponsorship is where I have the "BEGINNING" of difficulty, not that it's all bad. Especially when it comes to forth step.  A person who has resentments should be made to see their part in their resentment. All to often though the addict is made to blame.  A sponsee of mine was raped in jail and he had put it on his forth step.  So he had sexual issues, self worth issues, ECT.  I deferred to my sponsor on how to deal with such a resentment. He and his sponsor both told me to tell the kid, yea, it was bad, but you put yourself In jail, so it your fault. I've taken enough psychology to know you never under any circumstances  tell a rape victim it's their fault that they were raped. I told him to defer to a mental health professional, and for a time he improved. Later after being forced back into AA by the legal system he was again told on a fourth step that it was his fault for being raped. But this crazy "tough love", "it's your fault"  "now learn some humility and fix it", kind of thinking permeates AA to it's core.  The kid did stay sober, his determination was so strong the police found him with both barrels of a shotgun in his mouth and the back of his head splattered against the wall. Next to him they found and unopened bottle of wiskey and a note saying "this is how bad I don't want to drink". You see, he had floundered in AA and so of course the finger was pointed  at him for failure, by his family, by the program, and most people he knew. This is just one of countless horror stories. If you look at the founder. I realize that most believe AA  was co founded by Dr. Robert Smith M.D.  In reality, Dr. Bob was the first person to have tried the program and had any success. Everyone Bill Wilson tried his program on previously failed miserably. But looking at the heart of the origins of the program, and I dont mean the Oxford groups of whom Bill Wilson would derive his 12 steps from their 6 step program, I mean at the thinking of Bill Wilson himself. He says in his biography that he had a literal disease that left him virtually powerless over every vice and compulsion he indulged in.  AND I don't say this to degrade In anyway the hardworking and caring people of AA. Heaven knows, the vast overwhelming majority of AA's have their hearts in the right place, but the whole thing is based on an excuse. The idea of having a disease took the heat off of Bill.  The program  slowly built up around that notion that there's a disease to blame. After 20 years of life experience, and a lot of academia,  I believe the problem lies in unintentional conditioning. Really a learning disorder to put it in other terms. Susceptible individuals, usually because of one form of trauma or another seek out relief. By repeated chemical administration the brain slowly starts to think that chemical is necessary for survival. Probably because the instinctual systems become involved. When a compulsion is more powerful than a individuals desire for oxygen, and food ECT.  Words are useless, consequences will have no effect. Mostly because a person can't directly access the sub conscience.  But you can unlearn something. Email me for the real solution
  27. Chiaro Mar 19, 2018 - 06:37 PM

    A lot of people get wrapped up in abusing psychoactive substances that make them feel good.  Physical and psychological dependence ensue.  Both states of withdrawal may ensue.  There are people who just need motivation and life change to get away from their addiction.  There is another class of people who cannot stop.  The 12-steps are being attacked because they can't do anything for you.  You have to use the 12-steps for them to help you.  I have the disease, nothing else could help me. 

    When a service is offered (especially in a crisis), that service is expected to work.  In the case of the addict, simply providing 'treatment' cannot be viewed the same way as other services.  Substance abuse detox that transitions to the 12-step program requires a level of immersion on the end of the user.  I used to HATE hearing 'It works if you work it'.  But... it's true.

  28. kate Feb 05, 2018 - 06:45 AM
    Excellent, insightful, and an important point to acknowledge the value od 12 step work in fostering long term support and personal growth necessary to sustain recovery over the lifespan of a person suffering addiction.
  29. Crystal Jan 08, 2018 - 07:46 PM

    Sorry,I did not give my email which is Vampires@Yahoo.com. THANK YOU SOOOOOOO MUCH!!!!!!!!!!!!!!!


  30. Crystal Jan 08, 2018 - 07:44 PM
    i have an uncle that smokes up to two packs a day and no matter how many times i tell him to stop he just ingnores.I thinks he needs some serious HELP. Please, i hope you can email me to give him some advice.
  31. Adam Sledd Dec 02, 2017 - 09:50 AM
    The growing pile of bodies that our treatment system leaves in its wake is the evidence base for 12 step facilitation. It's time to stop propping up this folk remedy and move into the 21st century. Articles like this from the board which is taking over all assessment protocols nationwide are unethical and irresponsible.
  32. William Nov 14, 2017 - 11:07 PM
    In 2003 Congress ruled that 12 Step Programs are Religious Activities and not acceptable to be funded by HHS/SAMHSA Funding. My question is why do so many State Substance Abuse Agencies ignore this law and allow their providers to mingle religious 12 Step Activities with real treatment?


  33. 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 occurs...at 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.
  34. 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

  35. 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.


  36. 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.

  37. 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 






  38. 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.   
  39. 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

  40. Paul Bowman Feb 28, 2015 - 12:11 AM
  41. PB Feb 28, 2015 - 12:07 AM

    Great article

  42. 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.


  43. 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
  44. 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. 

  45. 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.

  46. 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. .   
  47. 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.

  48. 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. smartrecovery.org 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.
  49. 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.  
  50. Jerry Shulman Feb 18, 2015 - 08:28 PM

    Way to go Mike. 

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