The Relationship Between Substance User Treatment and 12-Step Fellowships: Current Knowledge and Research Questions

Abstract

This article reviews and synthesizes information about the relationship between two distinct approaches to helping substance users, formal “addiction treatment” and 12-step mutual aid. The following issues are addressed: Extent of formal treatment and 12-step fellowship participation for persons with substance use-related problems; overlap between treatment and 12-step participation; early attempts to “integrate” treatment and 12-step mutual aid; differences and similarities between the 12-step program and treatment; issues of spirituality in the 12-step program; effectiveness of 12-step participation as treatment aftercare; and whether help-seekers can be “matched” to 12-step. The article poses pertinent questions that could answered by additional research, including life cycle patterns of usage of treatment and 12-step, outcomes of such episodes, reasons for using different interventions at different times, feasibility of 12-step participation as a primary intervention, the relative contributions of striving for spiritual values vs. social support factors to the effectiveness of 12-step, and the comparative effectiveness of secular vs. 12-step mutual aid. The article concludes with a proposed reconceptualization of the relationship between formal treatment and 12-step mutual aid that may help in structuring future research.

In the rarer sort … inexorable sorrow takes the form of fellowship and makes the imagination tender. George Eliot (1876)

Keywords:

• 12-steps
• Alcoholics Anonymous
• mutual aid
• addiction treatment
• recovery
• spirituality

Notes

Notes

¹“Treatment” can be briefly and usefully defined as a planned, goal-directed change process, which is bounded (culture, place, time, etc.) and can be categorized into professional based, tradition based, mutual aid based (AA, NA, etc.), and self-change (“natural recovery”) models. Notwithstanding the traditional use of terms such as “addiction treatment,” “alcohol treatment,” and “drug treatment” in the literature, there are no unique models or techniques used with substance users—of whatever types—that are not also used with non-substance users. Editor's note.

²If one chooses to go beyond the traditional focus of the IP (identified person/patient), one is left with delineating the challenges, options, opportunities, and roles for the “matching” processes for these two models for “significant others” and a range of individual and systemic “stakeholders”—however they are or can be defined—the broad range of change agents and agencies, the communities-at-large with which these models are-can be-should be associated, and the types of networks that map the dimensions of substance use and its associated interventions. These issues were not referred to at the MEMSIDU meeting and thus will not be analyzed in this Proceeding's article, notwithstanding their importance. Editor's note.

³Although the concept of “disease” has been categorized in a variety of ways—biochemical, actuarial, functional, experiential, social, political, religious-spirit, economic, and consumer—it continues to be used in a “fuzzy” way by many in the field of substance user intervention, so that the “demands” of each model are not related to treatment planning, policy delineation, staff training, etc. Editor's note.

⁴One may also posit that, with the advent of nonlinear science and its underlying theories (chaos, complexity, uncertainty, and neural network theories), much of human behavior such as “drinking outcome” is complex, dynamic, multidimensional, level/phase structured, network based and bounded (by culture, time, place, age, gender, ethnicity, etc.) (Buscema, 1998; Barabási, 2003). If this view is viable, then simple or even complicated linear, cause-and-effect–based processes are unlikely to result in the hypothesized behavioral changes. Editor's note.

1. The reader is referred to an historical analysis of this concept by the Russian Prince P. A. Kropotkin (1921). The terms “mutual aid” and “self-help” are used synonymously in most of the later literature, although the former is more accurate conceptually. There is also an extensive literature on “natural recovery” that describes individuals who cease their substance use through “self-change” (Klingemann and Sobell, 2001); the present article does not include this issue.

2. This does not include tobacco or food-related disorders. For a consideration of primary and secondary diagnoses, their outcomes, and their formal treatment, the reader is referred to Adrian and Minh, in this volume.

3. There are also AA-affiliated groups specifically for the family members of AA members or those affected by alcohol use in the family (“Al-Anon,” or more fully, Al-Anon Family Groups), and for teenagers affected by alcohol use in the family (“Alateen”). For more details on the mutual aid model and options for participation, see Humphreys (2003).

4. Generalizable data are currently unavailable about how many drug users who utilize needle exchange programs (NEPs) and secondary or satellite exchange programs (SEPs), as well as other types of harm reduction programs, also participate in 12-step and/or formal treatment programs.

5. Powerlessness in Calvinism: “The effect of the Fall upon man is that sin has extended to every part of his personality—his thinking, his emotions, and his will. Not necessarily that he is intensely sinful, but that sin has extended to his entire being” (Romans 5:12). “Without the power of the Holy Spirit, the natural man is blind and deaf to the message of the gospel” (Mark 4:11f). “This is why Total Depravity has also been called ‘Total Inability.”’ (Barlow, 2004).Personal responsibility in Calvinism: “God has elected, based solely upon the counsel of his own will, some for glory and others for damnation” (Romans 9:15, 21). This doctrine does not rule out, however, man's responsibility to believe in the redeeming work of God the Son (John 3:16–18). “The elect are saved unto good works” (Ephesians 2:10). “Thus, though good works will never bridge the gulf between man and God that was formed in the Fall, good works are a result of God's saving grace. Bearing the fruit of good works is an indication that God has sown seeds of grace in fertile soil.” (Barlow, 2004).

6. “Stepwork” or “working the steps” constitutes study and activities dedicated to implementing the mandates of particular steps in the 12-steps. It is not a linear process; members may work on any steps that are appropriate for them at a given time in their recovery.