Marketing the 12 Steps and the Intent of AA's Traditions
Clarifying the Dichotomy Between
the 12-Step Approach and
Professional Psychotherapy and Counseling
by Kenneth A. Gleaves, Ph.D., LCPC, CADC, NCACI
The William Reid Group
Orland Park, Illinois
from The Journal of Rational Recovery Vol. 9 -- Iss. 2, Nov.-Dec., 1996
(used with permission; all rights reserved)
|About the Author: Dr. Gleaves has been involved in the substance abuse and counseling fields over the past 12 years as a practicing clinician, consultant, counselor, educator, presenter, and supervisor. He is a published researcher and has interests in the areas of counselor education and educational psychology. For the past five years he had been engaged as a coordinator for a community college-based substance abuse counselor training program. He is currently the Clinical Supervisor for a progressive counseling agency with offices in the Chicago metropolitan area.|
This paper examines the past and current practice of incorporating 12-step philosophy and principles into professional (financially reimbursed) substance abuse treatment programs, and takes issue with attempts to professionalize 12-step programs. The author presents nine of AA's 12 Traditions that are rendered problematic by past and current practices in the substance abuse treatment held, and argues for a clearer definition of professional counseling and psychotherapy as opposed to the indiscriminate application of 12-step principles that currently drive the majority of substance abuse treatment programs in this country. The author argues that the application of 12-step principles in a professional substance abuse treatment context violates professional standards and ethics, as well as undermining and running contrary to the 12-step Traditions themselves.
In the United States, Alcoholics Anonymous (AA) and similar 12-step
organizations have had almost complete reign over the substance abuse field
and have either actively sought to have their views on addiction emphasized
(primarily through the National Council on Alcoholism) or have passively
allowed their programs to be incorporated into professional treatment settings
which rely, in varying levels, upon 12-step group involvement. It has been
my experience (as a professional practitioner in the substance abuse/
The fact is that the 12-step philosophy is not therapy (or training for therapy), nor was it ever intended to be. What has happened over approximately the past 25 years is that, for a variety of reasons, many recovering and non-recovering counselors, therapists, and administrators in the substance abuse field have attempted to professionalize the 12-step program. The absurdity of this approach becomes apparent when one looks at the 12 Traditions of AA and compares what has been written (and, I would argue, very sensibly and for valid reasons) with what has become common practice in the treatment of substance abuse.
Why the 12-step approach cannot be "professionalized" into a psychotherapeutic framework.
Using the 12 steps of AA as a psychotherapeutic, counseling, or "treatment
program" for substance abusing/
Tradition 2: For our group purpose there is but one ultimate authority -- a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants; they do not govern.
I. There are at least one, and usually many more, "ultimate"
authorities in the professional addictions therapy world (program coordinator/
II. Therapists (as leaders) do ultimately "govern" in the
context of the therapeutic session. For those who may object to the term
"govern," I would comfortably interchange it with "possess
authority." In an individual, group, or family counseling context
it is incumbent upon the professional therapist to know when and how to
appropriately direct the course of therapy and to be competent in the exercise
of that authority based upon recognized theoretical frameworks and refined
professional judgment. Regardless of the school of therapeutic theory one
adheres to, it is generally understood that a professional therapist deals
Tradition 3: The only requirement it for AA membership is a desire to stop drinking.
I. There may be many requirements for "membership" in therapy. A client's drug use is only one piece of the puzzle. In an Humanistic or Holistic approach, the goal is to treat the whole person (or as much of the person as can reasonably be done). Professional addictions counselors need to see the "big picture" when dealing with their clients, who are complex and multifaceted. Clients and students have often reported to me that when attending AA issues such as other drug use, marital, and patenting problems are either not responded to or are pointedly closed out of the discussion with statements such as, "We're here to deal with your drinking and your sobriety." This narrow view is somewhat understandable, with regard to AA, if one realizes that: a) the stated intent of the group is to deal with alcohol problems and, b) by virtue of lack of professional training the majority of members would be completely unequipped to deal with complex developmental or lifestyle issues.
