The Surprising Failures of 12 Steps

Say you’ve been diagnosed with a serious, life-altering illness or psychological condition. In lieu of medication, psychotherapy, or a combination thereof, your doctor prescribes nightly meetings with a group of similarly afflicted individuals, and a set of 12 non-medical guidelines for recovery, half of which require direct appeals to God. What would you do?

Especially to nontheists, the concept of “asking God to remove defects of character” can feel anachronistic. But it is the sixth step in the 12 Steps of Alcoholics Anonymous—the prototype of 12-step facilitation (TSF), the almost universally accepted standard for addiction-recovery in America today.

From its origins in the treatment of alcoholism, TSF is now applied to over 300 addictions and psychological disorders: drug-use, of course (Narcotics Anonymous), but also smoking, sex and pornography addictions, social anxiety, kleptomania, overeating, compulsive spending, problem-gambling, even "workaholism."

Although AA does not keep membership records—the idea being pretty antithetical to the whole “anonymity” thing—the organization estimates that as of January 2013, more than 1 million Americans regularly attended meetings with one of roughly 60,000 groups. Dr. Lance Dodes, a recently retired professor of psychiatry at Harvard Medical School, estimates about 5 million individuals attend one or more meetings in a given year. Indeed the 12-step empire is vast, but Dodes thinks it’s an empire built on shaky foundations.

In his new book, released today, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry (co-written with Zachary Dodes), he casts a critical eye on 12-step hegemony; dissecting the history, philosophy, and ultimate efficacy of TSF, lending special scrutiny to its flagship program.

“Peer reviewed studies peg the success rate of AA somewhere between five and 10 percent,” writes Dodes. “About one of every 15 people who enter these programs is able to become and stay sober.”

This contrasts with AA’s self-reported figures: A 2007 internal survey found that 33 percent of members said they had been sober for more than a decade. Twelve percent claimed sobriety for five to 10 years, 24 percent were sober for one to five years, and 31 percent were sober for under a year. Of course, those don’t take into account the large number of alcoholics who never make it through their first year of meetings, subsequently never completing the 12 steps (the definition of success, by AA’s standards).

A report published by Alcoholism Treatment Quarterly in 2000 analyzed AA membership surveys taken from 1968 through 1996. On average, 81 percent of newcomers stopped attending meetings within the first month. After 90 days, only 10 percent remained. That figure was halved after a full year.

Additionally, there’s AA’s barefaced religious affiliations to consider. True, the 12 steps have been worded in such a way as to suggest a certain amount of leeway in which God (or “higher power”) one ultimately surrenders to; but AA is a self-identified Christian organization with a significant portion of its methodology rooted in prayer. As it says in AA’s founding literature, known as the Big Book, “To some people we need not, and probably should not, emphasize the spiritual feature on our first approach. We might prejudice them. At the moment we are trying to put our lives in order. But this is not an end in itself. Our real purpose is to fit ourselves to be of maximum service to God.”

So how did AA gain such a place of privilege in American health-culture? How did a regimen so overtly religious in nature, with a 31 percent success rate at best, a five to 10 percent success rate at worst, and a five percent overall retention rate become the most trusted method of addiction-treatment in the country, and arguably the world? It’s a central question Dodes seeks to answer in The Sober Truth. And he begins at the very beginning.

According to Dodes, when the Big Book was first published in 1939, it was met with wide skepticism in the medical community. The AMA called it “a curious combination of organizing propaganda and religious exhortation.” A year later, the Journal of Nervous and Mental Diseases described it as “a rambling sort of camp-meeting confession of experiences … Of the inner meaning of alcoholism there is hardly a word. It is all surface material.”

That perception has since radically changed, albeit gradually, thanks in no small part to the concerted efforts of AA’s early pioneers. They “realized early on that to establish true legitimacy, they would eventually need to earn the imprimatur of the scientific community,” writes Dodes. Which they did, with aplomb, largely by manufacturing an establishment for addiction scholarship and advocacy that did not previously exist. They created a space for AA to dictate the conversation.

