Therapeutic groups versus 12-step groups: An analysis of the AA prototype

By Cathleen A. Mann, PhD

Abstract: 12 step groups, especially in the form of Alcoholic Anonymous groups, have a rich history as evangelical, Christian-based groups, which operate under the guise of “treatment” for persons with substance abuse problems. However, research suggests that AA operates in a cult-like fashion and does not consider the individual differences of the person entering the AA program. Additionally, AA has been atheoretical, anti-medical, and anti-research since its inception in 1935. This paper attempts to examine the many deficiencies of AA as a group therapy model and to suggest some alternative approaches for psychologists to use when treating substance abusers. Therapeutic groups versus 12-step groups: An analysis of the AA prototype Most psychologists, physicians, lawyers and judges, and the average person have little awareness or in-depth knowledge of what AA (Alcoholics Anonymous) actually is, how it was founded, how it works, or the consequences associated with involvement with AA and similar 12-step groups. This paper will illustrate the origins of the 12-step movement, the group dynamics and pressure within and outside the movement, the structure and teachings of the 12-step groups, and discuss how 12 step philosophies and applications are, by and large, harmful to the substance user/abuser. There will also be some discussion of alternatives to the 12-step method, focusing on the positive use of group psychology to treat substance abusers.

Without a doubt, the general consensus in this country is that Alcoholics Anonymous is an effective remedy for alcohol-related problems, that it should be listed as the treatment of choice, that it has good success rates, and that it is based on sound principles (Peele, 1990; Fox, 1995). However, this is an erroneous myth. In reality, AA is a faith-based, Christian evangelical group, which has modified its marketing approaches somewhat, but still retains and maintains its one-sided view of alcohol problems or other addictions (Taleff & Babcock, 1998). In terms of group psychology, AA group meetings resemble cult-like processes. AA involvement uses well-known cultic principles to recruit, retain, and maintain its membership. Using psychological coercion tactics, AA offers freedom but delivers bondage. Alcoholics Anonymous is probably the most powerful group in the mental health and substance abuse field today, with an estimated membership of 2 million, and an estimated 90% of the addictions field treatment providers subscribing to the AA formula in their treatment centers, hospitals, clinics, and private offices (Finlay, 2000). Definition of Terms Alcoholism: “Primary chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. Often progressive and fatal, it is characterized by impaired control over drinking and the use of alcohol despite consequences. Alcoholism has major biological markers, including elevation of hepatic enzymes, low levels of cerebrospinal fluid in the brain, related endocrine problems, and hyper-responsive heart rate. Data may someday delineate the basic biological processes that predispose to alcoholism, and may lead to screening for vulnerability, which could lead to directed and permanent intervention.” (Ayd, 1998). Alcoholics Anonymous: “Self-help group founded in 1935 by two recovering alcoholics (one a physician) for the purpose of rehabilitating alcoholics.

AA has been a major contributor to effective assessment and treatment of primary alcoholism, but AA counsellors, as a rule, have trouble with alcoholism as secondary to primary psychiatric illnesses. Sometimes these counselors resist treatment of primary disorders with proper medications, often misleading the person into believing that all medications are addictive and equivalent to alcohol.” (Ayd, 1998). Denial: “Mechanism in which a person fails to acknowledge some aspect of external reality that would be apparent to others.” (Ayd, 1998). Group dynamics: “Generally, any and all of the collective interactions that take place within a group” (Reber, 2000). Group therapy: “A very general term used to cover any psychotherapeutic process in which groups of individuals meet together with a therapist/leader. The interactions of the group are assumed to be therapeutic and, in many cases, more effective than the traditional client-therapist dyad” (Reber, 2000). Brief Literature Review Physicians have played a distinctive role in the treatment of chemical dependency since the time of Hippocrates (Hayes, 1998). In the 1800s, temperance societies flourished for a time, and the issue of chemical dependency became politicized (Hayes, 1998). From 1900 to 1935, more physicians began studying alcohol as a potentially harmful substance, and research began in earnest (Hayes, 1998). In 1935, Dr. Bob (Dr. Robert Holbrook Smith, 11/26/1885 to 1/24/71) and Bill W. (William Griffith Wilson, 8/8/1879 to 11/16/50) formed the 12-step group, Alcoholics Anonymous, and the field and study of substance abuse and addictions has never been the same (Ragge, 1998). Finlay (2000) discusses the influence of Carl Jung and William James on the origin of Alcoholics Anonymous. Jung termed alcoholism as “a low-level search for God” (Finlay, 2000). Even though he was considered a spiritual psychologist by many, Jung was, in actuality, the ultimate religious generalist. He dabbled in the occult, held séances, believed in alien visitations and abductions, and considered himself the reincarnation of his grandfather (Noll, 1997). Jung also used psychedelic drugs as a means to “reach God,” so perhaps he is not the best teacher and example on how to diagnose and treat substance abuse problems (Noll, 1997). Brief overview of the addiction’s treatment field According to Taleff & Babcock (1998), the addictions treatment field has several dominant themes.

