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The 12-Step Program & Alcoholics Anonymous

Diane De Trizio

PSY 268

20 September 2006

Dr. Schlundt

 

 

 “Alcoholics Anonymous are no crusaders; not a temperance society. They know that they must never drink. They help others with similar problems . . . In this atmosphere the alcoholic often overcomes his excessive concentration upon himself. Learning to depend upon a higher power and absorb himself in his work with other alcoholics, he remains sober day by day. The days add up into weeks, the weeks into months and years.” 1

 

The Lowdown

 

What is it?

The twelve-step program is intended to be a guide for recovery of alcoholism.  Created and used by Alcoholics Anonymous, its goal is for members to get sober, stay sober, and to help others achieve sobriety.  It is not just stopping the addiction; it is understanding the emotional and mental causes.  The program itself is defined as “designed to assist in the recovery from addiction or compulsive behavior, especially a spiritually-oriented program based on the principles of acknowledging one's personal insufficiency and accepting help from a higher power” (http://www.answers.com/topic/twelve-step).

 

 

What are the steps?

1. We admitted we were powerless over alcohol, that our lives had become unmanageable.

2. Came to believe that a Power greater than ourselves could restore us to sanity.

3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

4. Made a searching and fearless moral inventory of ourselves.

5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.

6. Were entirely ready to have God remove all these defects of character.

7. Humbly asked Him to remove our shortcomings.

8. Made a list of all persons we had harmed and became willing to make amends to them all.

9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

10. Continued to take personal inventory and when we were wrong promptly admitted it.

11. 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.

12. 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.

Where did it come from?

            Bill Wilson and Dr. Bob Smith created the twelve-step program after meeting through Oxford Group.  The Oxford Group, however, was not geared toward alcoholics.  Instead it emphasized spiritual values and awareness.   Wilson and Smith used these values and added to them to create the twelve-step program.  They went forth on their mission together to bring sobriety to others.  In 1939, they published their first textbook, Alcoholics Anonymous, outlining their twelve-steps and their mission (http://www.alcoholics-anonymous.org/en_pdfs/m-24_aafactfile.pdf). From there the twelve step program has been adapted and put into use for many other addictions, and as a consumer product.  Wilson and Smith’s book has been edited many times and into many different languages.

     

What evidence is offered?

            Alcoholics Anonymous offers very few statistics in support of their twelve-step program.  They do, on the other hand, boast their 2,000,000 plus membership.  This number represents the number of people whom have admitted to their problem of alcoholism and are trying to work through it using the twelve-step program.  The twelve-step program is said to be used in 180 countries (http://www.aa.org/en_pdfs/m-24_aafactfile.pdf).  The twelve-step program through alcoholics anonymous does not make false promises.  Instead they speak through the numbers of their membership and their mission of achieving and maintaining sobriety.         

            Although they do not boast their success rate, Dr. G. Kirby Collier, psychiatrist, had the following to say about the organization. “I have felt that A.A. is a group unto themselves and their best results can be had under their own guidance, as a result of their philosophy. Any therapeutic or philosophic procedure which can prove a recovery rate of 50% to 60% must merit our consideration.” http://www.aa.org/bigbookonline/en_appendiceIII.cfm (The philosophy Dr. Collier refers to is the twelve-step program.)   

            Although A.A. does not put out any direct information dealing with who is sober particularly because of them, they did put out the following data.   After surveying all of their members, they came up with the following statistics:

Average sobriety of members is 8 years. 

36% have been sober for over 10 years.

14% have been sober between 5-10 years.

24% have been sober between 1-5 years. 

26% have been sober less that 1 year.

70% have a sponsor.

Members attend an average of 2 meetings per week.

30% were self motivated to explore the twelve-steps and Alcoholics Anonymous.

Before coming to A.A. 64% had received some other type of treatment (counseling etc.)

74% of those members said it played an important part in their recovery from alcoholism.

