November/December 2013 Issue
Alternatives to 12-Step Addiction Recovery
Support is available for people seeking options beyond the 12 steps, and proponents believe recognition will grow with future generations’ exposure to different approaches.
People trying to overcome addiction have a variety of experiences in treatment. They may receive outpatient, intensive outpatient, or residential treatment. They may access services in luxurious surroundings, community clinics, or prisons. They may encounter cognitive behavioral therapy, motivational interviewing, or family therapy.
Despite these differences, there is something that many people in recovery will share as they progress through and out of treatment: They will be asked, if not required, to “work the steps.” Indeed, the process of recovery from addiction has been dominated in the United States by the 12-step method established with the founding of Alcoholics Anonymous (AA) in 1935.
But AA and its various successors are not the only mutual-aid groups available to support people in recovery. For the past few decades, several other groups have tried to offer alternatives to those who want something other than a 12-step approach. These alternative groups historically have struggled to gain a significant following, but with the advent of new technologies and the rise of a new generation of people in treatment who want more control over their recovery, these groups believe the time has come for social workers and other behavioral health professionals to accept them as part of the mainstream continuum of recovery services.
“A big part of what I believe in is choice,” says Robert Stump, executive director of LifeRing, a group based in Oakland, CA. “One shoe does not fit all people. Every day that goes by, there are more and more people who are demanding that choice. [Alternative groups] may not cater to a large section of the American public, but we do appeal to a subset of Americans, and professionals should be aware of that.”
Different Roads to Recovery
Representatives of these organizations stress that it is not their goal to bash 12-step programs, and they acknowledge that such programs have helped countless people, including many who use the 12 steps to supplement their involvement with alternative organizations.
However, there are several important differences that may make alternative groups attractive to people in recovery who do not want to use a 12-step approach. These differences generally fall into the following four categories:
• Secularity: The 12 steps as originally outlined by AA are overtly spiritual, with references to “a power greater than ourselves,” God, and prayer. Other 12-step groups have retained the same or similar language. The alternative groups, on the other hand, promote themselves as secular in nature. A secular approach makes the groups more open and comfortable not only to atheists and agnostics but also to Buddhists, Muslims, and others who do not share a Western, Christian tradition, Stump says. The alternative groups are not antireligion, however, and many of their members belong to a religious denomination or identify as spiritual.
• Emphasis on internal control: Twelve-step programs emphasize the recovering individual’s powerlessness over alcohol, other substances, or behaviors and the need to rely on a higher power for assistance in overcoming addiction. Alternative groups reject this view and instead see individuals as having adequate power within themselves to overcome addictions. This view is evident in the language of alternative organizations, which emphasize phrases such as “empowering our sober selves,” “saving our selves,” and “self-management and recovery.”
• Evolving approaches: Although the number of 12-step groups has grown over the decades, the basic language and methods of the 12-step approach have not changed significantly since AA’s founding nearly 80 years ago. Alternative groups tend to be more open to changing their techniques in response to the development of evidence-based approaches to addressing addictions, such as cognitive behavioral therapy. The commitment to stay abreast of current research in the field of addictions is one of the main factors that attracted Brett Saarela, LCSW, to get involved in SMART Recovery. “It’s open to change. There’s no dogma about it,” says Saarela, vice president of SMART Recovery’s board of directors. “As new techniques are being produced, they’re evaluated and then incorporated. Nothing is frozen in time.”
• Shedding of lifelong labels: AA and other 12-step groups portray the battle against addiction as a lifelong one that requires constant vigilance and at least periodic attendance at meetings, even for people who have been in recovery for years. Alternative groups take a shorter-term approach, presenting themselves as tools that people in recovery can use until they no longer see the need for them. Women for Sobriety, for example, refuses to give its participants lifelong labels based on past behavior and instead focuses on the present and the future, says Laura Makey, one of the organization’s facilitators and treasurer of its board of directors. “If I quit smoking, I wouldn’t say I was a smoker for the rest of my life,” she says. “We are not defined by our past. The idea of having to label yourself as an alcoholic or an addict for the rest of your life, that is disempowering, especially for women.”
The alternative groups are not monolithic, however, and there are individual differences among the groups. For example, Moderation Management promotes a harm-reduction approach to alcohol use, while the other four groups are abstinence based. And the five groups mentioned above do not encompass every alternative to 12-step programs. For instance, many groups exist that provide services to people in recovery who want more religious-based support services than 12-step programs typically provide. These groups include The Calix Society, which is designed for Catholics in recovery, and Jewish Alcoholics, Chemically Dependent Persons, and Significant Others (JACS).
A Struggle to Gain Visibility
But why? In a consumer-driven society where people have countless choices with everything from what brand of yogurt they buy to what kind of car they drive, why does the 12-step approach remain dominant in recovery services? There’s no simple answer, and observers point to several theories to explain why alternative mutual-aid groups have not been able to catch on.
One factor is history. AA was established more than 40 years before any of the major alternative groups. When AA was established, there were few treatment options available for alcoholics, so the organization filled a void, says Susan Foster, MSW, vice president and director of policy research and analysis for CASAColumbia, a New York-based research organization that assesses the impact of substance use on American systems and populations. “[AA] was the only resource available for people with addictions to alcohol, and it was life-saving and critical to many people,” she says.