These themes are present in virtually all treatment approaches and form a basis from which to study the effectiveness of addictions treatment. As delineated by Taleff & Babcock (1998), these themes are: 

1. Blame the client for any treatment failure. It is customary in the addictions field for the treatment provider to put forth phraseology such as “He’s still in denial,” “she didn’t work the program,” “he hasn’t hit bottom yet”. Since the vast majority of treatment programs are 12-step (AA) based, any failure must be due to the individual’s unwillingness to submit to AA rigour, rather than a reflection of AA itself. 

2. Closeness equals pathology. In addictions treatment, the assumption by most 12-step oriented programs is that the “disease of alcoholism” is a family disease, and it is a prerequisite that the client/patient disengage from his/her family in order to “get well.” 

3. Too much knowledge is bad. Don’t think, just feel. This approach discourages rational thought and encourages decision-making based on emotional changes. Although it sounds reassuring, this approach tends to inhibit good reality testing, reliance on the self and one’s own observations and encourages compliance to the group norm (Goldhammer, 1996). 

4. Never trust the client, as all addicts are cons and manipulators. Strangely enough, while maintaining that alcoholism is a disease, AA and other disease proponents ignore the standard therapeutic requirement that, ethically and responsibly, individuals be told of alternative approaches other than a 12-step approach.

Additionally, while maintaining that alcoholism is a disease, AA philosophy does not permit medical evaluation and medication as part of the regimen for treatment (Peele, 1995). What AA does not want you to know is, yes, they consider alcoholism a disease, but only a disease of the soul or spirit, not a physical disease, and not a disease like any other disease (like diabetes for example) (Peele, 1990, 1995, 1998). A History of AA Founded in 1935, AA published its sacred writing, The Big Book, in 1939. William Griffith Wilson, known as Bill W., began drinking alcohol to excess after losing much of his fortune in the Wall Street crash of 1929 (Ragge, 1998). From 1933-1934, Bill W. was hospitalized at least 4 times in New York’s Towns Hospital (Ragge, 1998). During his hospital stays, Bill W. was introduced to the concept that alcoholism was a disease, completely out of his control, which was a revolutionary concept of the time. After his last hospital stay in 1934, a fellow “alcoholic,” Ebby Thatcher, visited Bill W. Ebby was heavily involved in a Christian revival group called The Oxford Group (Ragge, 1998). The Oxford Group was a mismatched group of individuals (almost exclusively men) who had rejected other religions (Ragge, 1998).

The group’s fundamental concept was called “God-control,” and was designed to supersede the power of men, and instead commit to realizing a world governed by people who were governed solely by God (Peele, 1995). Despite his involvement in the Oxford Group and adherence to its principles, Bill W. was readmitted to the hospital in 1935. During this hospital stay, Bill W. described an intense religious experience he termed “The Hot Flash,” and achieved the realization that God was now “my higher power” (Ragge, 1998). In late 1935, Bill W. met Dr Bob through mutual friends. Dr Bob had recently given up his medical practice due to his “alcoholism” (Ragge, 1998). Dr Bob began attending meetings of the Oxford Group, although reluctantly as he was reportedly an atheist. In time, however, Dr Bob began to see that “alcoholism” was really a disease, and that it was first and foremost a spiritual disease, requiring intervention from God for help, and a lifelong commitment to “God-control” (Peele, 1995). After the publishing of the Big Book, which contains the 12 steps to recovery and renewal, AA experienced phenomenal growth. Today, the 12-step philosophy is the most widely used and disseminated “treatment” for substance abuse in the world (Fox, 1995; Ward, 1990). Is alcoholism a disease? First and foremost, it is important to remember that the word “alcoholism” does not appear anywhere in the guiding book of the mental health, psychiatric, and allied mental health fields – the Diagnostic and Statistical Manual of Mental Disorders (APA, 1996).

