Are Twelve-Step Programs Still the Best Model for Addiction Recovery?

Tara Blair Ball

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In my marriage, I was a naive optimist, a wholehearted believer in someone who turned out to be a liar and a criminal, so I’m exceptionally cautious today. I’m obnoxiously careful. I spend a lot of time evaluating and thinking about myself, my life, the people in my life, and whatever I may find interesting.

I am also a member of recovery in a 12-step fellowship in my hometown of Memphis, and being one means it doesn’t escape the purview of my thoughtful investigations.

I attended my first 12-step meeting in Memphis when I was 23 years old with an ex-boyfriend of mine. He had recently gotten out of a 30-day stint at a rehab after serving 45 days in jail for his second DUI (Tennessee is a no-tolerance state) and was court-ordered to attend 90 meetings in 90 days. We went together because it was “for him,” though I, of course, had my own problems with drugs. Case in point, he and I had used together excessively for our entire relationship. My own dabbles with drugs had started when I was 12 or 13, around the same time my mother started beating me with objects (a tennis racket, a metal mop) and my first sexual assault. It then quickly escalated once I went to college.

From the outside, my addiction never seemed “too bad.” I graduated from a local high school in the top 10% of my class. I graduated from a Rhodes College in Memphis Cum Laude.

But I had never been able to hold down a job, had totaled two cars, had two suicide attempts, was financially dependent on my family and had been regularly stealing from them to get more since I was 14. I was isolated, friendless, and painfully miserable. Unlike many members, I had never previously sought help for my addiction, faced legal consequences, or attended treatment.

When I attended that first meeting, what I found was hope. What I found and why I stayed was because I found what I’d always wanted: a gut sense, a soul sense, of belonging and understanding, and a solution that meant I’d never have to feel miserable and alone again.

12-step fellowships, like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), have been in existence for over 80 years, and it’s been said that they have lasted that long because they work. The first AA meeting in Memphis was held in 1944. While I can't find anything specific, I've heard before that the first NA meeting in Memphis was in the late 70s or early 80s.

A New York Times article stated that AA claims that up to 75% of its members stay abstinent. Dr. Lance Dodes, a retired professor of psychiatry at Harvard Medical School, says instead, “Peer-reviewed studies peg the success rate of AA somewhere between five and 10 percent. About one of every 15 people who enter these programs is able to become and stay sober.”

I have had thirteen years of total abstinence from mind- and mood-altering substances. This doesn’t mean I haven’t had any substances in these past eleven years, but it does mean I have not abused any in that length of time. I’ve taken antidepressants (and really, what euphoria would I have gotten from “abusing” Zoloft?). I’ve had to take narcotics for two major surgeries. I took them as prescribed (they were actually given to me by someone else because I was worried I’d resort to abusing them if I was in too much pain), and I did not seek any more.

But years ago, I started seeing commercials for Passages Malibu, which promises a “cure” for addiction. Named “one of the most luxurious places to dry out” by Forbes Magazine in 2004, it has a reported 84.4% success rate. Marketed to addicts with substantially greater material resources than most (at $88,500 per month and a typical stay of three months), the commercials show shots of the $15 million mansion clients stay in, complete with fountains and marble columns, and shots of people getting spa treatments and petting horses.

And then SMART Recovery (Self-Management and Recovery Training) became in vogue at a local treatment center. It is a 4-point program that teaches tools and techniques for handling urges, thoughts, feelings, and behaviors in order to live a balanced life.

SMART Recovery is still rather new, but its effects have been studied (though there are questions about how the study was conducted). SMART Recovery meetings do meet in Memphis, Jeff Brandsma took groups of people in coerced attendance programs and randomly placed them into different groups of therapy which they were required to attend: 12-step (specifically Alcoholics Anonymous) or REBT. Over the course of two years, the REBT group did significantly better abstaining than the 12-step group (in fact, more than 10% higher).

SMART Recovery also doesn’t necessarily support the disease model of addiction. Most scientists can now point to common neurobiological patterns that underlie chemical and behavioral addictions. These characteristics include “(1) desensitization of the reward circuits of the brain; (2) increased conditioned responses related to the substance an individual is dependent upon; and, (3) declining function of brain regions that facilitate decision making and self-regulation.” These findings are the foundation of understanding addiction as a treatable disease.

SMART Recovery says in its literature: “We’re not trying to cure an imaginary disease. We’re concerned with changing human behavior” and “You may believe for example, that you have an incurable disease, that you have a genetic defect, that you are powerless, or that after the first drink or use or act you have to lose all control. These beliefs may actually be damaging you.”

These things have nagged at me. Why can’t I be cured of my ailment? Do I even really have a “disease?” Or why can’t I be self-sufficient and practice a bunch of tools and techniques to work through life’s struggles?? Not having to participate in a 12-step fellowship would free me up so. much. time. I wouldn’t have to go to meetings anymore, do service, work with a sponsor, or answer calls from others in recovery. I could like go to the gym a lot or write eighteen novels. I could do anything with all of that extra time.

There have been, though, critiquers of both Passages' promise of a “cure” and SMART Recovery’s promise of another way.

A reporter at LA Weekly took a look at the numbers for Passages. The stats include those who have been clean for only 30 days, and the quoted number never changes. This particular reporter dubbed the founders of Passages to be the “Holocaust deniers of the addiction recovery industry” because they deny the existence of addiction and deny that it is incurable.

Members of my recovery community have likewise sneered at how beneficial SMART Recovery might be. It is based on a proven psychological approach (Cognitive Behavioral Therapy), but it is not as widespread as 12-step meetings, not spiritually based (addiction is often called a “spiritual disease”), doesn’t have a built-in accountability system (like having a sponsor or someone you work with regularly in your program), and it requires commitment and self-reflection, which is the very thing that addicts most struggle with.

We are in the midst of an Opioid Epidemic. The US Department of Health and Human Services declared a national emergency in 2017. from

This graphic shows the awful data: over 130 people were estimated to have died every day from an opioid-related drug overdose in 2017 and 2018. 2.1 million people have an opioid use disorder. Beyond the graphic above, “an estimated 40% of opioid overdose deaths involved a prescription opioid.”

In April 2017, HHS unveiled a new five-point Opioid Strategy, with the five following priorities:

  • Improve access to prevention, treatment, and recovery support services
  • Target the availability and distribution of overdose-reversing drugs
  • Strengthen public health data reporting and collection
  • Support cutting-edge research on addiction and pain
  • Advance the practice of pain management

What and how the HHS will encourage prevention, treatment, and recovery support services has yet to be determined, but I find myself returning to myself and my own question when I began writing this: are twelve-step programs still the best model for addiction recovery?

My answer is really, “Maybe.” There’s not enough statistics out there to support one way or another. Dr. Dodes estimates that about 5 million individuals attend one or more 12-step meetings in a given year, so they still remain the most easily accessible option for individuals seeking recovery.

And in the end, does it matter? Can’t there be more than one road to recovery?

A friend of mine who is Mormon came to one of my recovery celebrations, and she said to me something along the lines of, “We both believe in this crazy thing that helps us makes sense of the world.” I blinked at her a couple of times, not sure what to make of her statement, but I got it after some reflection.

I see the world through the lens of my recovery, of my sense that I have a disease that is incurable, that my “medicine” is meetings and fellowship and a Higher Power, and that works for me. It doesn’t matter to me today if it’s not the only option and possibly not even the “best” option, because it’s what works for me.

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