SECTION 9: Mutual Help, Twelve Step, and Other

Recovery Programs
CHAPTER
Twelve-Step Programs in Addiction
Recovery
Edgar P. Nace, MD 69
Twelve-Step programs are a fellowship of men and women who offer their hope,
strength, and experience to anyone desiring to not drink or do drugs. Participation is
anonymous, there is no cost, and questions are not asked of newcomers.

ALCOHOLICS ANONYMOUS
Alcoholics Anonymous (AA) is an organization that has a single purpose:
to carry its message to the alcoholic who still suffers. In 2010, AA membership
exceeded 2 million, and there were 115,770 groups registered. AA does not engage
in fund-raising or lobbying: it endorses no causes and does not promote itself. It is
interested in the alcoholic person, not alcoholism per se. AA will decline outside
contributions and does not provide treatment or educational services.
AA refers to itself as a fellowship. A fellowship is a mutual association of
persons on equal and friendly terms: a mutual sharing, as of experience, activity, or
interest. There are no dues, but a collection is commonly taken at meetings to
assure that AA remains self-suporting and not dependent on outside funds. All are
welcome based on a desire to stop drinking. Admitting that one is an alcoholic is
not necessary, nor will AA attempt to proffer a diagnosis on an attendee.

The Program
To work the AA program means to study the Twelve Steps (Table 69-1) and
to follow the directions contained within these steps. In addition, AA members and
AA groups will respect and adhere to the Twelve Traditions (Table 69-2). AA
meetings may be open or closed. Closed meetings are for those who consider
themselves alcoholics or are questioning whether they might be alcoholic. Open
meetings are for anyone interested in attending a meeting. If an alcoholic person did
not wish to be seen at an AA meeting expect by other alcoholics, he or she would
attend only closed meetings.
A meeting is usually 1 hour in duration and may be followed by informal
socializing. A speakers meeting will consist of a member telling her story-
emphasizing what it was like (the drinking experience), what happened (the
process of recognizing the consequences of drinking and doing something about it),
and what it is like now (how life has changed since beginning recovery from
alcoholism). Step meetings will focus on one of the Twelve-Steps in a discussion
format. Discussion meetings are those where a topic is picked (e.g., gratitude) and
the group shares thoughts and experiences of the same.

The Birth of Alcoholics Anonymous

AA was founded in Akron, Ohio, in 1935 by Bill Wilson and Dr. Bob Smith.
By 1950, there were about 90,000 members. A 2007 survey by the General Service
office of AA estimated that worldwide, there were nearly 2 million members with
about 1.2 million of these members being in the United States. Members reported
attending an average of 2.4 AA meetings a week, and 79% of members had an AA
sponsor.

Table 69-1 THE TWELVE STEPS

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.

NARCOTICS ANONYMOUS
NA is the second largest Twelve-Step program focused on substance use disorders.
NA grew out of AA in Los Angeles in the late 1940s and follows the format of AA
with its Twelve Steps and Twelve Traditions. NA substituted the word addiction
for alcohol, removing drug-specific references. NA is open to all drug addicts with-
out regard to the type of drug or combination of drugs. NA literature describes the
purpose of NA as follows: NA is a nonprofit fellowship or society of men and
women for whom drugs had become a major problem. We meet regularly to help
each other stay clean. We are not interested in what or how much you used but
only in what you want to do about your problem and how we can help, NA
members are likely, on the average, to be younger than AA members. NA in its 2009
survey reports that 2% are under age 20, 14% age 21 to 30 (contrasting with 8% per
the 2007 AA survey), and only 4% over age 60 (contrasting with AA with over 16%
over age 60).

