Eric K. Mason
November 3, 2015
Effectiveness of 12-Step Self-Help Group: Literature Review
Self-help groups, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) have been a staple in the addictions self-help world for nearly a century. In addition to AA and NA, there are many other self-help groups with similar acronyms, such as CA (Cocaine Addicts Anonymous), GA (Gamblers Anonymous), and SLA (Sex & Love Addicts Anonymous). Collectively, these self-groups are known as 12-step groups, as their most important guiding principles are found in 12 steps, which people with substance use orders are told to follow in order to achieve sobriety and recovery from addiction.
The 12 steps are as follows:
- We admitted we were powerless over alcohol – that our lives had become unmanageable.
- Came to believe that a power greater than ourselves could restore us to sanity.
- Made a decision to turn our will and our lives over to the care of God as we understood Him.
- Made a searching and fearless moral inventory of ourselves.
- Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
- Were entirely ready to have God remove all these defects of character.
- Humbly asked Him to remove our shortcomings.
- Made a list of all persons we had harmed, and became willing to make amends to them all.
- Made direct amends to such people wherever possible, except when to do so would injure them or others.
- Continued to take personal inventory and when we were wrong promptly admitted it.
- 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.
- Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.
History of Addiction Treatment
Although many people tend to have the misconception that all addiction treatment sprung from the concepts of 12-step groups like AA, the study of addiction in the United States can be traced to a century before the founding of AA. One of the pioneers of addiction treatment was Benjamin Rush (1746-1813). Rush was one of the first and most prominent physician in colonial America. Rush was highly concerned with all aspects of public health. He was a prolific writer, an educator, and a social activist. He is often referred to as the “father of American psychiatry” (White, 1998). Indeed, he may rightly be referred to as the “godfather of alcoholism treatment.”
Rush published one of the first condemnations of alcohol in a 1782 newspaper. His article, “Against Spirituous Liquors,” called on local farmers to stop the practice of providing daily rations of liquor to their laborers. Rush contended in his article that the rations hurt the workers’ health, and being a true American pragmatist, their productivity, as well (White, 1998).
Rush’s greatest contribution to the field of addiction treatment was published in 1784 in the form of a 36-page pamphlet called “An Enquiry into the Effects of Spirituous Liquors Upon the Human Body, and Their Influence Upon the Happiness of Society.” “Enquiry” was published just as the consumption of alcohol was on the rise. In 1792, the annual per-capita consumption of alcohol was 2.5 gallons. In 1810, it was 4.5 gallons (White, 1998). In “Enquiry,” Rush interwove morality, science, and psychology to make his point against excessive alcohol consumption (White, 1998).
Rush’s views on addiction were before his time to say the least. Rush was, perhaps, the first to allude to alcoholism as a disease. He is considered to be the originator of the disease model of alcoholism (Maxmen & Ward, 1995). Furthermore, Rush believed that many alcoholics used alcohol to self-medicate—noting that many alcoholic women began drinking, hoping to get relief from menstrual cramping. He proposed the building of “Sober Houses,” the equivalent of our modern day rehabilitation centers. The idea that alcoholism was a disease to be treated, and controlled through abstinence was seen as ridiculous by many contemporaries of Rush (White, 1998).
Although Rush was able to identify many scientific explanations for addiction–such as the disease model, the self-medicating theory, as well as a genetic component to alcoholism (noting that it appeared to be intergenerationally transmitted)–addiction was viewed in unscientific terms by most in the 18th Century. That is, it was usually regarded as a moral downfall of the individual–a “disease of the will.” Nevertheless, Rush’s description of addiction as a physiological disease ultimately prevailed—remaining influential over 200 years later (White, 1998).
One of Rush’s original hypothesis would show up later in the psychoanalytic literature. He hypothesized that alcoholism was “suicide perpetrated gradually” (White, 1998). “Rush postulated that some people’s drunkenness sprang from a hidden desire for self-injury, and he conceptualized the bottle as a potential instrument of self-harm” (White, 1998). This line of thought would be revived in psychoanalytic literature by Dr. Karl Menninger some 152 years later (White, 1998).
Another pioneer in addiction treatment, Billy Clark, founded the Union Temperance Society in Moreau, New York in 1808—believed to be one of the first temperance groups in America (though Native American tribes are said to have formed such groups as early as 1772). Early temperance movements advocated the use of alcohol only in moderation, while encouraging complete abstinence from liquors, wines, and other distilled spirits. However, it was soon realized that drinking in moderation was a difficult—if not impossible—feat for the typical alcoholic to conquer. This realization would have a profound effect on how addiction would be viewed and treated (Crowley & White, 2004).
In the 1830’s, Rev. W.H. Daniels, Elisha Taylor, and Dr. Justin Edwards were some of the first to note that temperance in the form of moderation was not very successful. In a study of alcoholics, Daniels and Taylor found that out of 26 confirmed alcoholics, seven had relapsed into drinking distilled spirits through the consumption of non-distilled spirits, such as beer. Dr. Edwards created the American Society for the Promotion of Temperance, in which he set forth his aim to reform alcoholics by means of complete abstinences from alcohol (Crowley & White, 2004).
The conviction that alcoholics and addicts should struggle through addiction on their own and hope to cure themselves was on its way out. Ultimately, this would lead to the founding of self-help groups like the Washingtonians (a direct precursor of AA), Alcoholics Anonymous, treatment centers, and inebriate homes and asylums (early hospital-like settings for addicts). Bill W. and Dr. Bob borrowed heavily from prior self-help groups and pioneers of the addiction treatment field when founding AA (the first 12-step group) in 1935.
