12-Step programs, which are, after 80 years, still a foundational component of many treatment programs for addiction, have come under fire of late. Over the next 12 months, we will try to unpack the discussion in a helpful way with the help of James.
James Krah is a licensed drug and alcohol counselor at American Addiction Centers where he serves as Director of Desert Hope Outpatient. His direct, simple approach makes him an ever-popular 12-Step facilitator among those in treatment.
12-Step – Is it science?
One of the things science is bringing to the fields of addiction and mental health is the realization that the best treatment is highly individualized.
“Our field has traditionally seen the problem… as something we can do on a mass scale. However, the actual problem is addiction, a chronic illness, which, like all chronic illnesses, requires an individual treatment plan based on the patient’s goals.” – Dr. Howard Wetsman, Chief Medical Officer, Townsend Treatment Centers
In alcoholism, for example, researchers using MRI and PET scanning look at brain activity and the chemistry of the disease. They look at how the brain changes under alcohol use, over the short and long-term. Meanwhile, ongoing genetic studies link differing reactions up to individual markers. Study of the dopamine system zeroes in on the development of medications for better treatment in alcoholism and drug addiction. This research will discover more about brainwave markers such as P300 that correlate with the incidence of alcoholism. We are unlocking the genetic explanation for why some people can drink all their lives and not develop the disease of alcoholism, while others will launch a predictable trajectory toward alcoholism with their first drink.
Understanding the chemistry, brain activity, and genetics of alcoholism and other addictions will help develop much more effective treatments for the disease of addiction.
Used in combination, they will help professionals put together treatment suites that will vary from person to person.
We are not there yet.
Unfortunately, there is no “magic bullet” for treating alcohol-related problems. It is unclear why some people respond well to certain medications, but others do not. However, exciting new research is helping scientists learn more about how alcohol affects different people. – National Institute on Alcohol Abuse and Alcoholism (NIAAA)
12-Step – is it the only way?
No.When people ask for AA’s scientific credentials, they have often been put off by an “all or nothing” aspect to the from12-Step presentation – 12-Step is the only path; abstinence is the only goal. They point to individuals they know who have gotten sober and gone on to become successful at “casual drinking.” They point to others who live normal lives on medication and never set foot in a 12-Step group. All these possibilities can be true – on an individual basis. There are medications, long-term clinical therapies, and varying combinations of both.
According to the NIH: “A handful of medications are now available to treat alcohol problems, many of which aim to alter the short- or long-term effects of alcohol by either interfering with or imitating the actions of key neurotransmitters.”
On the other side, people point to relapse as proof that 12-Step is unsuccessful. To cite “relapse” as a criterion of failure would also be unscientific, since relapse is built into the nature of addictions such as alcoholism. Relapse can also be a healthy part of recovery, if the sufferer has the resilience to view it in this light.
According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA),
“Relapse is common among people who overcome alcohol problems.” – NIAAA
And 12-Step programs have become a key tool in the cause of bouncing back.
One of the most vocal critics of 12-Step programs, Harvard University’s Lance Dodes points to the harm caused when someone in recovery takes a drink and judges himself a “failure.” While it’s true that the 12-Step program is set up to support abstinence as a goal, it also doesn’t judge people for relapsing. Individual groups or people may place more tension around this issue than the 12-Step program itself.
In an interview for an Atlantic article, Dodes cites the case of J.G. who was harmed, according to Dodes, by 12-Step principles.
“Evening would fall and his heart would race as he thought ahead to another sleepless night. ‘So I’d have one drink,’ he says, ‘and the first thing on my mind was: I feel better now, but I’m screwed. I’m going right back to where I was. I might as well drink as much as I possibly can for the next three days.’
There are many important things going on in this story that can mean nothing for some individuals or turn into recurring land mines for others, especially in early recovery.
J.G. brought the all or nothing thinking to the table. He also brought the risky practice of using alcohol as a form of self-medication when he took a drink to sooth anxiety. But he felt it worked.
Dual diagnosis treatment would probably peel away the anxiety and treat it separately, perhaps as a mental health issue. The benefit of this approach is that it would give J.G. an additional coping mechanism for anxiety, one that doesn’t involve drinking.
But J.G. wanted to believe that he could continue to “self-medicate” with one drink here or there. That “casual drink” is the dream of many a person in recovery.
It’s true that some people can be that casual drinker – for each individual, the answer is in the genetic profile. But J.G. doesn’t know if he’s that drinker or not.
For every casual drinker, there are others who continue on, physiologically, to a place where alcohol begins to cause more anxiety rather than less. If J.G goes to this place, it won’t be long before he needs to take a drink just to feel normal. He has joined the ranks of the addicted.
In absence of J.G.’s genetic and chemical profile (the real scientific data in his case), this first “failure” is one data point in an ongoing experiment to find out whether or casual drinking is possible. While calling this “experimentation” takes “blame” off the table, it’s important to know that this type of experimentation is part of the reason relapse is so common. A few “relapsers” will go on to live the dream of casual drinking. Others will have to decide how many data points are enough to “surrender” to the fact that they are powerlessness over alcohol – the first Step of the 12-Step program.
Eighty years ago, when 12-Step was born, there was no ability to determine addictive genetics or predict ideal treatment medications. And even now, the ability to deliver such targeted treatment is still evolving.
“We’re both close and far,” says Dr. Wetsman, a leader in personalized medicine for addiction treatment.
“We’re close in that we understand a lot about the neurobiology of the illness and about how to tailor treatment to overcome individual’s barriers to progress. But we’re far away in getting patients, practitioners, insurance companies, treatment centers.” – Dr. Howard Wetsman
Does 12-Step offer anything scientific?
In general, the program is one of the largest providers of key components of a comprehensive recovery plan, as deemed by the latest science.
Community – A sense of not being alone, of acceptance and belonging
Support – Having someone to turn to when addiction challenges arise
Understanding – People with a shared experience; less self-explanation and more practical learning and strategy
Modeling – to see a way through by observing others and gain hope for improvement
According to Substance Abuse and Mental Health Services Administration (SAMHSA)
Recovery support is provided through treatment, services, and community-based programs by behavioral health care providers, peer providers, family members, friends and social networks, the faith community, and people with experience in recovery.
Peer providers, support, social network, a faith community, people with experience in recovery – 12-Step programs accommodate all these recovery-supporting ingredients.
In addition, the 12-Step program is non-judgmental and confidential. It is also ubiquitous – no matter where you are and when you’re available, you can usually find a 12-Step group (though individual 12-Step groups can vary in personality).
This makes the math, if not the science, pretty simple: it may be easier to find a way to incorporate 12-Step into one’s recovery plan than to try to assemble individually all the proven support components it offers.
Will it Work for You?
While it may be important to know the many ways recovery can occur across populations, unless you have a full, personalized work-up in hand, and you have a map that puts together all the components of treatment that are right for you, treatment is probably still going to be an experiment.
In his video introduction to 12-Step, James poses his simple question – will it work for you? – in the spirit of experimentation. 12-Step becomes a tool for a job, and we can take the tool and test it out. When most of us are handed a tool to ease our workload on a project, our first instinct is not to dismantle the tool. We take it and try to work with it. That is the spirit of 12-Step.