Another factor is how treatment services in the United States evolved after the formation of AA, according to Katherine van Wormer, PhD, MSSW, a professor in the University of Northern Iowa department of social work. Central to this evolution is the development of the “Minnesota Model” of treatment services, which focused on a 12-step approach, an insistence on abstinence, and emphasis on having trained recovering addicts joining professional staff as part of the treatment team (Anderson, McGovern, & DuPont, 1999). Eventually adopted by Hazelden, one of the best-known treatment providers in the country, the Minnesota Model became the one that was widely adopted across the United States.
The incorporation of recovering addicts into treatment services further solidified the popularity of 12-step approaches because counselors who have been helped by such approaches become passionate about them and want others to have the same experience, Saarela says. “You come to believe that [the 12-step approach] is the model you have to follow; to think about other options is sacrilegious,” she says. “It’s about questioning your whole foundation, and that’s a scary thing.”
In a recent article in the Journal of Groups in Addiction & Recovery, Kelly and White (2012) discuss other possible reasons for the dominance of 12-step groups, particularly AA. Among them is that AA’s lack of a highly centralized governing structure makes it relatively easy for anyone in recovery to start an AA meeting, whereas some of the alternative groups have a harder time establishing meetings because these organizations are stricter in their requirements regarding who can facilitate meetings. In addition, AA’s promotion of a spiritual approach to addiction recovery may be an especially good fit for the traditional view of the United States as a country built on religious values.
Finally, the authors describe a catch-22 situation in which treatment professionals are more likely to refer clients to AA because its popularity means that more meetings are accessible and that there is more research on its effectiveness. These referrals further cement AA’s dominance and keep alternative groups on the margins.
There are signs that alternative mutual-aid groups are becoming more visible in the recovery community. One indication is that technology has given such groups new opportunities for outreach. Several of the alternative groups have an online presence through online chat rooms and message boards, Facebook pages, and Twitter feeds. Some groups even run online meetings. Online interaction not only engages recovering addicts who cannot make it to meetings because of geography but also those people in recovery who feel more comfortable interacting technologically than attending meetings in person, Saarela says.
Alternative groups also have made renewed attempts to engage treatment service providers. For example, Women for Sobriety, SMART Recovery, SOS, and LifeRing worked together to create materials to educate providers of employee assistance program services, Makey says.
Educating service providers is vital to increasing the reach of alternative groups because these clinicians are the ones who most likely will influence clients’ decisions regarding their paths to recovery, says Jonathan Egge, LCSW, an addictions therapist and SMART Recovery facilitator in Pennsylvania. Providers also have influence over other providers. “Providers have to communicate better within the provider community,” he says. “The provider community has to do more to interact with itself so these issues are kept in the forefront.”
Saarela believes that as awareness of alternative groups increases, the hold that 12-step approaches have over recovery will loosen as people become exposed to other ideas. “Some years need to go by, and things will change,” she says. “The next generation will not be as die-hard, and it won’t seem as frightening to explore other options. They’ll see that people have been helped by different approaches.”
— Christina Reardon, MSW, LSW, is a freelance writer based in Harrisburg, PA, and a contributing editor at Social Work Today.
Alternative Mutual-Aid Groups for People in Recovery
Philosophy: SMART stands for Self-Management and Recovery Training (www.smartrecovery.org). It’s centered on a four-point program that emphasizes enhancing and maintaining motivation to abstain from addictive behavior; learning how to cope with urges and cravings; using rational ways to manage thoughts, feelings, and behaviors; and balancing short-term and long-term pleasures and satisfactions in life. The program’s tools are based on evidence-based interventions, including cognitive behavioral therapy and motivational interviewing.
Reach: SMART Recovery has approximately 1,000 meetings worldwide. It reaches an expanded audience through technology, offering online meetings and activities and maintaining a presence on Twitter, Facebook, and YouTube.
Philosophy: Moderation Management (www.moderation.org) is designed for people who believe their drinking has become problematic and want to moderate it before it gets harder to control. Participants are asked first to abstain from alcohol for 30 days, and during this time they are encouraged to think about how drinking has affected their lives and under which circumstances they had been drinking. After the 30 days of abstinence, participants are given guidelines about how to drink moderately. Participants who have trouble keeping their drinking moderate are encouraged to consider complete abstinence.
Women for Sobriety
Philosophy: Women for Sobriety (www.womenforsobriety.org) is designed to provide a safe, nurturing, and empowering environment for women in recovery. Its New Life Acceptance Program is centered on 13 principles emphasizing positive thinking, personal responsibility, and embracing the future instead of rehashing past mistakes.
Philosophy: LifeRing (www.lifering.org) has adopted a “3-S” philosophy focused on sobriety (abstinence from alcohol or drugs), secularity (recovery focused on human efforts vs. divine intervention), and self-help (personal motivation and effort as the key to recovery).
Reach: LifeRing had 177 meetings worldwide as of September. Most of these meetings are in the United States, especially in the Bay Area of northern California. LifeRing also offers a variety of online resources, including chat rooms, e-mail groups, an Internet-based bulletin board, and a social networking site.
Philosophy: SOS’ programming (www.sossobriety.org) is based on its Suggested Guidelines for Sobriety, which emphasize sobriety as a member’s top priority in life. Participants must develop strategies to remain sober even when facing situations that make them want to go back to drinking or using drugs.
Kelly, J. F., & White, W. L. (2012). Broadening the base of addiction mutual-help organizations. Journal of Groups in Addiction & Recovery, 7(2-4), 82-101.