The National Council on Alcoholism and Drug Dependence, one of the foremost American advocacy-agencies for recovering addicts, was founded in 1944 by Marty Mann—a wealthy and well-connected Chicago debutante, and the first female member of AA. The Center of Alcohol Studies at Rutgers University, an international leader in alcoholism-related research, was founded at Yale in 1943 under the direction of E. Morton Jellinek. Jellinek, the author of several seminal texts on alcoholism and an eventual WHO consultant on the condition, placed AA-founder and Big Book author Bill Wilson on the faculty—a man who claimed to have been cured of his own alcoholism not through the progress of scientific research, but by divine intervention.

In 1951, based on what Dodes calls “the strength of self-reported success and popular articles” (The Saturday Evening Post was a major supporter), AA received a Lasker Award, which is “given by the American Public Health Association for outstanding achievement in medical research or public health administration.” This despite “no mention of any scientific study that might prove or disprove the organization’s efficacy,” writes Dodes. But it was nevertheless a marked moment AA’s history; the moment it entered the medical establishment, and by proxy, gained implicit trust from the American public on matters of alcohol abuse.

Two decades later, in 1970, Congress passed a landmark bill called the “Comprehensive Alcohol Abuse and Alcoholism Prevention Treatment and Rehabilitation Act,” precipitating the establishment of the National Institute on Alcohol Abuse and Alcoholism, part of the U.S. National Institutes of Health. “Among those testifying to the lawmakers in support of the bill,” writes Dodes, “were Marty Mann and Bill Wilson.”

In 1989, America’s first drug court began sentencing “nonviolent drug offenders” to 12-step programs. Although court-mandated participation in 12-step programs would eventually be deemed unconstitutional (thanks to items like Step Six), Dodes claims “judges still refer people to AA as a part of sentencing or a condition of probation.”

This brings us to the present: an addiction-treatment landscape envisioned and engineered almost entirely by AA. TSF is the law of the land. If you have a drinking problem in 2014, or a drug problem, or a gambling problem, your medically, socially, culturally, and politically mandated solution is a set of 12 steps. The only other options, as asserted by the Big Book, are “jails, institutions, and death.”

And any suggestion that AA might be a flawed program, or not right for every addict, is met with scandalized looks and harsh retorts. AA, simply put, is pretty popular among the non-addicted. “In the absence of sophisticated knowledge,” writes Dodes, “platitudes and homilies rush in to fill the void, many of which obscure far more than they illuminate. Folklore and anecdote are elevated to equal standing with data and evidence. Everyone’s an expert, because everyone knows somebody who has been through it. And nothing in this world travels faster than a pithy turn of phrase.”

But society at large is guilty of more than just perpetuating the dominion of AA and TSF with “folklore and anecdote.” We are just as guilty of driving addicts into the program as the program is of raising the specter of a sole avenue to recovery.

Despite the popular glorification of TSF, addiction remains an oft-trivialized topic, and the addict an oft-ridiculed figure. A night of heavy drinking might be punctuated with an off-the-cuff comment like, “I am such an alcoholic!” Or incredulity expressed through hyperbolic questions like, “Are you on crack?” The meth-addict, as portrayed on TV shows like Breaking Bad and Inside Amy Schumer, is the commonly accepted lowest form of human-scum, deserving of not just ridicule, but violent death. The addict is disposable. Or a recyclable punchline.

When, as a culture, we ascribe the addict the lowest possible social value, is it any wonder why they flock to a fellowship of equally alienated individuals with common lived-experiences? Organizations like AA? It’s true addicts are deserving of treatment plans based in something more than blind faith—Dodes’s argument is more than persuasive in that regard—but pills and therapy and data and evidence aren’t necessarily enough to treat a condition so inherently linked to emotional wellbeing and self-worth. The addict, like any human, craves community. And if the greater community persists in shunning and shaming addicts, and AA remains the only door left ajar, then it’s to AA the addicts will go. And who could blame them?