TABLE 69-2. THE TWELVE TRADITIONS

1. Our common welfare should come first; personal recovery depends upon AA
unity.
2. For our group purpose, these is but one ultimate authority-a loving God as He
may express Himself in our group conscience. Our leaders are but trusted
servants; they do not govern.
3. The only requirement for AA membership is a desire to stop drinking.
4. Each group should be autonomous except in matters affecting other groups or
AA as a whole.
5. Each group has but one primary purpose - to carry its message to the alcoholic
who still suffers.
6. An AA group ought never endorse, finance, or lend the AA name to any related
facility or outside enterprise, lest problems of money, property, and prestige
divert us from our primary purpose.
7. Every AA group ought to be fully self-supporting, declining outside
contributions.
8. AA should remain forever nonprofessional, but our service centers may employ
 special workers.
9. AA, as such, ought never be organized; but we may create service boards or
committees directly responsible to those they serve.
10. AA has no opinion on outside issues; hence, the AA name ought never be drawn
into public controversy.
11. Our public relations policy is based on attraction rather than promotion; we need
always maintain personal anonymity at the level of press, radio, and films.
12. Anonymity is the spiritual foundation of all our traditions, ever reminding us to
place principles before personalities.

COCAINE ANONYMOUS
CA began in Los Angeles in 1982. CA is adapted from the AA program and follows
the Twelve-Step model. It is open to all individuals who want to stop using cocaine
as well as all other mind-altering substances. As of 1996, membership was estimated
to be 30,000 members in 2,000 groups.

MARIJUANA ANONYMOUS
Marijuana Anonymous (MA) was founded in 1989 and is based on the Twelve-Step
program of AA. MA is for those who experience marijuana as controlling their lives.

NICOTINE ANONYMOUS
Nicotine Anonymous, formerly Smokers Anonymous, was founded in the early
1980s and is modeled on AA. Nicotine Anonymous, as with other Twelve-Step
programs, emphasizes that the user is neither unique nor alone

AL-ANON AND ALATEEN

Al-Anon was founded in 1951 by Loss Wilson, the wife of AA cofounder Bill
Wilson. Al-Anon is an international fellowship of friends or relatives of alcoholics
who have been impacted by anothers drinking. They share their experience,
strength, and hope and follow their own Twelve-Step format. Al-Anon is not family
or group therapy and does not provide counseling in any formal sense. Alateen grew
out of Al-Anon and is for teenagers 13 to 17, Al-Anon meetings will focus not on
the drinker, but on the family members or friends of a drinker who tolerate abuse, or
indulge in excessive caretaking, and who may have developed low self-esteem
because they think that they should be able to help the alcoholic stop drinking.

PHYSICIAN FACILITATION OF TWELVE-STEP PARTICIPATION

Physicians and other clinicians should inform patients of the existence, format, and
benefits of participating in a Twelve-Step program. This recommendation is based
on empirical evidence that AA participation (and by extension use of other Twelve-
Step programs) and engagement/ commitment to AA are consistent predictors of
positive outcomes for addicted individuals.

OUTCOME STUDIES
Support for encouraging AA (and by extension other Twelve-Step programs) is
found in several large studies. One study compared alcoholics randomly assigned to
cognitive-behavioral therapy, motivational treatment (MT), and Twelve-Step
facilitation (TSF). TSF is a professionally led group therapy, which points patients
to Twelve-Step participation. TSF patients had significantly higher rates of
abstinence at 1-year and 3-year follow-ups. Another study among US veterans found
that at 1 year and at 18 months, those patients whose after care was only AA or
another Twelve-Step program had abstinence rates twice those who did not attend
any Twelve-Step program. There is some evidence that the number of meetings
attended functions in a dose-response relationship.

KEY POINTS
1. The purpose of AA is to assist the suffering alcoholic achieve sobriety, and it is
not involved in treatment, research, or social and political issues.
2. The only criterion for attending AA meetings is a desire not to drink
3. Physicians should be familiar with Twelve-Step programs and encourage patients
with substance use disorders to participate.
SUGGESTED READINGS
Alcoholics Anonymous. Alcoholics Anonymous: Twelve steps and twelve traditions. New
York: Alcoholics Anonymous World Services; 1978
Alcoholics Anonymous. Alcoholics anonymous: The story of how many thousands of men
and women have recovered from alcoholism, 4th ed. New York: Alcoholics
Anonymous World Services; 2001.
Kurtz E. Not-God: A history of alcoholics anonymous. Center City, MN: Hazelden; 1979.

Anonymous is a self-help organization for people fighting alcoholism, founded in

the US in 1935 and now having branches worldwide.