Rae Steward, a 33-year-old from California, struggled with alcohol and drug addiction as early as age 14. But it got really bad in her late teens and early 20s. “I barely remember those two years,” she said. “I was pretty much just blackout [drunk] the entire time.”
Then Steward found a treatment program, which pushed her to attend Alcoholics Anonymous meetings and follow the 12 steps first established in the 1950s by Bill Wilson. Attendees are encouraged to complete 12 guidelines — or “steps” — that combine spiritualistic ideals about addiction, along with the view that it’s a disease, to help them overcome their illness. Among the steps: submit to a higher power, address “defects of character,” and make amends for past problems.
Steward said that with the help of the program and AA meetings, she’s been sober for 10 years. “When I started doing the steps, I didn’t think they were going to work,” she said. “I still, 10 years later, don’t understand why they worked. But I feel like they gave me the design for living life. At this point, I just incorporate the steps in daily living.”
But for every Rae, there’s a Roger, who asked I use a pseudonym. He tried a 12-step treatment program in Indiana in 2012 and 2013 for his alcohol and stimulant drug use.
It didn’t stick. Within months, he moved to Virginia, and went back to drinking and using drugs. “I spent a year and a half staying blackout-ish drunk every night,” he said. He managed to keep working and hid his drinking and stimulant drug use. But things got worse. In September 2014, he was hospitalized for his alcohol and drug use. He got out and went back to drinking. By the end of November, he had stopped going to work and cut off communication with friends and family.
Suddenly, in December 2014, Roger decided to stop drinking. “I don’t really know why,” he said. Two days in, police did a wellness check — on his parents’ request — and that’s when he reconnected with his family. He moved to Michigan and started going to AA meetings, finding them helpful for a few months and even completing the 12 steps — but eventually dropped off.
Roger, now 26, has managed to stay sober without the meetings for the past three years. And although he credits the later AA meetings for giving him a support system, he eventually dropped the program altogether. Roger’s big change seemed to be due not to the 12-step program, but to the sudden realization that he was heading in the wrong direction — although, by his admission, he can’t explain exactly why he came to this realization.
Then there’s Betsy, who asked I only use her first name. She had a particularly bad experience with AA and affiliated Al-Anon meetings. She stopped drinking after a DUI conviction banned her from bars, but she said the AA meetings she attended had little to do with it. She couldn’t get a sponsor (as AA recommends), she didn’t complete the steps, and at one point she found herself in serious danger with a man from a meeting.
“I drove another man home,” Betsy said. “He was really not very stable. I ended up narrowly escaping being raped in his house. Looking back, I’m not sure how I got out of it. I was trying to be nice, but he definitely assaulted me in his house.” She added, “At the time, I was still sick myself, so I kind of thought it was funny. And a friend pointed out to me, ‘You know this wasn’t funny, right? That was not a funny thing that happened to you.’ And at that point, I started realizing there was something wrong.”
Betsy found herself fundamentally conflicted with AA’s philosophies. As an atheist, she always struggled to define her higher power. AA says people can define it however they want — even use a doorknob if they need to. Betsy tried to define her higher power as her cat, but it just never clicked. “I don’t believe in any of that stuff,” she said.
Betsy, who’s 42 and lives in Texas, is now 10 years in recovery, but not because of AA. After her struggles, she found a different, secular mutual support group, LifeRing — and that seemed to work much better in helping her address not only her drinking but the underlying problems that led her to drink so much in the first place.
So does Betsy show that the 12 steps don’t work? Does Steward show that they do work? Does Roger show that the 12 steps maybe do something but not all that much?
Here’s the thing: The results that Steward, Roger, and Betsy each got from AA, while disparate, aren’t abnormal. They’re representative of the 12 steps’ mix of successes and failures.
Over the past few months, I talked to experts who’ve researched 12-step facilitation treatment and AA, as well as people who attended the programs. My goal was to see whether the 12 steps really do help people overcome their alcohol addictions.
The answer: It’s complicated.
The simplest explanation is that 12-step treatment and AA meetings work for some people but not for others. J. Scott Tonigan, a researcher at the University of Mexico Center on Alcoholism, Substance Abuse, and Addictions (CASAA), said the research supports a “rule of thirds”: About a third of people maintain recovery from alcohol addiction due to 12-step treatment, another third get something out of the treatment but not enough for full recovery, and another third get nothing at all.
Getting to the bottom of this is crucial to dealing with a big public health problem. Based on federal data, more than 20 million people have a substance use disorder, and within that group, more than 15 million have an alcohol use disorder. Excessive drinking alone is linked to 88,000 deaths each year. So whether one of the most common types of treatment for this disease is actually effective could be a matter of life or death.