After coming to A.A. 65% of the members received some type of treatment.

84% of those members said it played an important part in their recovery from alcoholism.

(http://www.alcoholics-anonymous.org/en_pdfs/p-48_04survey.pdf)

           

What is the rationale? How does it work?

            The rationale of this program is by using the suggested steps of the twelve-step program alcoholics can be guided toward happy and useful lives.  Each step of the program serves a different purpose.  The most important step is the first one, the admittance that you have a problem.  The following steps are personal and spiritual and require personal desire for change.

            The program does not dictate that all steps need to be followed or in any sequential manner.  A.A. encourages members to read them carefully, but it is not forced upon them.  It is something that each member should want to do.  When they want to do it their probability for recovery is higher because they have taken the first step on their own.  The rationale of the twelve-step program is that the alcoholic must consider what steps they want to take towards their own recovery.  The program works by providing a guideline and suggested steps toward this recovery.  In addition, by discussing these steps in A.A., alcoholics are encouraged (but not forced) to explore the different aspects of the A.A. philosophy.  http://www.aa.org/en_pdfs/p-42_abriefguidetoaa.pdf At Alcoholics Anonymous (closed and/or stepped) meetings, members are asked to speak one at a time about their own experience.  The Step meetings are a discussion about one particular step.  This “works” in helping achieve sobriety by having a member explore himself and his problem. 

 

What are other sources for the twelve-step program (in association with alcoholism)?

            A.A. is not the only place that the steps can be explored.  There are numerous other outlets of the information.  For instance, pictured is a $5.95 book of worksheets for the twelve-steps. There are also free downloadable worksheets online that can be used in the privacy of any home.  This way they can sort through their problems without any fear of embarrassment http://www.12step.org/worksheets/worksheets.php. Each step has numerous questions to guide the person to understand if their alcohol habits are a problem or if there problem is negatively affecting them and those around them.

  Some Example Questions for Step 1:

·         Have you seriously damaged your relationships with other people because of your addictive behaviors? If so, list the relationships and how you damaged them.

·         If other people have told you how you how your have hurt them, then write down what they said.

·         Describe any missed appointments that resulted from your addictive behaviors.

·         Describe any memory lapses where you cannot account for where you were.

 

What is the role of religion?

          A large criticism of the twelve-step program is that it is too strong a religious regimen.   The defense for this however is that you can create your own religions.  For steps 3 and 11, for instance, it is important to note the inclusion of the phrase “as we understood” him, when a reference to God is made.  Although the twelve-steps formed from a Christian tradition, twelve-step and A.A. counselors solely encourage finding your own “savior”.  It can be whatever God the alcoholic believes in.  The spiritual power can even be the group.  The rationale is that the power believed in should be greater than oneself.  

 

“When men and women pour so much alcohol into themselves that they destroy their lives, they commit a most unnatural act. Defying their instinctive desire for self-preservation, they seem bent upon self-destruction. They work against their own deepest instinct. As they are humbled by the terrific beating administered by alcohol, the grace of God can enter them and expel their obsession. Here their powerful instinct to live can cooperate fully with their Creator's desire to give them new life. For nature and God alike abhor suicide”( http://www.12step.org/steps/ ).

 

Where else is the twelve-step program used?

            The twelve-steps are not only used for alcoholics.  The program has expanded to other topics as well such as: gamblers, drug users, and those who have compulsive behaviors.  These groups also have meetings similar to A.A. such as Gamblers Anonymous and Narcotics Anonymous. 

 

Special Circumstances

            Sometimes attendance at A.A. meetings is court-ordered.  It is important to note that in these cases, religion is not forced upon these members.  If desired they do not even have to look at the steps.  They do, however, have to show a desire to stop drinking.  Since meetings are closed and names are not allowed to be disclosed, the group leader will sign a sheet proving attendance.  Of the members of A.A. 11% are their because of a court order.    

