12 Steps Recovery from addiction has been described as a ‘voluntarily maintained lifestyle characterised by sobriety, personal health and citizenship’
David Webb 12 Steps
While in the right setting, such as a 12 steps rehabilitation clinic, many addicts have little trouble stopping drinking or using drugs, most, if not all, find maintaining sobriety, especially after reintegration back into society and return to normal life, much more difficult.
For the majority, without the long-term support and constant vigilance to curtail impulsive behaviour, it is impossible. In some addicts, incentive salience driven by changes in the limbic brain presents a lifelong vulnerability to relapse.
12 STEPS FURTHERMORE, THE HORRENDOUS CONSEQUENCES AND CHAOTIC LIFE CREATED BY YEARS OF ACTIVE ADDICTION, SOMETIMES COUPLED WITH LOSS OF FAMILY AND SOCIAL SUPPORT, FURTHER COMPOUNDS PRE-EXISTING LOW SELF-EFFICACY, LOW SELF-ESTEEM, POOR EMOTIONAL REGULATION AND HOPELESSNESS. IF ADDICTS ARE TO REMAIN SOBER, THEN THESE ASPECTS OF THEMSELVES NEED TO BE ADDRESSED AND THEIR THINKING STYLE AND SOCIALITY NEED TO CHANGE SO THAT THEY AREMORE FUNCTIONAL.
The 12 steps of addiction recovery (Table 1), originally described by Alcoholics Anonymous in 1939, is a framework for a learned lifestyle characterised by self-awareness, self-compassion, self-development, improved resilience and enhanced psychological wellbeing.2,4-6 By encouraging social participation and working with other recovering addicts, the 12 step process provides the recovering addict with a sense of common humanity and belonging, motivation to remain sober and an opportunity to find meaning and purpose.
At first sight, the 12 steps appear to be overtly religious, as is the Christian-based approach of the original text.4 The process has been criticised for this, along with (inaccurate) perceptions that recovery through the 12 step process requires admissions of powerlessness and to moral character defects or failings.7 Nevertheless, a contemporary interpretation of the 12 step process does not necessitate religious identification or belief in a god. Furthermore, some of the words from the 1939 text are used differently in the present day and it is helpful to understand the original context in which they were intended.
The following is a brief non-religious interpretation of the 12 step process, which forms a practical adjunct to treatment of addiction to alcohol and other drugs and an ongoing lifestyle to help maintain a less chaotic life and long-term sobriety.
12 STEP 1: Alcoholics Anonymous points out that alcoholism is characterised by two behaviours.4 Despite a conscious desire to abstain, the alcoholic is unable to leave alcohol alone for any extended period of time, and once they take a first drink, he/ she cannot stop. The drinking episode culminates in blackout and loss of consciousness. In other words, the addiction hijacks the addict’s sense of free will, in that they are no longer free to choose whether or not to drink or how much to consume.
This view is consistent with dopamine reward prediction error, incentive salience and post-use dysphoria mechanisms of addiction neurobiology.3,6,8-14 In contrast to being addicted to the high, in the absence of anticipated reward, the brain ‘wanting’ (distinct from ‘liking’) the addictive substance and post-use dysphoria, drive repeated, compulsive and excessive consumption. In this context, incentive salience, in which emotions are powerfully salient, also explains why addicts may relapse after even many years of sobriety.
Therefore, in these respects, the alcoholic is powerless over (his addiction to) alcohol. He/she cannot stop drinking by him/herself (without assistance). The addiction to alcohol is more powerful than the willpower of the individual.
It is important to note that, in contrast to the concept of ‘powerlessness’ in general that is too often mentioned as a criticism of this step, step 1 does not suggest that the individual is powerless. Clearly one retains considerable efficacy over one’s own life, whether or not to seek and be open to assistance and whether to participate in the recovery process.
Clearly the alcoholic’s life is unmanageable when they are drinking. However, due to poor coping skills, low self-efficacy and self-defeating thinking characteristic of the addictive psyche, and chaotic consequences of repeated intoxication, the alcoholic’s life is almost certainly unmanageable in between drinking episodes as well. This sets up a vicious cycle of adverse consequences and negative emotions and drinking to escape those that further contributes to chronic alcohol use.
