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Note: We made major changes in the Substance Abuse Intervention Guidelines, and linked additional information on Twelve Step Work beginning June 15, 2010. This is the former version of the Twelve Step Guidelines. Nothing has changed since the dates shown at the bottom of this page, except the insertion of this note and the URL for this page. Click this sentence for the original version of the Substance Abuse Guidelines.
Twelve-step work is probably the best known approach to substance abuse and addiction. By "twelve step work" we mean the approach to change taken by Alcoholics Anonymous, Narcotics Anonymous, and some other mutual support fellowships focused on changing a behavior that its participants believe they have become powerless over. This approach involves the use of twelve specifically defined steps originally published in the book Alcoholics Anonymous which members of that group often call the "Big Book." Those steps have been adapted with minor changes of wording to each of the other fellowships. Although the approach is based on the anecdotal experience of the 1930s, recent brain research validates much that the twelve-step pioneers believed.
We do not believe that the only appropriate thing to do with young people with substance abuse issues is twelve-step work. Some of the schools and programs with substance abuse programming we greatly respect use a combination of twelve-step work and other resources. In some of those schools and programs whose substance abuse work we highly respect, not all students use a twelve step approach, but those that do generally become fully involved in community based twelve-step work beyond the walls of the school or program where they are enrolled. In those schools and programs, due care has been exercised to expose their students / clients to the positives in recovery in the larger community while protecting them from negative influences.
On the other hand, we believe that schools and programs that admit students they know have a dependency or addiction history and they know have benefitted from twelve step work and do not permit twelve step activity to continue, are acting irresponsibly and would seem to be deriving their revenue specifically at the expense of concern for the lives and safety of the young people who patronize them.
We also want to challenge the twelve step programs that limit themselves to twelve-step work as it was practiced in the 1980s, but have little else to offer in the area of substance abuse. At issue is the opportunity for applying supplementary wisdom from other sources. With or without the application of twelve-step work, we believe the importance of Stages of Change and Motivational Interviewing are sufficiently well established that these are essential areas of mastery for schools, programs, and individual staff intervening with drug and alcohol issues. There are other resources that provide sometimes useful supplements to twelve-step work. For example the evidence based Seven Challenges program is a great help in bringing young people to a point of accepting the first step in twelve-step work. While some of the materials at Smart Recovery and Rational Recovery are really only about bashing twelve step work and are of negative value, both have some useful resources as well, especially Smart Recovery. Also Women for Sobriety has excellent resources.
We also want to challenge the programs that claim to be providing twelve step treatment while perhaps not even understanding twelve-step work. The power of twelve-step work comes into play as young people see the impact on the active addict or alcoholic getting support and affirmation from the people who have had years of recovery. Too many schools and programs that claim to apply a twelve step philosophy are only providing step workbooks and meetings attended only by their peers from the school or program they attend. This kind of thing is an example of playing to appearances rather than results. It is ineffective, but also worse than ineffective because it leaves the students/clients with the belief that they have attempted twelve-step work.
We also want to challenge the schools and programs that profess to use twelve-step work and don't permit their students/clients to practice obtaining support through the twelve step fellowships of their communities.
We want to challenge schools and programs that say it is not possible to convince teenagers to accept the spiritual dimension of 12-step work or to relate to being "powerless" as used in the first step. Yes, it is possible and competent staff and competently designed programming can achieve that. When we hear representatives of schools and programs make that claim we hear only a statement about the competence of their particular staff, not a general statement about substance abuse treatment.
Many of those schools and programs improperly refer to meetings limited to their own internal populations as Alcoholics Anonymous meetings or Narcotics Anonymous meetings. True Alcoholics Anonymous meetings or Narcotics Anonymous meetings are never limited to people associated with or vetted by a particular institution. They might be closed in the sense of being limited to actual alcoholics or addicts. However, if closed in the sense of participants being associated with a particular school or program and is called an Alcoholics Anonymous meeting or Narcotics Anonymous meeting, this shows blatant disregard for the fourth, fifth and sixth traditions and gross ignorance on the part of people operating that school or program with regard to something that ought to be their expertise. There is no problem with educating people with simulated Alcoholics Anonymous or Narcotics Anonymous meetings, if they are called simulated meetings and the same people get to real meetings when that is safe -- and they are taught the difference.
