The problem with 12-step plans

Breaking free of addictions such as alcohol, drugs, and smoking is hard and very often people who seek to do so enroll in the many 12-step programs modeled on the one made famous by Alcoholics Anonymous. Some judges even use such programs as part of their sentencing requirements.

But Lance Dodes, a psychiatrist who treats addictions and has studied the various programs, says that not only are these popular programs unsuccessful, they actually cause more harm than good. He is extremely harsh in his judgment about their effectiveness.

[P]eople stop drinking on their own at about the same rate as they get better in AA. There are some studies that have claimed to show scientifically that AA is useful. These studies are riddled with scientific errors, and they say no more than what we knew to begin with, which is that AA has probably the worst success rate in all of medicine.

It’s not only that AA has a five to 10 percent success rate. If it was successful and was neutral the rest of the time, we’d say OK. But it’s harmful to the 90 percent who don’t do well. And it’s harmful for several important reasons. One of them is that everyone believes that AA is the right treatment. AA is never wrong, according to AA. If you fail in AA, it’s you that’s failed. … People leave feeling much more depressed and discouraged and worse about themselves.

He says that these and similar 12-step programs have created such an aura of success that if a person does not succeed after trying them, then it is that person’s own fault and is urged to try over and over again.

And if you don’t do well in a rehab, the rehab says you’ve failed, come back again, and come back again and again for the same failed treatment. Whenever we hear about these celebrities who go in and out of the same rehabs, we blame them. We say, what’s the matter with them? They’re falling out of the treatment. No one says the treatment is no good.

He says that there is no sure-fire way to treat addiction but that it is important for addicts to realize that their habit arises as a substitution for something and that it is important to get them to understand what it is they are missing in their lives and deal with that root problem if they are to kick the addiction.

One thing that I have not been clear about is what constitutes a ‘success’ in such rehabilitation efforts. Does it mean that the person kicks the habit entirely forever? Is it considered a failure if an addict replaces the addition with a more harmless substitute (like chewing gum) that they never get rid of? What if they stop being severely addicted to alcohol (say) but end up drinking the occasional beer or at socially acceptable levels? Or if they find that they are totally dependent on a support group for their entire lives to stay sober?

I see all of these things as successes because people have replaced a practice that was harming their lives with one that is under control. But maybe that is because I have no experience with such extreme addictions and that there is no escape from them unless you make a total break.


  1. moarscienceplz says

    The problem with 12-step plans

    … is that the average American can’t count that high?

  2. moarscienceplz says

    But seriously, as I understand it, AA was invented by Bill Wilson and a handful of other alcoholics deciding what seemed right to them. No scientific testing was used, and to this day I don’t think AA even tries to discern the different aspects that psychological vs. physiological factors play in each person’s addiction. It is not far removed from eye of newt and tongue of bat.

  3. Al Dente says

    I know some alcoholics who became involved in AA. A couple of them go to two or three meetings per week and have done so for years. Talking to them, it seems to me that they’ve substituted one addiction for another. The only good point about being addicted to AA is it’s easier on the body than alcohol.

  4. sigurd jorsalfar says

    AA was very christian in its original conception, requiring the person in recovery to acknowledge that he was powerless and needed God to help him recover. Over time that got watered down from ‘God’ to ‘higher power’, but it still highlights the fundamentally faith-based, unscientific nature of AA.

    Lance Dodes certainly isn’t the first person to criticize AA like this, though he may be the best credentialed person to do so. There are some interesting youtube videos by a woman who is an opponent of AA. I don’t think she’s a psychologist but she seems to have a lot of experience with legal challenges against AA as a sentencing alternative. Sorry I don’t have links.

    There’s an interesting blog out there called Immortal Alcoholic where a woman who is married to an end-stage alcoholic recounts the trials and tribulations of dealing with and caring for such a person. The blog isn’t an attack on AA, but she does have posts talking about her husband being in a 12-step program and she doesn’t have anything good to say about them. AA comes across in her blog as just a substitute addiction, nothing more. It clearly hasn’t been effective in her husband’s case. Overall it’s a sad but eye-opening blog.

  5. J Walthers says

    Come on. Are you seriously going to post this person’s assertions for which he provides no credible evidence? He can’t even get his basic statistics right. If you look at the National Surveys on Drug Use and Health which are conducted every year, you see that of those people that meet criteria for alcohol use disorders, about 75-85% of them recover on their own. Of the 15-25% that remain, the majority of those will recover with some form of treatment, and only about 3% overall never recover with or without help, so if AA was really helping the same amount of people that get better on their own, it would show 75% efficacy in helping people achieve long-term abstinence.

    Although I don’t subscribe to the AA model of addiction, it is one of the most well-researched and empirically validated models for recovery (the works of J Scott Tonigan are a good place to start reading about AA efficacy and its mechanisms of action). At its core, its ‘prescriptions’ for acheiving long-term abstinence aren’t dissimilar from the very well-researched cognitive-behavioral methods, where the focus lies upon avoiding dangerous situations where possible and formulating effective methods for dealing with urges to drink and building a lifestyle filled with abstinence-oriented activities to replace the role of alcohol in one’s life.