For some people, the 12 steps really do work
The 12 steps have now become a powerhouse in the addiction treatment world, with millions of attendees worldwide each year in AA meetings alone. AA has also spawned a network of affiliated groups like Narcotics Anonymous, Marijuana Anonymous, Al-Anon (for family and friends of AA attendees), and more.
Professional treatment organizations have seized on AA’s popularity, particularly in the US. This led to the creation of the type of program that Steward attended, known as “12-step facilitation,” which pushes people to attend AA meetings and complete the 12 steps. An AA spokesperson said that the actual AA fellowship has nothing to do with professional treatment programs, telling me that “we do not operate, endorse, or comment on treatment facilities.” But the programs have over the decades become one of the most popular ways to treat addiction in professional settings, with federal surveys showing that more than 70 percent of addiction treatment facilities in the US deploy it “sometimes” or “always or often.”
Years of evidence show that the 12 steps, on average, really can help treat alcohol addiction. But that comes with some major caveats.
For one, studies typically focus on outpatient, one-on-one professional settings. This is different from typical AA meetings in a church basement, which are free and therefore most accessible to people in recovery. It’s also different from the residential treatment settings that dominate much of American alcohol addiction treatment today.
The best research also only focuses on alcohol use disorder. So whether the 12 steps work for other kinds of addiction — and whether non-AA programs like Narcotics Anonymous are effective at all — remains an open question in the research. (As such, this article focuses on the research and experiences of people using the 12 steps for alcohol addiction.)
For decades, there was a lot of bad research into the 12 steps, riddled with methodological problems that made it difficult to evaluate whether the approach is effective. In the 1990s, Project MATCH offered a better approach. The randomized clinical trial placed patients into a 12-step program, cognitive behavioral therapy, or motivational enhancement therapy. The results were promising for 12-step treatment: In an evaluation three years after the initial study, researchers concluded that there were few differences in effectiveness between these methods, and, if anything, 12-step treatment showed “a possible slight advantage” in reducing overall drinking.
Since then, other studies have produced similar results. A 2017 study on adolescent alcohol use disorder found that 12-step treatment fared similarly to both cognitive behavioral therapy and motivational enhancement therapy. A 2009 study found that people facilitated into higher AA attendance also reported more days of abstinence. A 2006 study similarly found that intensive referral to 12-step help groups like AA led to more meeting attendance and better alcohol and drug use outcomes.
And a 2006 review of the existing research by the respected Cochrane organization found that while no studies “unequivocally demonstrated the effectiveness of AA or [12-step facilitation treatment] approaches for reducing alcohol dependence or problems,” 12-step treatment fared about as well as other treatment programs.
These studies, however, have a big flaw: They lack a control group. This makes it difficult to gauge just how effective 12-step treatment programs — or, for that matter, cognitive behavioral therapy and motivational enhancement therapy — truly are. It’s possible that these treatments are all equally effective, but the question then becomes how effective treatment in general is over no treatment at all.
Still, a 2009 review of the research found that cognitive behavioral therapy produces “a small but statistically significant treatment effect” in general and a rather large effect when compared to no treatment whatsoever: “79% of individuals treated with CBT showed rates of substance-use-reduction above the median of those assigned to a wait-list or similar no-treatment control.”
Again, much of this research is looking at a narrow kind of program: 12-step facilitation treatment in an outpatient setting. It doesn’t speak to someone who only attends AA meetings, which by themselves are not professional treatment. It doesn’t even speak to residential treatment, when someone stays at a facility for weeks or months to get care.
John Kelly, an addiction researcher at Harvard Medical School, said that residential treatment and community-based options like AA meetings have shown “compelling evidence.” For example, some randomized clinical trials show that getting people to attend more AA meetings is associated with better drug and alcohol use outcomes. “But,” he added, “I would say we need more studies.” The question is whether greater attendance itself or some other factor — such as an underlying motivation to quit drinking — is driving the better outcomes.
But the overall research suggests that the 12 steps really do work — at least for some individuals.
Why the 12 steps work for some people
Official AA writings tend to pin the 12 steps’ success to their spiritual elements, with the final step even invoking “a spiritual awakening.”
While the spiritual element does something for some people, it’s not why 12-step facilitation treatment and AA work for many others. Albert, a pseudonym for a 37-year-old in Georgia who’s been sober for more than half a year, said he, as an atheist, finds the spiritual elements of the program to be a big negative. But 12-step treatment and AA meetings have still proven a big help to him.
“It did not provide a burning bush spiritual experience that changed my life,” he told me. “But it did put me in contact with other people that were sober or trying to be sober. That helped me make some connections and make some friends.” He added, “It can be difficult as a young adult to socialize without alcohol, or at least it seems like it to me.”
This speaks to one of the big non-spiritual reasons that 12-step treatment and AA work for some people: They help foster changes in a person’s social network.