We have made this point visiting treatment centers, where the above described practice was defended on the basis of the fact that the anonymous groups do allow "closed meetings." Again the defenders of this practice on this basis are showing their ignorance. A closed meeting in Alcoholics Anonymous is a meeting that is open only to alcoholics, not visitors. It is never a meeting open only to people with an affiliation with a particular other group, such as a particular school or treatment center. The issue has pragmatic significance in that it first suggests a lack of competence on the part of school or program staff that would sanction this kind of thing. More directly, it creates a confusion on the part of the students / clients, leading them to judge the impact of true twelve step meetings by what happens at the simulations.
Serious twelve step based treatment in a school or program anticipating students / clients moving to unstructured living after discharge (home, college, conventional boarding school) includes participation in real meetings of the twelve step fellowships and opportunities for full participation in these meetings plus sponsorship from community people, opportunities to gain experience in reaching out to recovering people in the community at large, and opportunities to witness community people finding acceptance and recovery without the advantages they have in a special school or program. Some otherswise well conceived twelve-step programs limit participation in interaction with twelve-step activities in the community outside the school or program in which the student is enrolled to the last few months before discharge; others begin that process near the time of enrollment. We understand arguments for both. But it is not reasonable to expect a person to maintain twelve-step recovery in the community after returning home or moving on to a non-therapeutic boarding school if they have not been a full participant in community based twelve-step fellowships while enrolled in the school or treatment program where they became sober.
The power of twelve-step recovery depends upon becoming part of the culture of the twelve-step fellowships. Use of twelve-step concepts in isolation from participation in those fellowships is probably useless. There is no reason to believe that any significant number of students / clients discharged from those programs will become more deeply involved in those fellowships than they were prior to discharge. What happened in the school or program is a rehearsal for the recovery effort that begins when the students / clients hit the streets. If there was not a genuine rehearsal, there is no reason to believe that genuine recovery will take place once on the streets.
We want to see a clear rationale for distinguishing addicted and non-addicted clients. It is virtually impossible to know at admission, regardless of background data supplied, who is addicted and who is not. We expect programs that admit clients with substance abuse history to be prepared to support both those who are and those who are not addicted appropriately. Appropriate support for both groups excludes pressuring people who are not addicted or alcohol or drug dependent in any meaningful sense to make the statement of the first step with reference to drugs or alcohol. Or to put it simply, if someone is not powerless over drugs and/or alcohol, it is transparently not appropriate to encourage them to lie and claim that they are.
This raises a very important issue. Twelve-step work was created for people who truly are powerless over alcohol. Of course that has been extended to other behaviors but defining concept is powerlessness. To define the terms "addiction" or "dependency" or "alcoholism" is a task we leave for another time, it is reasonably clear that the people who are most likely to feel powerless over alcohol or other drugs are roughly the same group of people who are addicted or dependent. Twelve-step work was not created for people who have made some bad choices regarding alcohol or other drugs, but are pretty much in control of their own lives, including when to use and when not to use. There is no question but what alternative methods (not twelve-step) of intervening in substance abuse can be quite effective with people who are not addicted and not powerless. Our consultant, Tom Croke, has commented that he has not seen a successful recovery for a person who was truly addicted without the involvement of some kind of spiritual renewal, although he has seen those that did not involve twelve-step work specifically.
