A 12-step program is a set of guiding principles and courses of action for recovery from addictive, compulsive, or other behavioral problems. Originally developed by Bill Wilson and Dr. Bob Smith, founders of Alcoholics Anonymous (AA) and first published in 1939 in their book, Alcoholics Anonymous: The Story of How More Than One Hundred Men Have Recovered From Alcoholism, this approach was initially designed to tackle alcohol abuse. The 12 steps and processes involved in this approach were transformed over the 1930s and 1940s into 12 principles that are the basis of most of today's 12-step programs.
This methodology and its approach to dealing with addictions and compulsions have been widely adapted by various organizations. For instance, the positive effects of AA programs and the improved quality of life achieved by some of its members and their families led to the formation of fellowships such as Al-Anon. People suffering from substance misuse who did not specifically relate to alcohol dependency started Narcotics Anonymous, which in 1953 obtained official permission from AA to use its 12-step methodology. Using the same principles, numerous other 12-step programs have been organized to address various addictions and compulsions, ranging from crystal meth to gambling (Gambling Anonymous), debt (Debtors Anonymous), food (Overeaters Anonymous), sex (Sexual Compulsives Anonymous), and emotions (Emotions Anonymous).
Twelve-step programs are behavioral transformation programs that, as described by the American Psychological Association, involve the following phases:
Individual self-admission of his/her addiction and/or compulsion
Recognition of a greater power that can give strength
Reflection and examination of past errors with the help of a sponsor (sponsor is a more experienced member of the group who assists, supports, and guides the newcomer in his recovery)
Making amends and correcting past errors
Accepting, identifying, and learning to live with the new code of behavior of the 12-step group encouraging abstinence
Serving as a sponsor and helping others who suffer the same addiction or compulsion
Twelve-step programs aim to deal with addiction or compulsion and its problems as manifested in physical, mental, and spiritual dimensions. Dealing with withdrawal symptoms and other bodily reactions, which generate the compulsion to continue abusing addictive agents, are examples of problems in the physical dimension, while cognitive processes that cause the individual's repetition of compulsive behavior represent the mental problems and obsessions that need to be addressed. To challenge these cognitive processes, the First Step of the program emphasizes and requires the individual member's recognition of the person's inability to deal with his/her problem on his/her own.
All 12-step programs involve a spiritual dimension, as they aim to treat the individual's “spiritual malady.” This is not a scientific process or claim by 12-step groups but rather a useful instrumental perspective. Twelve-step programs sustain their members' involvement, leading them to attend to the views of the group rather than dismissing them. The group's potent influence engages its members in an alternative worldview and reframes addiction as an illness, a visitation that must be expunged. This ultimately leads the individual member to experience a quasi-religious conversion, which provides relief and gives the suffering person respite from guilt.
Individuals suffering from addiction act out a pattern of self-destructive behavior accompanied by denials based on distorted perceptions. Intimate and positive encounters with networks, such as those in 12-step programs, brings the addict to the point of recognizing the dissonance between his/her own perceptions and those of the network members. For addicts, healthy and faulty attitudes usually coexist in conflict for long periods; in fact, it is often the cognitive dissonance produced by these contradictions that drives addicts into a defensive stance, fending off any attack on this awkward balance. Therefore, in a 12-step program, the addict is prodded to develop a constructive view premised on abstinence and on acknowledgment of the harmful nature of drug use. In 12-step groups, all members are expected to attend meetings with others who share their particular recovery problems and to engage in group dynamics by sharing their experiences. To reinforce recognition of the addiction problem and counter denial, in accordance with the First Step, group members are expected to identify with their problem through self-admission such as: “Hi, I am Joe, and I am an alcoholic …” Today, this self-admission technique is commonly used in support groups.
All new members of a 12-step program are expected to have at least one sponsor. A sponsor is a more experienced person in recovery who guides and maintains a one-to-one relationship with a less experienced member of the group. The personal and shared experiences of addiction between the new member and the sponsor and the mentor-mentee relationship provide powerful common ground and an important element upon which the program builds the path to recovery. In most 12-step programs, this relationship is based on spiritual principles with the fundamental objective of helping the sponsored member modify his/her behavior and overcome addiction. However, this mentoring and guidance role reflexively helps the sponsor as well by supporting their recovery and abstinence. In fact, completing the 12-step program implies competence in being able to sponsor new members.
The cohesiveness of the group and the shared perspective of its members and their recovery stories provide positive reaffirmations of the possibility for an alternative meaning and outlook in life. The group's message is unequivocal in that the new members must adopt the group's vision and perspective with respect to his/her addiction in order to be accepted in the group. The network, therefore, creates an ongoing pressure on the addict to relinquish the trappings of denial, which is typically used by addicts as a way to deal with conflict. The cohesive ties and engagement in the group help transform members' perspectives. Studies reveal that the higher the individual member's distress and the greater their engagement in the group, the greater the possibility of their recovery through the program. Hence, a cognitive restructuring of perspectives, in which addiction is couched, ultimately leads the new member to conversion and out of addiction.
About 20 percent of 12-step programs focus on addiction; the largest programs are Alcoholics Anonymous and Narcotics Anonymous, while others deal with compulsions ranging from debt to depression. Although most 12-step programs share the same basic principles and similar approaches to treatment, they have been adapted for specific treatment of different addictions or compulsions. The success of a given 12-step program does not imply its applicability and effectiveness in dealing with all other types of addiction or compulsion.
Twelve-step programs are most effective when accompanied by other therapeutic processes and procedures, such as psychiatric treatment, network therapy, family systemic therapy, and cognitive behavioral therapy. Research has shown that 12-step programs are also most effective with individuals who are unable to limit and/or control their addiction and who have consistently demonstrated vulnerability to relapse with a number of failed attempts to stop or cut back.
Although 12-step programs are used in hospital or institutional settings for inpatients suffering from serious addiction or compulsion, 12-step programs are not sufficient for individuals whose addiction is apparently unmanageable on an outpatient basis in spite of their social support network. This latter category includes long-term intravenous opiate addicts, alcoholics who have not been able to stop for even a brief period of time, and those with unusual destabilizing circumstances such as homelessness, severe personality disorders, and/or psychosis.
The different success rates of different 12-step programs in dealing with various pathologies and their often spiritual and quasi-religious approach—including their belief in a “higher power”—have limited the universal applicability of 12-step programs and raised many criticisms. The most significant criticisms, however, include lack of professional confidentiality, stigmatization, and conflict with cultural identity.
Given the absence of a professional therapist in most 12-step group settings, and although bound by their spiritual and group principles, 12-step group members are not legally bound to confidentiality. In fact, there are no legal consequences to discourage those attending 12-step programs from publicly discussing information disclosed during meetings. Therefore, professionals and paraprofessionals who refer patients to 12-step programs are required to advise their patients that their statements made during those meetings may be revealed at any time.
Given the cognitive restructuring of individual perspectives and perceptions and its iatrogenic effects on individual perception, identity, culture, and values, some consider the 12-step programs and their approach similar to a religious cult. Others, referring to the program's self-admission approach and emphasis, suggest that it increases deviant stigma. Other critics argue that 12-step groups' quasi-religious culture and its imposition and enforcement upon its members strips them of their cultural identity. However, the composition of 12-step groups suggests that their members have bicultural identities and use these programs as a complement to their original or ethnic values, culture, or religion.
Alcoholics Anonymous (AA), Cognitive Networks, Cohesion Networks, Religious Communities, Trust and Networks.
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