After months, years, or decades of drug or alcohol use, people with addiction typically have surrounded themselves with peers and friends who also use drugs. This becomes, as Kelly of Harvard Medical School put it, “one of the major threats to sobriety.”
By attending meetings, attendees can connect with others who want to stop using drugs. This new social network provides support for sobriety, and creates a means to socialize without using drugs.
David Sanderson, a 55-year-old from Prince Edward Island, Canada, said this matched his experience. “Immediately for me, it was this connection with people that I knew,” Sanderson said, describing his first meeting. He talked about how important “the meeting after the meeting” was in helping him connect to other people — and how that helped add people to his social network who weren’t so interested in drinking. At the same time, he didn’t find much value in the spiritual aspects of the 12 steps.
Stories like Albert’s and Sanderson’s are backed by several studies, which found that changing a person’s social network can make it easier to abstain from drugs. “It’s the social support that makes the difference,” Christine Timko, an addiction researcher at Stanford, told me. “When people have fewer people doing drugs and drinking in their social network, and they have more people in their social network who aren’t using and drinking, then they’re better off themselves in terms of being able to not drink and use.”
Twelve-step treatment and going to AA meetings, Kelly said, also “boost your ability to cope with the demands of recovery.”
This is the kind of thing that cognitive behavioral therapy tries to do: It teaches a person how to resist alcohol and drugs when offered, how to deal with difficult life events without resorting to drugs, how to cope with stigma about addiction, and on and on. It essentially teaches the patient how to develop the attitudes and behaviors that may be needed to resist relapse.
“You could be forgiven for looking at AA as a quasi-religious, spiritual entity,” Kelly said. “But if you went to 10 AA meetings and listened, you would hear, essentially, cognitive behavioral therapy.”
The 12-step treatment patients and AA attendees I talked to corroborated this. Listening to other people’s stories helped them find coping mechanisms to overcome triggers for drinking, from exercises to staying in close contact with other attendees to simply drinking a lot of club soda at social events in which drinking was happening. They learned how to deal with environmental cues and social stress without resorting to alcohol and other drugs.
Even Steward, who attributed some of her success to AA’s spiritual elements, said that the biggest change, at the end of the day, came from other elements of the 12 steps that gave her a sense of support and structure she could leverage throughout her life. “Really,” she said, “what I’ve gotten is the ability to not be an asshole.”
Why the 12 steps don’t work for others
For all the success stories with the 12 steps, there’s also many of disappointment.
The biggest sticking point seems to be the 12 steps’ spiritual element. Critics such as Maia Szalavitz, an addiction journalist and author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, have focused on this part of the program to argue that the 12 steps really shouldn’t be considered treatment at all.
“Let’s say you go to a doctor to get your depression treated,” Szalavitz told me. “If they told you that you had to surrender to a higher power, address your character defects, make a moral inventory, [and] pray, you would probably think that you had gone to a quack.” She added, “If we’re going to argue, as the 12-step people strenuously do, that addiction is a disease, it cannot be the only disease for which the treatment is confession and prayer. That’s just not acceptable.”
This is why Roger fell in and out of the program. Although he’s agnostic, he tried to make it work — following AA’s recommendation to, if needed, make his higher power a doorknob. “But it’s really weird to pray to a doorknob,” Roger said. “That’s a strange thing to do.”
This is something that critics of the 12 steps brought up again and again: When zealotry, spirituality, and religion come into the picture, people can get judgmental. Betsy, for instance, said she was mocked and chastised by other attendees for making her cat her spiritual power — even though it’s the kind of thing that AA recommends.
What further complicates this is that different AA meetings and communities function differently. Albert said that his current AA group is LGBTQ-friendly and includes a lot of atheists and agnostics. But depending on where someone lives and attends meetings, the experience can be different — and much more negative.
Gerald Zeigler, a 44-year-old in Montana, said that he is religious, but the 12 steps still didn’t work for dealing with his alcohol addiction. Although he found some value in the group support provided by AA meetings, he felt he was “shamed” by the program — as if his struggles in recovery reflected some sort of character flaw.
“Everybody has character flaws, but I don’t think that’s the reason for alcoholism,” Zeigler said, arguing that addiction should be treated as a medical condition, not a moral, spiritual, or religious issue. “It was a real turn-off for me.”
In some cases, rigid interpretations of the 12 steps can even lead people to reject treatments or approaches that work for some people.
A 2015 article in the Atlantic by Gabrielle Glaser, which came up in my conversations, emphasized the potential of naltrexone and other medications that can help people stop drinking. The evidence shows that these medications can help maintain abstinence and reduce heavy drinking — but they don’t work for everyone, and their success can differ depending on how they’re used. Among the people I talked to who used naltrexone, its effectiveness varied.