On the other hand, the expectation of clients who engage in professional substance abuse counseling is (or ought to be) to be able to deal with a variety of issues which are related to their presenting problem of substance abuse. To respond to clients in professional therapeutic settings in the same limited way as is found in 12-step groups would be clearly unethical and misrepresents counseling and psychotherapy. I do not contend that addictions therapists should be masters of all clinical techniques or therapeutic modes, but I do contend that responding to clients with the narrow view that the substance abuse counselor can only deal with the client's drug use is an appeal to mediocrity. If a substance abuse counselor can do nothing more for a client than what could be done at a 12-step meeting, what is the purpose of professional substance abuse counseling in its own right? The 12-step approach of narrow selectivity of problem definition and range of intervention is clearly out of touch with the expectations of a professional counselor.
II. What about the client who does not have a desire to stop drug use? This issue is really at the heart of the one-size-fits-all view of abstinence as the only acceptable outcome of treatment. The generalized and largely unsubstantiated claim that abstinence from all mood-altering chemicals is necessary and sufficient to address the varied experiences, beliefs, and behavioral patterns of all clients who present for substance abuse treatment is both unrealistic and unresponsive to the recognition of individuals as unique beings with the capacity for rational thought. Given that we currently live in a culture which clearly neither values nor promotes abstinence (as demonstrated by the abandonment of a former federal policy of Prohibition) it is unrealistic to apply an essentially nineteenth century temperance philosophy to sophisticated latter-twentieth century individuals. In addition, such an approach virtually nullifies what many theorists see as a root cause for substance abuse; failure to learn how to practice moderation and responsibility in one's use of mood-altering substances. I do not advocate the "proper use" of illegal substances, but the fact remains that while they are available their use seems inevitable. Thus, a more realistic approach to this situation would be to begin by examining the contexts, patterns, and reasons behind an individual's choice to use mood-altering substances.
However, such a view is in complete contradiction to the tenets of 12-step
philosophy, which has been oversimplified into statements which convey
the message that if alcohol (or other drugs) cause problems in your life,
alcohol (or other drugs) is a problem for you. This parsimonious approach
seems sensible until one takes a closer look. Any number of things in my
life can be related, or causally connected, to problems in my life. Do
I then say one or the other thing is the problem? Such a view passes quickly
from simple-minded to irrational. It also puts the focus on things
that are external to the individual, rather than on how the individual
needs to change his/
Related to the issue of desire, there is an important question of whether
involuntary clients (DUI/
Tradition 5: Each group has but one primary purpose -- to carry its message to the alcoholic who still suffers.
I. Therapy and counseling groups have a primary purpose (with regard to a specific presenting problem or cluster of symptoms) but also have a responsibility to meet the client's needs at several levels. As addressed earlier, the narrow focus of AA or other specifically-oriented 12-step groups is not a viable practice in the realm of professional substance abuse counseling.
II. What about the alcoholic who isn't suffering from his alcohol addiction,
but from other related disorders? Are these clients turned away? Or, on
the other hand, is the 12-step approach forced on them because the therapist
knows what's best for them? The issue here is that proper assessment and
diagnosis is crucial for the professional practitioner in the substance
abuse treatment field in order to clearly understand the client's position
and world view. Refusing to accept a client's plain and probably truthful
statement (from his/
III. Ideally, a comprehensive substance abuse treatment program should
address not only the active using of drugs and its problems, but also adjustment
difficulties in recovery, marital/
Tradition 6: An AA group ought never endorse, finance, or lend the AA name to any related facility or outside enterprise, lest problems of money, property and prestige divert us from our primary purpose.