For AA to continue to utilize the term “alcoholism,” which has no professional or current research basis, is completely disingenuous. The DSM-IV (APA, 1994) separates alcohol use problems into two categories: abuse and dependence. The major difference between the two is that dependence suggests physical symptomatology associated with the disorder. It is important to realize that both abuse and dependence labels are based (with the exception of physical symptoms) on behaviours and consequences of those behaviours. Nowhere in the DSM-IV is there a research-based observation that substance dependence has (or needs) a religious component for recovery. The DSM-IV (APA, 1994) does state the following, quoted in pertinent part: In most cultures, alcohol is the most frequently used brain depressant and a cause of considerable morbidity and mortality. At some times in their lives, as many as 90% of adults in the United States have had some experience with alcohol, and a substantial number (60% of males and 30% of females) have had one or more alcohol-related adverse life events. Fortunately, most individuals learn from these experiences to moderate their drinking and do not develop Alcohol Dependence or Abuse. (1994, p. 194, emphasis added). Mann, Herman & Heinz (2000) discuss the formation of the disease model of alcoholism, but with an entirely different conclusion than is reached by the AA proponents. Mann, et al. (2000) state that pharmacological approaches to the treatment of addiction, in general, have had the most success. Rather than view relapse as “not working the program” a la AA, Mann, et al. (2000) view relapse as “neuroadaptation, sensitization, and monoaminergic dysfunction,” all occurring physically within the brain, and having nothing to do with acceptance or, or lack thereof, a spiritual awakening. Group process and dynamics within the AA model the 12 steps of AA are taken literally from the Oxford Group teachings. In the Oxford Group, these steps were used as a cure for sin (Ragge 1998). In 12-step groups, the steps are purportedly used as a cure for “alcoholism”. Half of the 12 steps mention God, giving the 12-step organization a “religious’ ‘ (although AA likes to call it-a spiritual) cast (Peele, 1995).

The references to God, the concept of the individual powerlessness in the 1st step, the confession concept in the 5th step, the idea of evangelism in the 10th and 12th steps come directly from the Oxford Group, which was a Christian evangelical group (Ragge, 1998). For the first 40 years since AA’s beginnings in 1935, it was the exclusive self-help group for substance abusers in this country. Criticisms of the AA model are many. It is reported to be highly male-dominated in administration; it makes no provision for the non-religious or atheists; and is historically anti-psychotherapy and anti-medication (Ketcham, Asbury, Schulstad & Ciaramicoli, 2000). In many ways, AA operates in a time vacuum straight from the religious fervour of the 1930s and has made every attempt to prevent the incorporation of new research and new insight into the nature of addictions and has refused to consider any new approaches to group psychology or individual psychotherapy which have arisen out of the research conducted in the past 65 years. In fact, AA operates as a closed system, eschewing any injection of newer techniques. AA wants everyone to accept the “disease of alcoholism,” according to its definition, yet refuses to accept psychobiological changes in research, such as antidepressants, which may treat the underlying causes of addiction. Instead, AA sees the “cure” for alcoholism as a moral cure, one based in acceptance of a Christian evangelical religious base, with complete and utter fidelity to the AA way of doing things (Ragge, 1998). Ragge (1998) provides the following illustration of group psychology at work in the AA model: AA meetings are held in a wide variety of locations.

