Breaking Out of the 12-Step Lockstep

Commentary, by Maia Szalavitz

In the 1980s and '90s, 12-step programs like Alcoholics Anonymous were the gold standard for addiction treatment. Even among the non-addicted, they had become an accepted part of American culture. In Tim Robbins's 1992 film, "The Player," the title character attended AA meetings not because he drank too much but because that's where the deals were being made. In 1995, New York magazine suggested that single women attend AA to meet men.

But today, the recovery movement -- with its emphasis on childhood victimization, lifetime attendance at 12-step groups and complete abstinence from all psychoactive substances -- has fallen from pop culture favor. "There was a time when it was almost the 'in thing' to say you were in recovery," says William White, author of "Slaying the Dragon," a history of addiction treatment. Thankfully, that is no longer the case.

Vogue, Elle and the New York Times Magazine have recently run articles critical of the recovery movement. The "addictions" section of the bookstore -- once taking up several bookcases in superstores -- has shrunk to a few shelves, with a growing proportion of critical books. By the late '90s, the number of inpatient rehab facilities offering treatment centered on the 12-step process was half what it had been earlier in the decade. And AA membership, which grew explosively from the late '70s through the late '80s, has held steady at about 2 million since 1995.

Still, it is difficult to say goodbye to an organization and philosophy that may have helped save my life. Between the ages of 17 and 23, I was addicted to cocaine and then heroin. For the next 12 years, I was an often enthusiastic participant in 12-step recovery. Eventually, however, it became difficult to imagine defining myself for the rest of my life in relation to behavior that had taken up so few years of it.

During my last five years in the program, I had become increasingly uncomfortable with what it presented as truth: the notion, for example, that addiction is a "chronic, progressive disease" that can only be arrested by 12-stepping. The more research I did, the more I learned that much of what I had been told in rehab was wrong. And yet, I'd indisputably gotten better. Once an unemployed, 80-pound wreck, I had become a healthy, productive science journalist. That science part, however, became the root of my problem with a model based on anecdote as anodyne.

The 12-step model has always been rife with contradiction. Its adherents recognize, for example, that addiction is a disease, not a sin. But their treatment isn't medical; it's praying, confession and meeting. And while they claim that the belief in a "God of your understanding" on which the program rests is spiritual, not religious, every court that has ever been asked whether ordering people into such programs violates the separation of church and state has disagreed with the "non-religious" label.

So why have the contradictions come to the fore now? For me, the first step came in 2000 when I wrote about New York's Smithers Addiction Treatment and Research Center and its attempts to modernize treatment. Its director, Alex DeLuca, saw that options needed to be expanded beyond AA. Guided by DeLuca, Smithers began publishing studies funded by the National Institute on Alcoholism and Alcohol Abuse showing that adding treatment options, including support for moderation rather than abstinence, was effective.

However, when a group of people in recovery learned that those options included moderation, they protested, and DeLuca was fired. Imagine cancer or AIDS patients demonstrating against evidence-based treatment offering more options. This deeply distressed me, as did AA's religious aspects. In any other area of medicine, if a physician told you the only cure for your condition was to join a support group that involves "turning your will and your life" over to God (AA's third step), you'd seek a second opinion.

The insistence on the primacy of God in curing addiction also means that treatment can't change in response to empirical evidence. Which leaves us with a rehab system based more on faith than fact. Nowhere is this clearer than in the field's response to medication use. The National Institute on Drug Abuse is pouring big bucks into developing "drugs to fight drugs" but, once approved, they sit on the shelves because many rehab facilities don't believe in medication. Until 1997, for example, the well-known rehab facility Hazelden refused to provide antidepressants to people who had both depression and addiction.

Those who promote just one means of recovery are right to find medication threatening. When I finally tried antidepressants, after years of resisting "drugs" because I'd been told they might lead to relapse, my disillusionment with the recovery movement grew. Years of groups and talking couldn't do what those pills did: allow me not to overreact emotionally, and thus to improve my relationships and worry less. I didn't need to "pray for my character defects to be lifted" (AA's 6th and 7th steps) -- I needed to fix my brain chemistry.

This is not to say that I didn't learn anything through recovery groups. The problem is their insistence that their solutions should trump all others. Many recovering people now use medication and groups both -- but within the movement there is still an enormous hostility toward this and a sense that people on medications are somehow cheating by avoiding the pain that leads to emotional growth.

Another contradiction in the notion of 12-step programs as a medical treatment shows up in the judicial system. Logically, if addiction were a disease, prison and laws would have no place in its treatment. However, to secure support from the drug-war establishment, many 12-step treatment providers argue that addiction is a disease characterized by "denial" -- despite research showing that addicts are no more likely to be in denial than people with other diseases, and that most addicts tell the truth about their drug use when they won't be punished for doing so.

Because of "denial," however, many in-patient treatment providers use methods that would be unheard of for any other condition: restrictions on food and medications, limits on sleep, hours of forced confessions and public humiliation, bans on contact with relatives and, of course, threats of prison for noncompliance. 

If these programs wanted what was best for their patients, they would support measures to fund more treatment and divert people from jail. Watching famous 12-steppers such as Martin Sheen fight against California's Proposition 36, which mandates treatment rather than punishment for drug possession, was the final straw for me.

If their argument is that people won't attend treatment without the threat of prison, how do they explain all the alcoholics they treat? How, for that matter, do they explain that 12-step programs were started by volunteers? Their opposition only makes sense in the context of a view of addicts as sinners, not patients.

The view that one can only recover via the moral improvement of the 12 steps is doing more harm than good. It is supporting bad drug policy, preventing people from getting the treatment they need and hampering research. 

Yet it is important not to dismiss 12-step programs entirely. They provide a supportive community and should be recommended as an option for people with addictions. Let evidence-based research determine how people are treated medically for drug problems.

New York writer, is co-author of "Recovery Options: The Complete Guide" (Wiley).

(Originally published June 9, 2002 as an Op-Ed commentary on page B03 of the Washington Post. 2002 The Washington Post Company.)


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