 

Negative Feedback

            It is important to note that not everyone views the twelve-step program as a proper solution to alcoholism.  Some devout Christians believe that the first step removes moral depravity from alcoholism by claiming that no control was allotted to the alcoholic (http://www.rapidnet.com/~jbeard/bdm/Psychology/codep/12step.htm).  There exist other critiques of the step, such as step 9- Made a list of all persons we had harmed, and became willing to make amends to them all.  Critiques draw into question the self-serving nature of the steps.    

                Another very important criticism comes from and online organization, “Orange Papers”.  They put forward that spontaneous recovery from alcoholism is approximately 5%.  Depending on what is being counted and when, 5% is the approximate success rate of Alcoholics Anonymous.  According to this critique then, Alcoholics Anonymous and the twelve-step programs success rate is essentially 0%.  (http://www.orange-papers.org/orange-effectiveness.html)  This will be explored further in the section exploring the published work.

 

1. Dr. W. W. Bauer, broadcasting under the auspices of The American Medical Association in 1946, over the NBC network.

 

The Published Opinion

          There are multiple studies that examine the effectiveness of the Alcoholics Anonymous twelve-step program on alcohol recovery compared to other methods.  The answers to these questions however are conflicting.  First we will examine the opinions that it is helpful, then those which claim there is no effect.

It is helpful!

            In a cross-sectional retrospective survey of 4422 adults age 18 and up (who were classified prior-to-pass year alcoholic dependent according to the DSM-IV guidelines), researchers questioned what role help-seeking plays in recovery.  Dawson, Grant, Stinson and Chou (2006) looked at three different treatment methods.  The methods were as follows: 12-step participation, 12-step and formal treatment, and formal treatment only.  They performed 4422 at home interviews with a randomly selected from a list households.  The following table shows the likelihood of recovery for each of the treatment methods.  All but one (NR and the 12-step program) reached statistical significance.    

 

Type of help and interval since onset of dependence

Type of recovery

Any recovery HRRab(95% CI)

Non-abstinent recovery HRRab(95% CI)

Abstinent recovery HRRab(95% CI)

Total exposure period

  12-Step participation only

2.76 (1.75–4.36)

1.51 (0.80–2.86)

5.88 (3.09–11.22)

  12 Step and formal treatment

2.66 (2.24–3.16)

1.44 (1.12–1.86)

4.53 (3.34–6.16)

  Formal treatment only

1.67 (1.17–2.38)

1.77 (1.14–2.76)

1.80 (1.09–2.98)

Years 0–3 after onset

  12-Step participation only

2.49 (1.05–5.90)

1.08 (0.29–4.03)

9.87 (3.09–31.51)

  12-Step and formal treatment

2.07 (1.34–3.19)

1.05 (0.58–1.89)

5.59 (3.21–9.74)

  Formal treatment only

1.32 (0.71–2.47)

1.49 (0.73–3.03)

0.83 (0.23–3.05)

Years 4–9 after onset

  12-Step participation only

4.09 (2.32–7.22)

3.03 (1.37–6.72)

8.18 (3.31–20.19)

  12 Step and formal treatment

2.38 (1.64–3.45)

1.19 (0.64–2.22)

5.01 (2.73–9.21)

  Formal treatment only

2.08 (1.17–3.68)

2.05 (0.96–4.38)

2.93 (1.18–7.29)

Years 10+ after onset

  12-Step participation only

2.15 (0.99–4.66)

0.76 (0.20–2.85)

3.89 (1.53–9.91)

  12 Step and formal treatment

2.62 (1.92–3.60)

1.68 (1.10–2.56)

3.69 (2.32–5.87)

  Formal treatment only

1.83 (1.00–3.34)

2.03 (0.89–4.60)

1.73 (0.76–3.92)

a Hazard of recovery among individuals with specified type of help relative to those who never sought help, based on time-dependent proportional hazards models. Adjusted for age, gender, race/ethnicity, education, employment history, marital history, childbearing history, family history of alcoholism, age at first drink, interval to onset of dependence, early onset of dependence, number of symptoms, average daily ethanol intake during period of heaviest drinking, multiple episodes of dependence, tobacco use, illicit drug use, and history of mood, anxiety and personality disorders. n of cases for all models = 4014.