In most cities, AA members, separate from AA itself, band together to establish clubhouses-storefronts or houses used exclusively for Twelve Step meetings and socialization by groupers. The membership of groups varies widely. There are also many exclusive meetings in private homes where an invitation is necessary and ‘undesirables’, however, they may be defined, are not invited. The larger, more prestigious meetings tend to take on the atmosphere of a great crusade and may have up to several hundred people in attendance, and consistently have speakers with 20 or more years of Time. In keeping with the traditions of the Oxford Group, everyone is on a first-name basis. Large meetings normally have one or two speakers who give their ‘pitch’. The reading of the sacred text is also part of every meeting. The Oxford Group, being ‘more spiritual than religious acknowledge its Christian roots, doesn’t use the Bible at all; rather, it uses another sacred text, the inspired Word of God as expressed through Bill W. -the Big Book. (p. 81-82). How could the individual group identity be expected to survive this type of group dynamic and onslaught? The power of many others, who seem to all know this hidden secret of “alcoholism,” is very difficult for the individual to resists. Placing and reading of sacred text written by the group’s leader is also an enormously powerful group persuasion technique. AA members, after hearing and experiencing such rousing testimonials and rituals, become captives. AA does NOTHING to provide skills or tactics to quit the addiction; instead, it tells members to stop trying and give up. Ragge (1998) continues: In continuing the traditions of the Oxford Group, AA uses elders as its preachers. The best speakers tended to have the ‘worst bottoms,’ both emotionally and behaviorally. The speaker opens the sermon by identifying himself by his first name and disease or diseases. The diseases are usually identified as such through the existence of the Twelve Step programs for those ‘suffering’ from them. Using only the first name is considered essential for beginning to break through ‘denial’ and establish humility. It is also considered essential that humility is maintained because without humility God will not protect the alcoholic from the Devil Drink. (p. 83). Problems and consequences associated with the AA model Barlow, Burlinghame & Fuhriman (2000) discuss the therapeutic applications of group psychotherapy for mental health and substance-abusing populations. Barlow, et al. (2000) state that all groups have the same type of problems-how to deal with leadership issues; negative and positive interactions within the group; and how to use group therapy as a “change agent”. Ketcham, Asbury, Schulstad & Ciaramicoli (2000) attempt to put forth a comprehensive examination of alcohol treatment in general, and alcohol treatment in groups, specifically. Ketcham, et al. (2000) state that alcohol abuse and dependence is a physiological disease, with neurotransmitter deficits at the core of the dysfunction. Additionally, Ketcham, et al (2000) suggest that nutritional factors play an important role in the development and maintenance of alcohol-related problems.

This group of researchers heavily criticizes the current substance abuse policies and approaches, stating that there is not nearly enough education as to the physiological components of alcohol addiction and far too much reliance on outdated models and approaches. In AA, Ragge (1998) states: Speakers find it important to give certain warnings to the newcomer. These are consistent with the presumed three major components of alcoholism as a physical, emotional, and spiritual/moral disease. The presumed uncontrollable craving that develops after the first drink or perhaps just a sip falls under physical attributes. The emotional aspect of the disease is ‘alcoholic thinking’. Symptoms that the newcomer is cautioned to watch out for (dangerous thoughts) include thinking that you might not be an alcoholic, thinking you don’t need the program, disagreement with someone with more time, thinking that you don’t need a sponsor, and thinking that you can stop without the program. (p. 89). What a wonderful illustration of a fear-driven thought control program! Not only does the group member now have to label him/herself according to their disease, but also, they must define themselves and their life hereafter based on the lowest point in their life up to this moment. Remember the first step in AA: “I admit I was powerless…” Admitting that one is powerless, opens up a unique possibility of control by external forces, including the group and other so-called “recovering alcoholics” who comprise the group. Failure to acknowledge powerlessness means an automatic label of being in “denial”. Regardless of attempts to objectivity a definition of denial, the term itself is very subjective and very judgmental. One person’s denial is another person’s truth, and for someone in authority and in a position of trust (like a group therapy leader) to label someone as “in denial” carries heavy emotional weight and potentially harmful consequences.