Effectiveness of 12-step Groups
Although 12-step Groups are not exactly the same as psychotherapy groups, they share many similarities. For example, factors often found in group psychotherapy that are therapeutic for clients, are also found within self-help group meetings. This includes the eleven therapeutic factors cited by Irvin Yalom in his well-known book The Theory and Practice of Group Psychotherapy (2005). These eleven therapeutic factors are as follows:
1. Instillation of hope
3. Imparting information
5. The corrective recapitulation of the primary family group
6. Development of socializing techniques
7. Imitative behavior
8. Interpersonal learning
9. Group cohesiveness
11. Existential factor
Indeed, research points out that the universality factor, prevalent in 12-step group meetings, is often cited by 12-step members as particularly helpful. Universality is the concept that group members benefit from realizing that they are not unique in the problems they are experiencing. In other words, learning that others people have similar problems (Wilcox, 2015).
One study reported that patients in an inpatient treatment program for alcoholism indicated that they cited talking to “other alcoholics” as the most helpful aspect of being in treatment. The same study found that speaking with a counselor who was in recovery was the second most helpful, followed by attending group therapy. Attending AA meetings was rated as the fourth most helpful. The therapeutic concept of universality can found in each of these examples. Talking to a counselor who was a non-alcoholic was rated the 16th most helpful out of a list of 22 options (Wilcox, 2015).
Although many members of 12-step groups profess that 12-step meetings are responsible for their recovery from addiction, 12-step groups officially do not keep statistics or involve themselves in the effectiveness of their model. Outside research has found that 12-step groups are effective in reducing alcohol and drug use (as measured by number of days abstinent and number of alcoholic drinks consumed between those involved in AA and a sample of those not attending AA meeting); however, certain characteristics were found to be a prerequisite in order for it to be effective (Wilcox, 2015).
For example, AA was found to be effective for those more likely to engage in help-seeking behaviors, as well as those high in religiousness and spirituality. A different study indicated that attachment style plays a role in who benefits from 12-step groups. Individuals, who are seeking a since of belonging and community may be more willing to participate in 12-step meetings; thus, more likely to benefit (Ellis, 2014).
Conversely, the same study found that AA was less effective for those who were considered dually-diagnoses with depression and addiction. A different study pointed out that people with greater neurocognitive deficits were less likely to attend 12-step meetings. However, participants with neurocognitive deficits who did attend 12-step meetings showed a greater reduction in alcohol and drug use than participants without neurocognitive deficits who also attended 12-step meetings (Brown, 2014). In short, AA is effective for certain people with addiction as their primary problem, while it is not as effective for others who may also be experiencing additional psychological problems (Ellis, 2014).
Other studies have looked at what can improve 12-step meeting attendance. These studies found that a contingency-style program in which hospital patients receive some type of reward for attending meetings would improve attendance rates. Another study revealed that a simple prompt by a nurse, counselor, or doctor to attend a meeting improved rates of attendance significantly (Brown, 2014). Although these studies looked at improving attendance rates, they did not examine the effectiveness of 12-step groups in reducing drug use or reducing symptoms of psychological disorders.
Often times, addiction treatment professionals assume that simply attending 12-step meetings will reduce alcohol and drug use; thus, they may consume themselves with trying to persuade clients to attend meetings, rather than try to understand why the client chooses not to attend 12-step meetings. Those involved with 12-step groups often say that if you attend meetings and follow all of their advice, then you will stay abstinent from alcohol and drugs. Although this may be true for some people, several research articles point out that this is not the case for all people.
The red herring argument of 12-step group members is that those who relapsed did not follow the 12-step program exactly 100%. This is get-out-of-jail free card. Ultimately, it serves to allow 12-step programs to operate without self-critical examination of their own effectiveness. A common mantra amongst 12-step group members is “we’ve never known an alcoholic or addict who stayed clean without the 12 steps.” This is an ironic statement, since 12-step programs do not track their own effectiveness or affiliate themselves with other treatment approaches; therefore, they surely have very little objective, supporting evidence on which to base this claim.
Nevertheless, 12-step programs are often helpful for people with addiction. Ultimately, it is important to keep in mind that 12-step programs may help some, but be less effective of others (such as those dully diagnosed). Therefore, when working with individuals with substance use disorders, it is important for mental health and addiction professionals to keep in mind that 12-step programs are not a universal solution for addiction.
Brown, S. (2014). Mediated and moderated effects of neurocognitive impairment on
outcomes of treatment for substance dependence and major depression. Journal of Consulting and Clinical Psychology, 82, 3, 418–428.
Crowley, J.W., & White, W.L. (2004). Drunkard’s Refuge: The Lessons of the New York State Inebriate Asylum. Boston: University of Massachusetts Press.
Ellis, A. (2014). Attachment style and psychological sense of community in the context of
12-Step recovery. American Psychological Association 2014 Convention Presentation
Maxmen, J. S., & Ward, N. G. (1995). Essential Psychopathology and Its Treatment. (2nd.). New York: W.W. Norton and Company.
White, W.L. (1998). Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington: Chestnut Health Systems.
Wilcox, C. (2015). Effects of long-Term AA attendance and spirituality on the course of
depressive symptoms in individuals with alcohol use disorder Psychology of Addictive Behaviors, 29, 2, 382–391