           

            The study found that only one-quarter of the alcoholics surveyed had ever sought help through one of the three methods listed above. They also found that nearly twice as many people who sought both formal treatment and participated in a twelve-step program recovered compared to those with formal treatment only.    In conclusion, this study found that help-seeking does play a major role in recovery and that the twelve-step program plays a major role in this.

            In a randomized control design, Witbrodt and Kaskutas (2005) assigned their treatment participants to either abstinence or the twelve-step program.  Participants were in interviewed as a baseline, then again 6 and 12 months later.  For the baseline they used the Quick Diagnostic Interview Schedule for Psycoactive Substance Dependence III-R and grouped diagnoses into the following three categories: 1. alcohol, but no drug dependency, 2. drug, but no alcohol dependency, 3. both drugs and alcohol dependency.  They split these groups up equally and randomly into the two treatment groups.  After six months the abstinence group was questioned using the Addiction Severity Index.  The twelve-step program group’s attendance at meetings was measured and questioned about their experience.  Covariates such as alcoholic friends were taken into account as well. 

            In the end the abstinence group had approximately one half of the participants clean for at least 30 days.  The twelve-step program participants only had an increased abstinence rate for those participants whom had a sponsor and whom had attended a substantial number of meetings.  The number of A.A. meetings was also directly correlated with the number of specific twelve-step activities, “bring the body, and the mind will follow”.  Results concluded that the number of twelve-step meetings attended and steps followed had direct effect on the success rate of recovery.

            It has been stressed that it is really up to the person suffering from alcoholism to make the change.  Bogenshutz, Tonigan and Miller (2006) performed a study considering the level of self-efficacy of a recovering alcohol and their sobriety successes.  The purpose of the study was to evaluate the role of self-efficacy on the sobriety period of those associated with Alcoholic Anonymous and their attendance forthwith.  Method of analysis was covariance and structural equation modeling using 6,9,12 and 15 months as check in dates using the data from Project MATCH (Matching Alcoholism treatments to Client Heterogeneity).  The two measures used were the attendance record and that was compared to the levels of self-efficacy as assessed by the Alcohol Abstinence Self-Efficacy Scale. The participants were split into two groups Type-A (late-onset) alcoholics and Type-B (childhood risk factors existed).  The study found that the numbers of meeting attended has a strong direct relationship to abstinence regardless of Type (A or B).  There was no difference between the two types in self-efficacy.  Their study included 1,284 people, 74% of which were male.

 

            The same study stated that there exists little research on the mechanisms of each step.  Nonetheless, Bogenshutz, Tonigan and Miler also documented the findings of some other related studies. The most relevant of these was performed by the Project MATCH research group (1993, 1997, 1998).  They performed a study on 952 outpatients and 774 post-inpatient subjects who were randomized to one of three studies, CBT- cognitive behavioral therapy (Kadden et al, 1992), MET -Motivational Enhancement Therapy (Miller et al., 1992) and TSF- twelve step facilitation (Nowinski et al., 1992).  The criteria only considered drinkers who drank an average of 21 days in a month and 17 drinks per day.  The study found that a much larger difference exists between the initial self-efficacy of the two types.  Not only are Type-A are more likely to stay sober, but they also found that it did not matter which treatment was used. 

            Although it seems that this would not seem significant in the argument that the twelve-step program is useful for alcoholics one must consider the context.  In common circumstances the twelve-step program would be more easily accessible because it is the only free option of the three.  Also, the twelve-steps are driven by acceptance and admittance of a problem.  The desire to change is what truly makes the difference.

 

It is useless!?

