Step-by-step approach to abstinence-based recovery
The ‘12 steps’ are at the heart of Alcoholics Anonymous (AA), which was co-founded in 1935 by Bill Wilson and Dr. Bob Smith. They present a step-by-step guide to recovery, beginning with someone recognising that they have a problem and surrendering to what they need to do to get better. Although the 12 steps focus on the individual (and their medical and spiritual recovery), AA puts an emphasis on ‘fellowship’, social support, and mutual aid. The 12 steps were originally developed for alcohol and AA, but are now used in many other fellowships including Narcotics Anonymous, Cocaine Anonymous, and Gamblers Anonymous.
The 12 steps:
The key tenets of Alcoholics Anonymous are sometimes referred to as the ‘AA six pack’: don’t drink, go to meetings, ask for help, get a sponsor, join a group, and get active. Each AA group is autonomous and self-funded through contributions from members. The official website provides information and advice on how to start a new group, including considerations such as where to hold meetings, how to attract members, and what reading materials to have available. It also has a list of current meetings.
There are several different ways to work the 12 steps. Some people do so with the support of a sponsor and through attending meetings. Others participate in more formal 12-step treatment programmes, such as the Minnesota Model.
A Cochrane review published in 2020 found three cases where 12-step programmes were associated with better outcomes against the measure of ‘continuous abstinence’. For AA, abstinence is the critical outcome, but this may not be the most important outcome for everyone. Furthermore, these particular interventions involved manualised, weekly sessions for 3 months with therapists, making them a highly-structured, professionalised, and intensive add-on to the typical AA group.
Other than its ability to cultivate a social network of supportive peers, a defining feature of Alcoholics Anonymous is the spiritual/religious nature of the original 12 steps. A 2019 review of spiritual/religious interventions found that they were probably effective for people with substance use problems, but did not find that spiritual/religious components were the only active ingredients operating, or confirm that they were operating at all.
A review of how Alcoholics Anonymous works highlighted features that 12-step programmes share with other approaches, including heightening confidence that one can resist drinking, bolstering motivation for abstinence and commitment to recovery, developing coping strategies such as avoiding high-risk situations, and strengthening social support.
Twelve-step programmes have a low barrier of entry, which means that they might be more accessible for particularly marginalised and disenfranchised groups of people than formal models of treatment and support. However, 12-step programmes do not have the same strength of evidence of effectiveness as psychosocial therapies such as motivational interviewing and cognitive-behavioural therapy.
The 12 steps at the heart of Alcoholics Anonymous have a religious tone, with seven of the steps “refer[ring] either to a deity – ‘God,’ ‘Him’ or ‘a Power greater than ourselves’ – or to religious practices such as prayer.” While the umbrella group for Alcoholics Anonymous in the UK acknowledges the programme has its origins in a Christian group, it says there is “only one requirement for membership and that is the desire to stop drinking. There is room in AA for people of all shades of belief and non-belief.”
The Big Book of Alcoholics Anonymous, written by Bill W. in 1939, has been instrumental in many people’s journey to recovery. However, when it was written, it was created primarily with men in mind. The fourth edition stated that “what we have said applies quite as much to women [as men]”, yet, little about the language has changed.