How far can 12 steps go?

Americans have a penchant for 12-step programs. The original beacon for a path out of addiction - Alcoholics Anonymous - has grown past 50,000 groups in the US (and twice that worldwide). And its message is being reincarnated in self-help fellowships to fight drugs, gambling, overeating, sexual addictions, smoking, and even indebtedness.

Conventional wisdom has it that the 12-step approach - in which an individual acknowledges his or her powerlessness before the addiction, turns to a higher power, and takes specific steps to change - is the most effective route out of addiction. Its popularity seems to support that. Some 90 percent of residential and outpatient treatment programs draw directly on its principles.

Yet there are many who question not that it helps thousands, but whether its predominance may get in the way of some people finding their freedom. There are issues, some critics say, related to its quasi-religious nature, its definition of addiction as an incurable disease, the creation of long-term dependence on the program, and the way courts and other agencies mandate addicts' participation. Are some with alcohol or drug problems being coerced to follow a path that may not be suited to their needs and beliefs?

"The problem is that people think AA is the only correct treatment," says Lance Dodes, assistant clinical professor of psychiatry at Harvard Medical School. "That's true only for a subset of the population, and many people are harmed by it."

An AA representative declined to respond, saying it is the group's tradition to refrain from controversy and not comment on what others say about alcoholism or about AA.

Over the past 70 years, AA has helped huge numbers to find sobriety and a new lease on life. "If you look at the number of groups and 2,000,000 members worldwide, it's clearly got longevity and appeal," says Barbara McCrady, clinical director of Rutgers University's Center of Alcohol Studies. Yet AA's own surveys show that of the people who attend a meeting, 9 out of 10 drop out within the first year. Research hasn't yet been done on its siblings, Narcotics Anonymous (NA) and others, she says.

For many who stay with it, the benefits can't be overestimated. A big-time drinker who turned to drugs after a family tragedy, "Alan" was in denial about his situation. Near the end of college, though, he was weary and tried unsuccessfully to quit. It was only when he tagged along with a friend to an NA meeting that his turnaround began.

"Listening to people's stories, I knew I was an addict and these were people I could relate to," he says. "Going to meetings, I'd stay clean for a while and then use. It took six months 'til I got clean for the last time." He's been free for six years but attends meetings several times a week.

"Once you stay clean for a while you realize drugs were only the tip of the iceberg," Alan adds Alan who asked that his real name not be used. "You also need to change your compulsive behaviors and how you react to situations. There's a wealth of knowledge in that room."

Keith Humphreys at Stanford University's School of Medicine sees this kind of "instillation of hope" as a crucial factor in changing addicts' lives. "Most people feel defeated and have a frightening sense they can't control their own behavior," he says. "They go to a group and see others who've had the same problem now doing well, and that instills a lot of hope."

Twelve-step groups provide a valuable public health benefit, says Dr. Humphreys. Not only are they widely available, but one cost study showed that people going to the groups require $5,000 less per person from the healthcare system annually. "Multiply that by more than a million people getting treatment each year, and they are taking an extraordinary burden off the system," he adds.

At the same time, the very limited research done so far doesn't back up the conventional wisdom. Comparisons of professional treatment based on 12-step with other professional treatment modes show no superior outcomes. Longitudinal studies of self-help groups in treatment showed them comparable on most dimensions with any other kind of treatment except in the area of abstinence, where they had better results.

Given the limited evidence and quasi-religious nature of 12-step plans, some object to the way courts and other agencies mandate addicts' participation.

"Several aspects of AA don't work for everyone - such as its spiritual or religious nature, or the emphasis on powerlessness, or its group approach," says Stanton Peele, a psychologist and lawyer who has written several books on addiction, including "Resisting 12-Step Coercion."

Some courts have ruled it unconstitutional to require participation because they deem the program religious, while others have ruled it is not. AA literature emphasizes that its message is spiritual but not religious - that people decide on their own what the higher power is, and for some it is simply the group itself. The only membership requirement is the desire to stop drinking.

Other issues some find troubling relate to theories of addiction. The 12-step message is that addiction is an incurable disease, that while while alcoholics can become sober, they remain alcoholics, and should stay in the program to maintain that sobriety. In each meeting, people introduce themselves: "I'm [name], and I'm an alcoholic," no matter how long they've been clean.

The disease model isn't helpful, Dr. Peele says. "If you had an 18-year-old drinking way too much on weekends, would the best approach be to take him to AA and convince him he has a lifelong disease?" he asks.

Dr. Dodes, who has treated various forms of addiction, says the disease idea takes the moralizing out of it, which is good, but discourages people from understanding the problem. "They think it's a physical problem, which it's not, or a genetic problem, which it's not, or a biological or chemical problem, which it's not," he says. In his book "The Heart of Addiction," he describes it as psychological.

"All addictions are an attempt to treat a sense of overwhelming helplessness," which is accompanied by rage over that helplessness, he says. He helps people identify the kind of helplessness that's troubling them and address it, "not by white-knuckling it but because they understand what is happening."

While AA requires you to make "a fearless moral inventory" and make amends to those you have hurt, Dodes adds, that sometimes leaves people feeling something is very wrong with them while not getting to the root of their emotional trouble.

While many talk of a genetic element to alcoholism, Dodes reviewed the genetic research and says there is no such gene, that there is at most the idea of a susceptibility gene, but it's not been discovered either. McCrady suggests addiction has psychological, genetic, and/or social components.

Others object to what they see as the creation of a dependency on the program itself. An alternative program, Woman in Sobriety, for example, aims to help people take responsibility for themselves and then move on with their lives on their own.

Yet the ongoing group support offers valuable benefits, some argue. People who leave addictions behind usually require new friends who don't drink or take drugs. "I have friends that have over 20 years of abstinence," says Alan. "They've been through all kinds of crises ... but didn't return to use. That gives you strength."

Practitioners and problem drinkers, however, say drinking problems differ greatly and it's a fallacy that one must be in lifelong recovery. "There are people with less severe problems who can benefit from a limited period of counseling and then they are just done with it," says McCrady.

In fact, a 1996 study showed that three- quarters of those who'd recovered from alcohol problems had done so on their own. For her book, "Sober for Good," Ann Fletcher interviewed some 200 people who had recovered through various means, from AA to secular self-help groups, psychological counseling, and religion.

But there are also millions who don't know where to go for help. An estimated 14 million Americans have drinking problems; only 1 in 10 receives treatment. Experts say more treatment options for addictions need to be supported.

Meanwhile, those in AA and NA point to results. "I was at a regional NA conference in Richmond last weekend with about a thousand people," Alan says. "All these people who used to be addicts, what was their drain on society? Now they're clean and working and productive. It's amazing."

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.

Source: Alcoholics Anonymous