According to Trimpey (1998), AA is cult-like in its approach for the following reasons: 
1. AA is a religious organization with supernatural beliefs
2. AA espouses irrationality, rigidity, and anti-intellectualism.
3. AA is built upon a charismatic leader, who is still worshipped and revered today.
4. AA has a hierarchical, authoritarian structure that cannot be questioned.
5. AA requires submission of the individual to the “will of God”.
6. AA claims to have the ultimate truth and embodies dogmatism.
7. AA encourages and often requires separatism from family and non-AA members.
8. AA claims its “Program” is exclusive and the only path to salvation.
9. AA is the ultimate in self-absorption among members and the group itself.
10. AA uses economic exploitation.
11. AA goes to great lengths, mostly psychological tyranny, to retain members.
12. AA utilizes mind control techniques and intimidation. Additionally, AA’s well-known reputation as “slogan therapy” can be compared to thought-stopping techniques used in better-known cultic groups. The group structure of AA itself is cult-like, with the discouragement of two-way sharing. Instead, a member is chosen to share in a monologue fashion, with only agreement from members in the audience as the acceptable response. No cross-talk is allowed at AA meetings or in their small group sessions (Ragge, 1998). While some cults curse or damn defecting members, AA promises that those who leave “the Program” will inevitably suffer from a “malady called the dry drunk. This dry drunk concept is one of the most sinister mind traps ever devised to retain errant members.

Knowing intimately how addicted people cannot imagine a satisfactory life without the substance, AA novices are told that quitting drinking or using is useless since addicts cannot possibly be happy.” (Trimpey, 1998) It is instructive to compare and contrast AA and mainline cults with Langone’s (1998) definition of cults using thought reform (mind control) programs: 
1. Obtaining substantial control over an individual’s time and thought content, typically by gaining control over major elements of the person’s social and physical environment.
2. Systematically creating a sense of powerlessness in the person.
3. Manipulating a system of rewards, punishments, and experiences in such a way as to promote new learning of an ideology or belief system/behaviour advocated by leadership.
4. Maintaining a closed system of logic and an authoritarian structure in the organization.
5. Maintaining a non-informed state existing in the subject (p. 3, emphasis added). 

Differences between therapeutic groups and self-help groups Major assumptions and varied beliefs about the causes and “cure” of substance dependence have been promulgated. As the research improves, and knowledge is gained, many theories have been debunked or proven to be harmful. Self-help groups modelled after the 12-step model continue to render “treatment” to substance abusers based on an old, outdated and potentially harmful model-the so-called “moral model” (Jacobs & Goodman, 1989). The biopsychological model of treatment has gained acceptance through research into addictions and substance abuse (Pinel, 2000). The biopsychological model provides an encouraging, holistic model, which does not rely on the shame-based and morality-fueled models of the 12-step movement (Pinel, 2000). AA is blatantly anti-medical, stating the failure of physicians to recognize, diagnose, and properly treat alcoholics (Peele, 1995). Even though AA has increasingly emphasized a “disease” model of alcoholism, it is vital to understand that AA does NOT mean a medical disease, but a spiritual one. Peele (1995) states that AA uses denial as its main motivating mechanism, and rather than use denial as a starting point, AA uses denial as an excuse to justify emotional abuse by AA adherents while in treatment. Peele (1995) further explains, “In keeping with the self-righteous, evangelistic spirit of the [AA] program, any objection to its requirements was treated as a denial.

Money was a regular topic at the sessions, and those group members who claimed financial problems were told to ‘pray to a Higher Power’ In place of legitimate psychological and ethical counselling, most AA members are participating in religious rituals, which are exclusive, binding, and controlling. Peele (1990, 1998) claims, that in his studies of the AA phenomena, “AA works no better, and is perhaps worse, than no treatment at all.”