But some 12-step treatment programs and AA participants are actively hostile to the idea of using medications to treat addiction. They interpret sobriety as fully quitting all drugs, and using naltrexone to stop drinking falls short of that. (This stigma extends to opioid addiction, for which medications are widely considered the gold standard for treatment, and even other mental health issues, such as depression and anxiety.)
This does not apply to every 12-step treatment program or AA group. A spokesperson told me that AA does not take an official stance against medications, leaving those issues to individuals and their doctors. And the Hazelden Betty Ford Foundation, a big treatment provider based on the 12 steps, uses medications to treat addiction, as do many other treatment providers. But not everyone is on board.
Along similar lines, 12-step treatment programs nearly unanimously reject moderated drinking as a potential outcome for participants. But some people can succeed with moderate drinking. Betsy, for one, still drinks “maybe twice a year,” she said. And from her perspective, she’s now doing fine.
All of this gets to a fundamental conflict within the heart of the 12 steps: The same rigidity that gives people like Steward a structured guide to life also turns off others. As Betsy told me, “I don’t like having to fit into their framework.”
Some 12-step treatment programs have also been tied to a confrontational approach. This has been popularized in a lot of media, such as the Sopranos scene that starts with a well-meaning intervention and ends with several characters beating the person they believe needs to get help. It’s also led to some bizarre AA spinoffs, like the Synanon movement that eventually devolved into what journalist Zachary Siegel described as “a violent cult.”
The reality, Tonigan of CASAA told me, is that the confrontational approach “is horribly ineffective.” The best research shows that positive reinforcements, such as motivational training and life enrichment, are much more effective means of getting people to stop drinking. (This is also true for encouraging changes that can combat problems beyond addiction.)
But just as the emphasis on spirituality and acceptance of medication varies from 12-step group to 12-step group, so too does each group’s focus on compassion versus confrontation. And that can create some truly bad experiences for some people, causing them to relapse — and potentially put their lives at risk once again.
For addiction, we need as many options as possible
Every single person I talked to, regardless of whether the 12 steps worked for them, did have one point of agreement: The 12 steps and AA should be available, but they shouldn’t be the only option.
“There’s a lot of good people in AA, and there’s a lot of support there, there’s a lot of compassion there,” Zeigler said. “I just find it so bizarre that it’s treated as the option for everybody.”
“AA has worked,” Sanderson, who has been sober for more than two decades, said, “and I’ve felt no reason to try other programs.” But, he added, “if anyone has difficulties with any of the concepts in AA, grab on to whatever is going to work.”
This echoes what researchers told me as well. As Keith Humphreys of Stanford put it, “We don’t have anything that works for everybody. There’s very few places in medicine where you do.” So there need to be as many alternatives as possible.
Yet the reality, researchers said, is that most treatment facilities in America are based on the 12 steps — making it the only option for many people. While alternatives like SMART Recovery or LifeRing do exist, they’re not nearly as available as AA — and they certainly aren’t built into professional treatment programs in the same way as the 12 steps.
That’s not because other mutual help groups are expected to be worse. Kelly of Harvard told me that he “would bet that SMART Recovery, LifeRing, [and] these other mutual help groups, if they were as available and accessible, they would produce a similar benefit to AA. I don’t think it’s the unique, specific aspects of AA that make the difference; it’s rather these common therapeutic factors, which are incorporated into all of these mutual help groups.”
In the real world, though, these non-AA options for support groups can be rare — to the point that it’s difficult to study them, facilitate participation in them, or simply sign up for them.
Albert experienced this problem firsthand: The hundreds of AA meetings held in his city every week make it easy for him to find a time and place that’s convenient for him. The same is not true for other programs, which tend to have maybe a handful of meetings each week. “It just doesn’t work practically,” Albert said.
The problem is further compounded by poor access to even 12-step treatment facilities. Health insurers can be resistant to paying for addiction care, even though they’re required to under federal law — forcing patients to shell out as much as thousands of dollars a month out of pocket. Waiting periods for treatment can also span weeks or months, making it difficult to get people into care during limited windows of opportunity.
As a result, a 2016 report by the surgeon general found that only 10 percent of people with a drug use disorder get specialty treatment. (Although, notably, some research suggests that more than half of people successfully deal with their drug use disorders without treatment.)
Government policies and health care providers could change all of this by putting more resources toward greater access to treatment and alternative groups. More individuals could try to start local branches of the alternatives. New technologies could be used to hold meetings online instead of in person.
The goal should be to get a broad range of options for a disease that is marked by individualized characteristics that require individualized approaches. But the reality falls far short of that.
“There’s just not a lot of widely advertised options available,” Albert said. AA and 12-step treatment are “the most well-known and most recommended option, so that’s kind of where you tend to go.”