Because of the anonymity of twelve-step groups it is very hard to get viable outcome studies, but the anecdotal evidence of recovery through twelve-step work is very compelling. We are aware of some supportive research that we will be posting or referencing in the future. Most of that research documents a comparison of recovery rates between people attending twelve-step meetings vs. those do not. From a strict research point of view, this research leaves many questions unanswered, but it does provide some basis for validating a twelve-step approach. Twelve-step meetings, with all of their imperfections – and there are many imperfections – are available everywhere. So the question is where is the evidence of a more effective approach to ongoing support for a genuine addict or alcoholic? We don't mean to suggest that there can be no satisfactory answer, but we certainly want to know that the program has a credible answer to the question. To suggest that people leave a school or program "cured" and not needing further support is to misunderstand alcoholism and addiction. We don't object to some schools and programs having a non-twelve step answer to that question if they can base it on a genuine understanding of available evidence and serious understanding of what is involved. But we do want to know why they think another approach is better. This challenge does not apply for students/clients who do not appear to be addicted or alcoholic in the "powerless" sense.
We see twelve-step work avoided for reasons that reflect at best reflect misunderstanding, but at worst, reflects bias with the stated reasons merely used as excuses. These are some of the reasons (excuses) we hear about from schools and programs.
1. One therapeutic school that has much quality that we like prohibits all twelve-step activity – including for students who have benefitted from twelve-step activity in the past. That alone is irresponsible – if that is to be the policy for whatever reason, then students who have previously benefitted from twelve-step work should be totally excluded from that program. But the reason is even more bizarre. One of their owners has told me that their focus is on keeping their graduates clean and sober for the first year, and they don’t want twelve-step because it involves a lifetime commitment. What makes this bizarre is that that one thing that the limited research available on twelve-step work seems to confirm is that people who attend twelve-step meetings in the first year of recovery outside of a structured environment are more likely to remain sober than those who don’t.
The “lifetime commitment” statement is ridiculous. Mainstream twelve-step groups we are aware of are not cults that make it difficult to leave. (We have heard of one example of a local twelve-step group encroaching cult territory, but that is a highly unusual situation). There is nothing in the approved literature of Alcoholics Anonymous, Narcotics Anonymous or any other twelve step group we are familiar with that calls for lifetime commitment. The literature of Alcoholics Anonymous has long stated that alcoholism is a lifelong illness from which people recover but are not cured. Recent neurological research supports that. It is common for twelve-step people to make twelve-step participation a way of life, but it is also common for many successfully recovering people to allow their involvement in the twelve-step groups to fade away gradually as recovery takes hold.
Members of Alcoholics Anonymous often correctly point out the danger of that, as there are many tales told at meetings of people with many years sobriety who took a drink or a drug and quickly reverted to where they had been, and got back on track due to re-investment in twelve-step groups. We agree that when a person has relied on twelve-step meeting participation for recovery, they put themselves at risk when they stop, but we also know people who have done it successfully. We also know some who have done it and it led to tragedy. If the "lifetime commitment" is to maintaining sobriety for a lifetime, that is a principle supported much more broadly than just in twelve-step groups. It is supported among other places in scientific research on addicts and alcoholics. But there is no basis for the suggestion that “lifetime commitment” is a sound reason for rejecting twelve-step participation for all.
2.sThe spiritual component of the twelve-step groups raises a vast array of issues. First, we commonly hear something to the effect that “You simply can’t work with the spiritual component of the twelve-step groups with teenagers.” That is not true. When we hear that, it is simply a reflection on the competence of the people making the statement. Far too many clinicians, schools and programs do that effectively and consistently. We do think the awkwardness and ill-conceived programming with which most Christian churches approach youth, plus the number of young people affected by religious abuse in some form, makes this task more difficult, but we consistently see examples of this task being performed with excellence.
to spiritual issues and misunderstandings), there are locations where
which attention to “freedom of religion” and “separation between church
and state,” two concepts we vigorously support, have been twisted to
make the spiritual components of twelve-step work impractical if not
illegal, essentially gutting the effectiveness of twelve-step work.
The state of
The third problem that arises surrounding misunderstanding of the spiritual component of twelve-step groups is what we call “spiritual competition.” We hear this mostly from Christian fundamentalist sources. The fear is something like what might be behind the question, “If my child can attend twelve-step programs and understand God in any way he (sic) chooses, then what is to prevent this from going in the direction of devil worship?” First, we have never heard of something like that happening in a twelve-step group but perhaps it has. If someone has a credible account of such an event, tell us and we’ll publish it). Second, there is no problem in a twelve-step group in naming the God of one’s own religion as the “higher power” of twelve-step work.” Third where teens are concerned, we do advocate some parental vigilance and accountability regarding what happens in twelve-step activities. See information below regarding “cautions.”