            In a study of 100, 20-63 year old married men in Great Britain, Orford and Edwards (1977) found that participants who spent twelve months in alcoholics anonymous faired no better than those who had only one therapy session with a psychiatrist and their spouse.  Each participant was properly diagnosed as an alcoholic by a psychiatrist then randomly assigned to one of the two treatment groups.  Half went to the psychiatrist once with their spouse and discussed their disease.  The other half were offered an array of services starting with alcoholics anonymous and the twelve-step program to inpatient treatment.  In the end there was no significant statistical difference between the groups.

            Although this is a small sample size a more comprehensive critique (over a dozen studies) is available through http://www.orange-papers.org/orange-effectiveness.html.  The “Orange Pages” has a compilation of studies that try to discredit the twelve-step program.  Many of these articles are dated from over twenty years ago, but given the nature of the study this fact should not matter.  More statistical evidence is needed however. 

 

Conclusion

            Since Smith and Wilson introduced the twelve-step program it has gained a very large following and has impacted many lives.  Alcoholics Anonymous, in particular, utilizes these steps in order to help alcoholics achieve sobriety.  The twelve-step program became popularized through A.A. and now covers a large spectrum of diseases, from addictions to compulsions.  The published research is lacking in the area of the exact mechanisms of the twelve-step program.  However, the conclusions drawn by the research on A.A. is comprehensive enough to cover the twelve-step program since that is the philosophy of A.A.  Although there are criticisms on the program overall it seems like a useful tool for someone who is seeking help to get and stay sober.  Additional assistance can be procured through worksheets and other group sessions talking about the different steps.  The issue of spontaneous recovery in comparison to the twelve-step program needs to be further researched in order to be sure.

 

References

Bogenschutz, M.P., Tonigan, J.S., & Miller, W.R. (2006). Examining the effects of alcoholism typology and AA attendance on self-efficacy as a mechanism of change. Journal of         Studies on Alcohol, 67, 562-568.

 

Dawson, D.A., Grant, B.F., Stinson, F.S., & Chou, P.S. (2006). Estimating the effect of help-    seeking on achieving recovery from alcohol dependence.  Addiction, 101, 824-832.

 

Jim Orford and Griffith Edwards, (1977). Alcoholism: a comparison of treatment and advice,            with a study of the influence of marriage, Oxford [England] and New York : Oxford     University Press, ISBN: 0-19-712148-9.

 

Miller, W.R., Zweben, A., Diclemente,  C.C. and Rychtarik (1992)., Motivational            Enhancement Therapy Manual: A Clinical Research Guide for Therapists Treating          Individuals with Alcohol Abuse and Dependence. Project MATCH Monograph Series,   Vol. 2, DHHS Publication No. (ADM) 92-1894.

 

Nowinski, J., Baker, S., and Carrol, K. (1992). Twelve Step Facilitation Therapy Manual: A      Clinical Research Guide for Therapists Treating Individuals with Alcohol Abuse and          Dependence. NIAAA Project MATCH Monograph Series, Vol. 1, DHHS Publication No.   (ADM) 92-1893.

 

Project Match Research Group (1993). Project MATCH: Rationale and methods for a               multisite clinical trial matching patients to alcoholism treatment. Alcsm Clin. Exp.           Res. 17:1130-1143.

Project Match Research Group (1997). Matching alcoholism treatments to client         heterogeneity: Project MATCH posttreatment drinking outcomes. J. Stud. Alcohol 58:    7-29.

Project Match Research Group (1998). Matching alcoholism treatments to client         heterogeneity: Treatment main effects and matching effects on drinking during      treatment. J. Stud. Alcohol 59:631-639.

 

Withrodt, J. & Kaskutas L. (2005).  Does Diagnosis Matter? Differential Effects of 12-Step      Participation and Social Networks on Absitnence. The American Journal of Drug and        Alcohol Abuse, 31, 685-707.

 

 

 

 

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