I. This dynamic has often been applied in reverse through no apparent fault of the AA organization. How many chemical dependency treatment programs proudly proclaim, "We use a 12-step model"? In my experience, quite a few. Apart from the difficulties inherent in such an approach that have already been noted, the most glaringly obvious problem with pronouncements like that above is that 12-step philosophy was never intended as a model for treatment, psychotherapy, or any related use. Perhaps the greatest offenders with regard to the endorsement, financing, and lending (or borrowing) of the AA name have been the nationwide chains of providers (in hospital and clinic settings) of chemical dependency treatment. In typifying the renowned American penchant for that which is quick and easy, corporate mentalities have marketed 12-step principles with the savoir faire of developing a chain of grocery stores. Contributing to this abuse of 12-step principles has been the seemingly endless line of volunteers, usually recovering themselves, who have accepted invitations from mass-marketed treatment centers to host in-house AA and other 12-step groups, help organize and structure alumni groups at treatment facilities, and generally do much of the work that the so-called professional addictions counselors hired by the agency were meant to do. Such well-intentioned but nonetheless unethical use of twelfth step work points to the ease with which people who need to believe in a program, rather than themselves, can allow themselves to be manipulated into behavior which directly conflicts with the very principles they claim to espouse.
II. In many places in this country where a consequence of operating a motor vehicle while under the influence of alcohol or some other drug is the loss of one's driving license, hearing officers and other court-appointed officials often reflect training which overvalues a petitioner's involvement in 12-step groups when considering reinstating that petitioner's driving privileges. Where such involvement is not directly mandated by the court, it is certainly a requirement for remaining in treatment with most substance abuse treatment facilities. Requirements for driving license reinstatement hearings can include such direct violations of 12-step principles as the petitioner presenting validated (signed by members) AA attendance sheets, bringing sponsors to hearings, and presenting testimonial letters from members of the petitioner's AA group. The question here is who is endorsing what and for what purpose?
III. AA counselors (those who espouse 12-step principles and who are often recovering) routinely make what amounts to paid referrals to AA meetings. In addition, they are paid to monitor clients' meetings. Case workers for a variety of court settings engage in this practice as well, particularly in the context of DUI offenders. To me, this seems to be as clear a case for endorsement as can be.
Tradition 7: Every AA group ought to be fully self-supporting, declining outside contributions.
I think it is safe to say that the vast majority of substance abuse
therapists working in the field are paid. Their salaries come, directly
or indirectly, from clients paying for services (individual therapy, group
counseling, etc.). If an addictions counselor is running a 12-step treatment
Tradition 8: Alcoholics Anonymous should remain forever nonprofessional, but our service centers may employ special workers.
I. The above Tradition is the clearest indictment against those who would presume to professionalize 12-step programs. I do not know how the meaning of the above Tradition could be made any clearer. For instance, there is no professional degree in 12-step therapy. No certificate granting or licensure authority confers recognition of 12-step proficiency, beyond a reasonable historical understanding of such organizations and their function. Quite simply, the above Tradition says what it says. How it could be misunderstood or misinterpreted is beyond me.
II. The AA counselor (if so self-identified) is a nonprofessional
by definition, assuming that he/
Tradition 10: Alcoholics Anonymous has no opinion on outside issues; hence the AA name ought never be drawn into public controversy.
The AA name itself, as far as I know, has never been drawn into public controversy, but 12-step counselors have severely compromised its philosophy (and the substance abuse treatment field) through the points I have mentioned earlier: a generally stubborn refusal to see other alternatives ("I've paid my dues so don't tell me"; "Only an alcoholic or addict can understand addiction") and a general unwillingness to recognize that the disease concept (among other points related to 12-step philosophy) is not universal in that it fails to explain other significant life area impairments both before and after drug abuse. Indeed, it could be argued that the fact that I am writing this and taking AA and related organizations to task (in the company of other concerned professionals) demonstrates that the letter of this Tradition is practically on the breaking point.
Tradition 11: Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio and films.
I. As stated before, paid referrals made by addictions counselors violate the attraction vs. promotion aspect of this Tradition. The same can be said for substance abuse treatment programs that require 12-step group attendance as a condition of remaining in counseling, as well as judicial and employer mandates.
II. Chemical dependency programs espousing a 12-step treatment mode violate this Tradition and as a rule offer no other alternative to clients they serve. A one-sided emphasis does not allow for a democratic basis for clients to interact in, nor can they make informed choices about other treatment options. In a culture which has prided itself on freedom of choice, an open marketplace, and the democratic process, this state of affairs is puzzling and points out a cause for social concern regarding such dictatorial policies.