Fourth, and this is closely related: We hear, “We don’t need Alcoholics Anonymous, we just need Jesus.” First we want to acknowledge having witnessed genuine recovery in a purely religious context. We point out, however, that the founders of Alcoholics Anonymous were previously active in Frank Buchman’s Oxford Group, which had all of the religious and spiritual foundation of today’s twelve-step groups, but lacked the immediate contact between recovering people focused on recovery. It did not work for those people until they began to gather specifically to share their recovery. Most purely religious recovery is handicapped by the same element. We don’t claim it can’t work, but for many people it works better for religious people in recovery to take their God with them to twelve-step meetings – if they otherwise are people who would benefit from twelve-step work.
There are also a number of cautions in using twelve-step work that we endorse.
1. Alcoholics Anonymous was founded by middle aged, white, well educated, protestant, upper middle class men. This creates a need for people who do not fit that description (currently most people in Alcoholics Anonymous and other twelve-step groups) to have some guidance in bridging a culture gap here.
2. Twelve -step meetings do attract all kinds of people including some who would be a negative influence, especially on teens. These can include predators. Teens attending meetings need to have specific guidance on using twelve-step programming in order to avoid problems.
3. Many twelve-step groups include significant numbers of people attending only because a court has required it. This affects the quality of some groups. It is necessary to make sure there is really a culture for abstinence from the addictive behavior being addressed in a twelve-step group before becoming committed to that group.
4. Although not in keeping with the official traditions of Alcoholics Anonymous, groups will frequently pressure speakers including new members not to discuss events and issues that trigger drinking. The Third Tradition states that “The only requirement for A.A. membership is a desire to stop drinking.” However, speakers who have difficulty with a triggering condition are likely to be called out for seeking support for dealing with that at an Alcoholics Anonymous meeting. This includes the situation where there is also a drug addiction and people are more likely to drink when taking drugs. This probably arises from the fact that Alcoholics Anonymous members want people to accept responsibility for their drinking and memories of the day when mental health professionals wanted to find excuses. Other twelve-step groups tend to be more liberal in this regard.
Schools and programs advocating twelve-step recovery need to provide guidance to avoid these problems. This website will eventually publish an article on that topic.
Programs need to have a clear rationale for use or non-use of twelve-step work in cases of addiction. We would want to see four things from such programs: (1) We want to see research support for the choice. (2) We want to know that the decision was made by people with an accurate understanding of the twelve-step fellowships, and (3) If a school or program does not include quality twelve-step support at least as an option, we want to know that they are not admitting people who have been addicted or dependent and have benefitted from twelve-step work, and finally (4) those programs that do not support integration of dependent and addicted people into the twelve-step fellowships need to be specific as to the means of support for continuing recovery that will be available to their clients after discharge since this support will be denied them.
Feedback is invited. We will publish selected feedback. Email FamilyLightResponse@yahoo.com
Disclaimer: No program review, no matter how positive, is a blanket endorsement. No criticism is a blanket condemnation. When we express our level of confidence in a school or program, that is our subjective opinion with which others might reasonably disagree. When we assert something as fact, we have done our best to be accurate, but we cannot guarantee that all of our information is accurate and up to date. When we address compliance with our guidelines, you need to remember that these are only OUR guidelines -- not guidelines from an official source. We have also set the bar very high, and do not expect any school or program to be in total compliance. It is not appropriate to draw a conclusion of impropriety (or even failure to live up to conventional wisdom) from our lack of confidence in a school or program or from less than perfect conformity to our guidelines. Some will say we expect too much. Readers are responsible for verifying accuracy of information supplied here prior to acting upon it. We are not responsible for inaccuracies.
Last update 11-01-08
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