    More than that, the assertion that people develop substance use disorders because they are substituting for something missing in their lives or because they are feeling trapped or helpless is laughable at best. Even a cursory review of the phenomenology literature would show you that individuals, especially those struggling with alcohol use or dependence drink for a incredible variety of reasons, the overwhelming majority of which are not ‘substituting’ or ‘feeling trapped or helpless’.

    In this person’s defense, I will stipulate that there are issues to be taken with the AA model of addiction and recovery, not the least of which is the assertion that the individual is powerless over his/her disorder and needs the help of a ‘higher power’ to recover. One of the most important lessons we have learned from the Motivational Interviewing literature is that helping the patient to develop a healthy, realistic sense of self-efficacy is crucial to helping them acheive their recovery goals.

    The issues with AA notwithstanding, I have to say that just because this person is a physician and ‘treats addiction’ doesn’t make his/her assertions on the subject accurate, intelligent, or useful. I can point you to a few holistic addiction treatment ‘specialists’ who would be every bit as full of shit as this guy appears to be.

  6. smrnda says

    I’ve found there to be scant evidence that AA works, mostly since the organization doesn’t seem to keep statistics (an issue that’s also common in overtly faith-based programs) and it seems that, at best, the success rate for AA appears close to the spontaneous remission rate.

    On the idea that addiction is owing to some other factor, this always struck me as a huge unfalsifiable hypothesis; AA seems to believe this, and has invented the idea of the ‘dry drunk’ – a person who quits drinking without the 12 step program, because AA belief is that the problem is something else other than addiction. If you quit drinking without their self-improvement program, they invent a way to argue you’ve made no progress.

    Overall, I also think too many people who are problem drinkers but clearly not actually addicted get treated as the same as addicts, and the ‘one size fits all’ philosophy does harm to all.

  7. says

    People talk about “gateway drugs”, how one habitual use or addiction leads to a worse one. How is trading addition to drugs for an addiction to religion any different?

    Smokers often don’t quit until they face cancer, and sometimes not even then. Everything I’ve seen and read says people don’t quit until they hit rock bottom, whether that means they are dead or they are sick of the addiction and want to change voluntarilty. Like anything else such as morals, it’s a matter of personal responsibility and will.

    Al Dente (#3) –

    The only good point about being addicted to AA is it’s easier on the body than alcohol.

    “Good” is debatable. Mental damage from occult religion (e.g. stress) can be as physically damaging as any substance.

  8. MattP (must mock his crappy brain) says

    @5, J Walthers

    Where exactly did you get those numbers from the NSDUH results? The 2012 report* only discusses the incidence of US citizens qualifying as abusing, or dependent on, a substance under the DSM IV criteria (all detailed in Section 7), how many of them received treatment, and how many needed and/or received treatment.

    I see nothing about success of any treatments, either of ‘specialty’ treatments or self-help groups. The word ‘recover’ appears nowhere in the linked report. If you are talking about the TEDS discharge report, how did you get the numbers you assert?


  9. J Walthers says

    @ #8 aha, yes you are correct. It’s actually the NESARC (national epidemiolgical survey on alcohol and related conditions) that provides thhat information, not the NSDUH. My bad on that one. Still, the NESARC estimates show that of all people that meet criteria for dependence in any given year, 75% of them no longer meet criteria for dependence the following year.

  10. Dunc says

    What if they stop being severely addicted to alcohol (say) but end up drinking the occasional beer or at socially acceptable levels?

    I’d say that’s the greatest success of all. If you can only manage your addiction through complete abstinence, you’re still an addict.

  11. says

    The real problem is that 12 Step programs foster a cult mentality. “You are utterly helpless without us. You will always be sick without us. You must follow the program EXACTLY or you will always be sick. You must believe as we tell you to believe. You must do as we tell you to do. You must repent. You must evangelize. If you have any doubts or worries or fears, you must bring them to another member because only WE can help you get better. Do not question. Do not look around for anything else. Stay focused on us, and ONLY on us.”

    This is the case with AA, Al-Anon, NA, OA, the whole boatload. It is down right creepy.

  12. says

    @Al Dente #3 – “… it seems to me that they’ve substituted one addiction for another.”

    That has been my experience, too, both directly and from friends and family who have “worked the program.” Most people in AA (and NA and OA and all the rest) who are “successful” have addict personalities, and success comes by replacing one addition with another.

    “The only good point about being addicted to AA is it’s easier on the body than alcohol.”

    On the body, sure. On the mind and spirit? No. The program “works” by fostering a sense of helplessness and doom. From the steps themselves:

    1. We admitted we were powerless over (fill in the blank) — that our lives had become unmanageable. (We cannot be blamed for our actions, as we have been possessed by a demon that we are powerless to fight.)