Tradition 12: Anonymity is the spiritual foundation of all our Traditions, ever reminding us to place principles before personalities.
I. The psychotherapy field is replete with personalities (theorists and practitioners), both popular and scholarly. In most instances, the value set of the theorist makes it difficult to apply the theory in therapeutic practice without the practitioner's subscribing at some level to those values. At a surface level it would seem highly unlikely that a successful adaptation of 12-step principles could be formulated into a theory of psychotherapeutic practice without concomitant attachment to the theorist or group who developed such a modification. That outcome would violate the above Tradition.
II. The addictions field has become jammed up with personalities, beginning with Father Martin and including such authors and speakers as Claudia Black and John Bradshaw, to name but a few. The upshot of this increasing wave of speakers and writers on the lecture circuit is that a good deal of misinformation about 12-step programs and their philosophy (with the exception of consistent praise for them) has been disseminated and consumed by eager groups desperate to hear messages they believe will save their lives, or someone else's. This is clearly not what the founders of AA and other self-help groups had in mind. In fact, the very concepts of self-help and peer support as nonprofessional, anonymous, and "grass roots" would seem to rule out the amount of publicity and hoopla accorded to self-professed savants.
I suggest that those who clamor most loudly in praise and defense of 12-step groups pay a bit more attention to the tenets of their philosophy as written by the original authors, as opposed to marketing re-written interpretations and poorly reasoned justifications. For those who aspire to become responsible professionals in the substance abuse treatment field, the maundering of self-interested Sophists and converts sets a poor example.
III. Recovering therapists who consider becoming mentors or sponsors to their clients cannot help but put their personalities before the principles of their 12-step program by virtue of the professional relationship they engage in with the client. They are viewed as a professional (whether or not they act accordingly) and in that capacity have significant personal influence upon the clients with whom they work.
One could go on a bit more with regard to this topic, but the points made thus far arguably stand for themselves. The concerns expressed in them spell out a real ethical crisis for the substance abuse treatment field and bear further exploration. In today's Human Services market, issues of accountability and credibility are coming to the fore in many areas other than the field of substance abuse counseling; medicine and business are two examples that come readily to mind. The issue of accountability, being able to demonstrate that what one says one does actually happens, has been the bane of the addictions treatment and psychotherapy fields since they began. By the very nature of the type of work practitioners in these two fields engage in, outcomes are justly notorious for being elusive and difficult to clearly define. As a justification for this state of affairs, I do not believe that the social sciences are simply an analog to the physical sciences.
The social sciences (psychology, anthropology, sociology, etc.) deal with variables of human existence which have shown themselves resistant to quantification at almost every turn. I do not mean to say that the physical scientist necessarily has an easier time of it, but rather that the methods of investigation practiced by the physical sciences simply do not meet the needs of the social scientist in the long run. Behaviorists and social learning theorists (to name but two schools of thought) would probably take issue with these views and I do not intend to settle this worthwhile debate in these pages. The point I wish to make is that, from a standpoint of ethical practice in the social sciences, the hub of one's accountability and credibility is the consistency one demonstrates in one's approach to social problems. Put simply, once the rules are established are they followed?
As I have pointed out, those who seek to professionalize the 12-step
approach consistently violate the rules of their own game. In some cases
this has been done quite artfully, while in others the approach has been
patently ham-handed. The issue of most concern to me, then, is credibility.
How credible is an approach that says one thing (quite nobly) and often
practices another? The conflict and incongruity between the philosophy
of 12-step programs as practiced in their own context and their application
to the context of professional substance abuse treatment is simply too
great to ignore. Whether one approaches this situation from the view of
credibility, ethics, or validity, it comes up the same -- 12-step philosophy
is not psychotherapy, counseling, or treatment for substance abuse, or
a rigorously researched model of applied psychology and should not be utilized
for such purposes. Twelve Step philosophy is just that; a system of
loosely organized beliefs which serve to bring together lay people in a