Quality & Science

Editorial Comment 7/28/2020: Masks and the 12th Step

by Editor-in-Chief: Dr. William Haning, MD, DFAPA, DFASAM | July 27, 2020

EDITORIAL COMMENT:  Masks and the 12th Step


In Stephanie Brown’s “Treating the Alcoholic” there is a section entitled “a psychological view of the 12 steps.” While paralleling the process of recovery - employing a 12-step model - with psychotherapy, she and George Vaillant have made the case for it being a maturational process.  This is not surprising. When one compares the unconscious defense systems to each of the levels of function represented by those 12 steps, there is an eerie parallel. The most primitive defenses such as denial are addressed earliest; and the most mature defenses, such as altruism, become components of the last steps.  Using Vaillant’s scheme, those defenses are organized thus: 

  • Level I – pathological defenses (psychotic denial, delusional projection)
  • Level II – immature defenses (fantasy, projection, passive aggression, acting out)
  • Level III – neurotic defenses (intellectualization, reaction formation, dissociation, displacement, repression)
  • Level IV – mature defenses (humor, sublimation, suppression, altruism, anticipation)

Separately, the 12 steps of AA, NA, and Alanon are clear and elegant, and deserve to not be abbreviated.  Most of the readers will have considerable familiarity with the full-text version of these steps.  But for this discussion, what is needed is a mnemonic, a reminder of the general nature of those steps.  Mine is: Surrender, Hope, Trust, Inventory, Confession, Readiness, Petition, Butcher's Bill, Payment, Maintenance, Communion, Action & Aid.


What has this to do with masks, with infection barriers during a pandemic? Fabric infection barrier masks are the material representation of altruism.  Unlike N95 masks and protective costumes, their primary function is notto ward off infection, not to defend against acquiring the virus. The masks markedly reduce the expulsion of the virus into the surroundings, and thus reduce the likelihood of giving the virus to others. Happily, while wearing a fabric mask alone and wearing it solo is only weakly effective against acquiring contagion, when worn in the presence of others who are all wearing their fabric masks, it provides nearly complete protection for all.  In the words of my partner, “…Mask-wearing is mostly about doing something for the good of others.” 


Notably, in examining the success of some countries, there appears to be a correspondence between success in infection control, and the regional tradition of mutual reliance.  It is as if the benefit accrues to cultures with higher titers of altruism. 

William Haning, MD, DFASAM