    2. Came to believe that a power greater than ourselves could restore us to sanity. (Only God can save us.)

    3. Made a decision to turn our will and our lives over to the care of God as we understood Him. (*ALWAYS* it is the Christian god, usually the god of Evangelical Protestantism.)

    4. Made a searching and fearless moral inventory of ourselves. (The first step that has nothing to do with supernaturalism or superstition.)

    5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. (Confess and be saved.)

    6. Were entirely ready to have God remove all these defects of character. (Because addiction is never a medical problem or a matter of biology: it is a character flaw and if you get addicted it is YOUR OWN DAMNED FAULT!)

    7. Humbly asked Him to remove our shortcomings. (Confess and be saved.)

    8. Made a list of all persons we had harmed, and became willing to make amends to them all. (This step has nothing to do with supernaturalism or superstition, although it does smack of “salvation through works.”)

    9. Made direct amends to such people wherever possible, except when to do so would injure them or others. (Same comment as 8.)

    10. Continued to take personal inventory and when we were wrong promptly admitted it. (Getting a tad repetitious, aren’t we? It’s almost like they padded the steps to come up with a magic number.)

    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. (Repent and be saved.)

    12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to others, and to practice these principles in all our affairs. (Once you have graduated, you must stand in airport waiting lounges, selling flowers and books to bring enlightenment to a benighted world.)

    As I said above, it is a cult from start to finish.

  13. ToastyKing says

    @ #10:

    I don’t think it’s for you to determine what should be an acceptable recovery goal for individuals struggling with substance use disorders. If The individual determines that abstinence is in her/his best interest and if in pursuit of that goal, the individual lives a happy, healthy, fulfilling lifestyle, who are you to wag your finger and say that’s not good enough?

  14. Dunc says

    I did not at any point say that I thought abstinence wasn’t good enough. Good enough for what?

    I don’t regard addiction as a personal or moral failing. You are projecting your own attitudes to addiction onto me.

  15. Timothy says

    I’m with J. Walthers on this one:

    “The issues with AA notwithstanding, I have to say that just because this person is a physician and ‘treats addiction’ doesn’t make his/her the subject accurate, intelligent, or useful. ”

    I’d like to see the research that Dr. Dodes is using to make his case.

    Despite AA’s origins being connected with Swiss psychiatrist Carl Jung, I’ve never been enamored with the philosophy of AA. If I was an addict, I am honestly not sure this approach would work for me. However, after more than 20 years in the mental health field, the 12-step model seems to work for an awful lot of people. (Anecdotal information, yes. Sample bias, yes. But I believe you’d get a similar response from any experience mental health professional.) Yes, many of them realized they are substituting one addiction for another. Yes, it can become like a cult. Yes, there are people for whom it does not work. Yes, the whole ‘Greater Power’ thing turns off agnostics and atheists.

    However — again as a practicing mental health professional — there are VIRTUALLY NO OTHER OPTIONS for people in recovery (unless they are very wealthy. See the constant stream of celebrities into private, for-profit care facilities, the media coverage of which skews many American’s perceptions of the availability of drug/alcohol treatment in America.)

    America has spent enormous amounts escalating the war on drugs for decades, while at the same time slashing funding for drug/alcohol treatment programs. Gone are the days when people with drug problems could stay 60 or 90 days inpatient. In America at least, we are unwilling to fund any serious treatment programs, let alone fund the research to evaluate those programs. And the hard, cold fact is that some people in recovery need daily treatment. Even in outpatient therapy, patients are generally restricted to one visit per week. Especially in the early stages of recovery, many patients need daily support.

    Our American money / profit focused culture refuses to provide the care folks in recovery need. Whatever its faults, AA provides a place where — for over 60 years, and in almost anywhere in this country — people can go to daily meetings to get support with their sobriety if they need it. All at no cost.

    And for these factors alone, I say: Well done, AA.

  16. Timothy says

    Point 2:

    Dr. Dodes says,

    “It’s not only that AA has a 5 to 10 percent success rate. If it was successful and was neutral the rest of the time, we’d say OK. But it’s harmful to the 90 percent who don’t do well. And it’s harmful for several important reasons. One of them is that everyone believes that AA is the right treatment. AA is never wrong, according to AA. If you fail in AA, it’s you that’s failed.”

    … substitute ‘biological psychiatry’ ….

    It’s not only that biological psychiatry has a 5 to 10 percent success rate. If it was successful and was neutral the rest of the time, we’d say OK. But it’s harmful to the 90 percent who don’t do well. And it’s harmful for several important reasons. One of them is that everyone believes that biological psychiatry is the right treatment. Biological psychiatry is never wrong, according to biological psychiatry. If you fail in biological psychiatry, it’s you that’s failed.

    … and you come pretty close to the truth. To be fair, I don’t know the success rate of psychiatry, so I don’t know if the “5 to 10 percent’ is accurate. But it can be pretty abysmal.

    A case of the pot calling the kettle black, methinks.

    Ok. I’m off my soap box now.


Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>