Are Twelve Step Approaches Evidence-Based for Addictions Recovery?

For a long time since Bill Wilson and Dr. Bob Smith founded Alcoholics Anonymous (AA) in 1935, AA’s twelve steps were the standard of care in addictions treatment. AA is a mutual help group for people with alcohol use disorders, guided by standard literature and twelve steps aimed at helping people make amends, develop spiritually, and connect with others in similar situations.

Original 12-Steps of Alcoholics Anonymous

AA’s model has been adopted by other groups such as Narcotics Anonymous (NA), Gambler’s Anonymous (GA), Overeater’s Anonymous (OA), and other variations. In each case, these groups continue to rely on the twelve steps, with minor adaptations, and have been generally known as 12-step support groups.

People in 12-step groups help each other with bits of collective wisdom beyond official literature, including the admonition to change “people, places, things” to remove triggers for use; the acronym HALT, reminding members never to get too Hungry, Angry, Lonely, or Tired; and the serenity prayer:

God, grant me the serenity to accept the things I cannot change,
Courage to change the things I can,
And wisdom to know the difference.

While meeting formats vary, they tend to include members sharing about their experiences and struggles while living in recovery and readings and discussions of the 12-step literature. Twelve-step groups also encourage members to find sponsors to provide advice based on their own recovery experience. Generally, people who have been abstinent for awhile become sponsors for other, newer members.

Many hundreds of people have testified that 12-step support groups saved their lives, and some scientific research seems to support the efficacy of 12-step groups (Humphreys et al., 2014Witbrodt et al., 2014; Moos & Moos, 2006).

Other people have criticized 12-step groups, pointing to the high rates of dropout, the heavy spiritual and moralistic emphasis, the inconsistent and contradictory logic in its literature, and the variability of groups depending on who is in them. Furthermore, about half of women who have participated in AA have experienced “13th-stepping,” the practice where group members, usually men, target new members, usually women, for dating or sex. In some cases this common practice has resulted in rape.

Despite their limitations, 12-step support groups remain an important part of many peoples’ lives in recovery, particularly if they feel belonging to their group. Research shows that social support is an important part of recovering from addiction. People who are a part of a strong group of people committed to sobriety are more likely to stay abstinent than people surrounded by old friends who may still be drinking or drugging.

Twelve-step groups are not the only addictions support group option, however. For people who want the social support without the spiritual emphasis, other mutual help groups exist, such as SMART Recovery (Self-Management and Recovery Training) and Moderation Management.

The Minnesota Model and Modern Rehab

The ubiquity of 12-step support groups was expanded to treatment in the 1950s by the Minnesota Model, a 12-step-based program developed by two people (not yet trained in addictions) working in a state mental hospital that was quickly adopted by the Hazelden Foundation, one of the oldest and most well-known rehab centers. The Minnesota Model is an intensive program including mandatory 12-step meetings, lectures, and counseling.

Rehab centers like Hazelden provide this type of care for 28-day periods on an inpatient basis. For many people with addiction, inpatient rehab may be their first contact with addictions treatment. Rehab centers have been criticized for high relapse rates, and for not following up with patients following discharge. Research on the efficacy of standard, 28-day rehab programs is notoriously scarce.

Twelve Step Facilitation (TSF)

Much later, in the 1990s, Twelve Step Facilitation was developed as a standardized adaptation of 12-step support groups, intended as an early, individual therapy delivered by a counselor. TSF helps to introduce many of the concepts of 12-step support groups, and encourages patients to engage in support groups following therapy. However, TSF is distinct from AA and other 12-step support groups.

“TSF is not officially related to or sanctioned by AA. It is available as a manual for standardized use by addiction treatment facilitators with a focus on abstinence as a treatment goal. Participation in AA meetings and other official AA activities (such as service and AA social events) is encouraged as a means to that end.” – Nowinski, Baker, & Carroll, 1999.

Some studies have demonstrated that Twelve Step Facilitation has helped people use 12-step support groups to support abstinent lifestyles, though when compared with TSF, cognitive behavioral therapy may be better for long-term support. As a first step toward engagement in 12-step support groups, TSF seems to be helpful and is often used in inpatient rehab settings.

Despite the ubiquity of 12-step groups and programs, scientific studies evaluating how well they work have not yet established, conclusively, whether 12-step-based approaches are effective. Reviews of the literature find mixed results, with some studies finding positive effects, some finding negative effects, and some detecting no statistically significant influence. Studies face methodological challenges (particularly self-selection bias), and most often do not distinguish between 12-step support groups, inpatient rehab, and TSF (perhaps because their content is so similar).

The first mandate of medical treatment is to do no harm. Because some studies have found 12-step programs to be detrimental to people, and because their effects are otherwise inconsistent and inconclusive, 12-step-based treatments cannot be considered to be evidence-based. Evidence-based treatments for addiction do exist, and include cognitive behavioral and dialectical behavior therapies, mindfulness training, and a range of pharmaceutical treatments. Typically, addictions treatments must be individualized, and must account for the type of substance or behavior used, co-occurring mental disorders, and trauma history.

With a scarcity of evidence, treatment providers must decide on a case-by-case basis whether 12-step groups, inpatient rehab, TSF, or some alternative is best for a person in recovery. Twelve-step groups and facilitation do work for many people, but they are not for everyone.

The primary benefit of 12-step support groups and programs is subjective, depending on the quality of the human relationships in a given group and on the importance of spirituality to the person in recovery. Social support is recommended for people in recovery from addictions, but other mutual help groups may provide this without the problematic aspects of the 12-step approach.

After extensive research, the most balanced recommendation I can make is if you are a person in recovery, consult your doctor first, and choose the treatments that work for you. The goal is to create a stable and positive life in recovery, and if a treatment is not adding to this goal, it is not for you. In this case, if the medicine tastes bad, it is bad.

If you are a treatment provider or a drug court judge, please be advised that 12-step groups and programs are not evidence-based, may sometimes do harm, and therefore, if recommended at all, should be one of many treatment and recovery support options offered.

I wrote this post following a discussion with Anne Giles, in which she requested balanced research on the efficacy of and difference between 12-step support groups, inpatient rehab, and Twelve Step Facilitation. The positions I take in this post are mine, and cannot speak for her, or for Handshake Media, Inc. 

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