‘All or nothing’ – are 12-steps right for everyone?

The 12-step fellowships are a life-saver for some – but for others, the concept of total surrender can do more harm than good. Alex Boyt makes the case from his own experience.

I was first arrested for drugs in 1973, did my first three rehabs by 1987, and having been told early on I had a progressive and terminal disease that needed a permanent 12-step solution, I did about 3,000 Narcotics Anonymous meetings over the next 28 years. Though twice in my life it had played a central part in pulling me out of extreme injecting drug use, I was never convinced by the requirement to surrender and admit powerlessness.

photo by Nigel Brunsdon

The notion that I would always be an addict because I once had a problem felt very limiting to me. The relentless echo chamber of the fellowship however had me trapped, afraid that to question the need for a 12-step remedy would lead me back to jails, institutions and death.

The continuous references to God and prayer had always been an irritant, but what really began to grate on me was the requirement to swallow and regurgitate the ‘fact’ of suffering from an endless incurable illness that meant eternal vigilance. The sense of belonging was undeniably valuable, but it was conditional on acknow­ledging the 12-step programme as a God-given gift for which one must be grateful.

Within the 12-step environment you cannot have conversations about healthy ways to disengage, since leaving is the first step to relapse. Stories of people doing well without NA meetings were rarely mentioned and then dismissed as rare excep­tions, or otherwise as people who had never really had ‘the problem’ in the first place.

‘I began to discover that endless
disease was not seen by all as
the optimum route to wellbeing.’

When I started to work in the addictions field in 2005 however, I began to experience a wider world of addiction and recovery and to discover that endless disease was not seen by all as the optimum route to wellbeing. I came across research papers and data, witnessed the tensions between harm reductionists and abstentionists, and began to build a picture of reality that made more sense to me.

I found support groups for people trying to leave 12-step fellowships, heard of counsellors who specialised in helping de-programme people from the fellowship mindset and I caught up with people I knew from Narcotics Anonymous in the ’80s and ’90s – many of whom had long given up meetings and were doing fine, abstinent or not.

I embarked on the process of disengaging myself, though the years of exposure to fellowship mantras had me wondering if, somehow, I was being deceived by a mind I had been taught I could not trust. When I met fellowship people, there was often a look of concern in their eyes and I found myself being defensive and feeling a little uneasy… I thank my therapist for supporting me through the transition.

Nonetheless, as I continued my journey it became clearer that the 12-step model, sold to me as the one true route out of addiction – though it suited some – did not hold up so well to closer inspection. Although you can, of course, find numbers and evidence to support any stance, I found the large American NESARC study that showed most people with a drink problem recovered without any intervention (12-step or otherwise) and many without abstinence.

I started to look at success rates which could be measured in different ways; many of the headline numbers put AA success rates at around 10 per cent, though better for those that stuck around longer.

‘The 12-step environment is no magic
bullet… recovery in its various
forms takes place elsewhere.’

The peer support, collective direction and structure of 12-step fellowships are a perfect combination for some. But it could be argued that for the population as a whole, 12-step intervention is little better than doing nothing. What is clear is the 12-step environment is no magic bullet and that significant amounts – if not more – recovery in its various forms takes place elsewhere.

Another piece of research that resonated with my experience was the Miller et al study, showing that when you want to find the main predictor of relapse, belief in the disease model is a significant factor. The ‘all or nothing’ measure of success and failure within the total abstinence framework is a two-edged sword. If you convince someone that any use is a calamity and that any attempt at self-control is futile, it can be a dangerous combination. A beer on a sunny afternoon will wipe all the clean time and status within the support group and bring the shame of failure bearing down, so there is very little more to be lost in returning to problematic use.

Now someone who has never come across the disease concept would very likely, well, just have a beer. The powerlessness message may help those who are totally abstinent, but is more likely to harm those who are not.

If we throw into the mix people who have been persuaded off their psychiatric meds by well-meaning amateurs in the name of being ‘clean’, then risks begin to increase. If you function well and are happy with total abstinence of the purest kind, then great, and hats off to you. But it is rarely right to tell someone with a whole personalised set of trauma and resources to follow your path.

Those on methadone may not be ‘clean’ in some people’s eyes, but it is the number one evidenced intervention in reducing drug-related deaths, which are at an all-time high. Those on medications are often being kept safe by them, but all too often are subject to stigma within the 12-step environment, and pressure mounts to stop taking them.

‘Telling someone with problematic drug
use to get clean can be like telling
a homeless beggar to get a job.’

Some say that addiction is an equal opportunities affliction, but that is demon­strably false. The data shows that deprived communities have the highest rates of addiction, and the privileged have better rates of recovery. Too often I hear celebrities extolling the virtues of 12-step recovery – and that is all very well If you are successful, with significant internal and external resources. But telling someone with problematic drug use to get clean can be like telling a homeless beggar to get a job.

Last time I wrote an article discussing the merits of the 12-step environment the letters pages were hot for months, attacking and defending me, and I was reluctant to take the flak again. Nonetheless I write this for two reasons.

Firstly, I say to those for whom it works well: be gentle with others. The chances are that they may well find a way to recover without the fellowships, so go easy on the ‘all or nothing’ rhetoric. You may mean well, but it does not help everyone.

Secondly, for those who do not feel the fellowship environment is right for them, either initially or after some time, there is nothing wrong with exploring other options. If my son had a problem, the 12-step solution would not be my first choice.

I was thinking about those I know with drug histories who have died too early – either accidentally or who have killed themselves – and you know what? It’s the ones who have been told they are powerless and have failed without abstinence that make up the majority who have gone. I don’t hold this up as evidence; just an observation from my experience.

The six 12-step rehabs I went through were sometimes a godsend and at other times served only to reinforce my sense of failure. The fellowships have been a great resource for me at critical times, and the weird cult-like structures have been useful to turn things round. But the premise of endless disease has not felt healthy for me in the long run.

I know many people who consider the 12-step model a life saver for which they are very grateful. I know others who used it for a while and then happily moved on. But I also know too many who have felt diminished by their experience.

I will end with a word of caution. A support structure is a big deal; if you leave one, don’t do it without putting something else in place. And if you choose a beer on a sunny afternoon after a period of 12-step abstinence, the sense of failure is more likely to do the damage than the thing you consume.

Whatever you choose, I wish you well.

Alex Boyt has worked until recently as a service user coordinator in London and is still actively involved in drug policy debate

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