Accepting the premise that individuals have a spiritual and moral disease from which they will never recover forever negates their sense of personal empowerment, their self-esteem, and their ability to choose for themselves. As with all maladies, unless at risk for imminent harm to him/herself or others, the individual should be able to choose what treatment (if any) is best for him/her or choose to have no treatment at all. This universal belief that psychological treatment is a cure-all or a panacea for loosely termed psychological problems needs to come to an end. Any psychological intervention is not going to work unless the individual willingly, and with full knowledge and disclosure, agrees to such treatment, and is allowed to leave that treatment at any time and on his/her own terms. Anything less than this is a travesty of psychological interventions. One example of a therapeutic substance abuse treatment group model operating in a positive trend is “Smart Recovery”. Their literature describes their group treatment philosophy and treatment approach this way (, 2000): 
1. We help individuals gain independence from addictive behaviour.
2. We teach how to enhance and maintain motivation to abstain; cope with urges; managing thoughts, feelings and behaviour; balance momentary and enduring satisfactions.
3. Our efforts are based on scientific knowledge and evolve as scientific knowledge evolves.
4. Individuals who have gained independence from addictive behaviour are invited to stay involved with us, to enhance their gains, and to help others.
5. We assume that addictive behaviour can arise from both substance use and involvement in activities. We assume there are degrees of addictive behaviour, and that all individuals to some degree experience it.
6. Gaining independence from addictive behaviour can involve changes that affect an individual’s entire life, not just changes directly related to the addictive behaviour itself. (SmartRecovery.Org, 2000, emphasis added). Senay (2000) has delineated strategies for group psychotherapy for substance abusers as containing elements of peer support in a safe environment free from judgment. Senay (2000) emphasizes the need for groups to facilitate skills in each other in an attempt to eventually leave the group, become independent, and achieve mastery. This is a very strong contrast to the 12-step model which emphasizes dependence on the group, and the edict that one will “die or go to jail” if the “program of AA” is not regimentally followed for the rest of one’s life.

One of the best hopes for ethically sound group therapy for substance abusers is to give and receive feedback from others in a safe, supportive environment. A group therapy setting in which individuals learn to rely on each other, correct negative experiences of the past, and improve communication and conflict management skills should be the focus of good group therapy. Ideally, we can take the lessons learned in the group therapy setting into our real lives outside of the group, and we will grow in independence from the group, not continue to rely on the group for the rest of our lives (in order to prevent death as AA espouses). Good group therapy allows individuals to be just those individuals. There are no entrance requirements, other than respectful interaction, and certain group members are not required to define themselves based on the lowest point of their lives to date. It is possible that an individual’s inner voice, intuition, and personal sense of right and wrong should lead them in making decisions; thus, decisions should not be made based on how the group defines reality. 

Summary and Conclusions 
As a general rule, it would be helpful if the United States government would mandate ethically sound, research-based, and outcomes-based research for substance abuse, rather than relying almost exclusively on an outdated, harmful, outmoded, non-scientific, Christian evangelical approach to a biological disease. Second, the United States government needs to declare an end to its punitive and criminal attack (the so-called war on drugs) on a medical disorder. No other medical disorder in the world would allow its participants to be told that they had a moral failing and they needed to get right with God before they could receive “treatment”. It is an outrage that substance-dependent persons are told to rely on an external, mythical figure-the higher power-rather than rely on themselves to control, modulate, and change their behaviour. AA group therapy is a misnomer.

AA group meetings are indoctrination sessions, whereby mind-stopping and mind-numbing slogans are chanted, and where every problem, no matter how severe, can be met with a ditty like “One day at a time,” or “Stop your stinking thinking”. Alcohol addiction does not occur as a result of a moral or spiritual failure; instead, it occurs because of genetic predispositions and biological factors. The abuse that goes on in a typical AA group setting should be recognized as such and stopped completely. As an organization, AA is very secretive and refuses to consider alternative worldviews other than its own – one of the hallmarks of a cult. Court-mandated or employer-forced attendance at AA meetings calls into question the relationship between the government and AA’s mission as a religious organization and may be a violation of the United States Constitution’s edict of separation of church and state (Barlow, Burlingame & Fuhrimann, 2000). What is promising is that AA abuses of the past have come into the light, so to speak, and there are more than 40 alternative group therapy models for substance abusers that do not espouse AA tenets. Newer innovations and research into the relationship of the brain and addictive potential are promising, as well. For psychologists, what is important in all of this is that we do not impose our personal religious philosophies (or lack thereof) on unsuspecting persons. We do not, as psychologists, force anyone into treatment or require a general mental health decline in individuals through the use of powerless statements or threats of harm if they leave the group therapy sessions. We should always work toward autonomy, independence, greater positive social involvement and interest, and treat clients as the best they can be, not the worst they ever were. 

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