12 STEP 2: What is a power greater than myself? Simply put, it is not me. I need assistance to recover. Even if the alcoholic is able to sustain sobriety for short periods, they inevitably return to drinking. They may tell themself that now they have it under control, that they will be able to moderate their drinking. The AA text describes this inability to learn from past experience and the conviction that, despite all evidence to the contrary, this time will be different, as ‘insanity’.4,5
There is no suggestion in the 12 steps that alcoholics should blindly accept from the outset that the 12 step process will enable them to recover. It is merely suggested that, with assistance, they give it a chance. Through seeing the benefits of the program in the sobriety of others, and in experiencing the positive changes that occur in their own lives as a consequence of implementing this lifestyle, they gradually come to understand (we came to believe) that a sober, rewarding life is achievable and sustainable.
12 STEP 3: If life is to change, and relationships and consequences of behaviour are to improve, and if one is to break the cycle of chaos and drinking, then it is intuitive that the alcoholic should have at their disposal a functional reference framework within which to act in future. Self-centered motives that inform impulsive decisions and behaviours need to be replaced with more mature functional thinking and actions. Step 3 offers the alcoholic a framework from which to start.
Although many alcoholics may identify with a God, others do not. The 12 step program refers to “God as I understood him”. Regardless of religious or spiritual convictions, alcoholics are invited to define for themselves what God, if he/she were to exist, might be like. A typical list of ‘godly’ characteristics (or principles) might look like that presented in Table 2. It is then suggested that they begin to make decisions and act based on these characteristics that they have identified as desirable. They are invited to “act like the person you want to become”.12 STEPS
12 STEP 4: In contrast to criticisms of this step that suggest that alcoholics are made to admit to ‘moral failings’, the ‘moral inventory’ referred to in step 4 is not intended as a judgement on character. Step 4 is an invitation to ‘discover the truth’ where unawareness and pursuing one’s own motives has led to negative consequences, dysfunctional relationships, resentment and reactionary drinking. The alcoholic is asked to identify episodes of past anger, regret, guilt or embarrassment and where they were responsible in these situations. Note that they are not asked to identify their ‘part’.
If I have a part, then you must have a part, and if you have a part, then my part is justified: “Putting out of our minds the wrongs the others had done, we resolutely looked for our own mistakes. Where had we been selfish, dishonest, selfseeking and frightened? Though a situation had not been entirely our fault, we tried to disregard the other person entirely”.4 Through identification of self-seeking motives, the alcoholic is in a position to adjust future behaviour by substituting these motives with the principles identified in step 3. Introspective, carefully considered decision-making based on principles rather than motives informs more functional behaviour with less chaotic consequences. Life becomes more manageable. Furthermore, compassion for others facilitated by step 4 may increase the capacity to accept compassion from others and the ability to show greater compassion to self.15 12 STEPS
12STEP 5: Talking to another person about the inventory established in step 4 is helpful in a number of ways. It helps to establish a sense of common humanity, to put events into perspective and to invite an opportunity for council. Addiction is characterised by dysfunctional thinking and behaviour, associated with shame and a sense of isolation. Talking to another (recovered) addict, discovering that one is not alone, is cathartic, reduces feelings of isolation, fosters self-acceptance and opens the door to healing.
It engenders a sense that one can be forgiven and can forgive. It creates a sense of humility, honesty and willingness to change without descending into selfpity.5 Although there is no substitute for one addict talking to another, other appropriate people who may be helpful in step 5 include addiction counsellors, healthcare professionals, friends, family members and religious advisors. Steps 6 and 7 represent, with humility, a commitment to maintain the framework for decision-making that has been outlined in step 4.
12 STEPS 8 AND 9: Active addiction is characterised by behaviours that are self-centered and dishonest. Almost inevitably during that time others are maltreated, harmed or compromised in various ways. By carefully reviewing where their behaviour may have caused harm to others or society and, where possible making amends for that, the alcoholic is able to free themself from associated guilt and shame and pre-empt or avoid repercussions of past activities that may adversely affect their life in future and compromise efforts at sobriety.
Decisions about who to approach, how to approach them and how it may be possible to make amends should be objective and carefully considered. Consequently, discussion with appropriate counsellors is encouraged before approaching others.
12 STEPS 10 AND 11: As previously implied, the steps, rather than being discrete actions, are a framework for a maintained lifestyle. They are separated and numbered so that the lifestyle can be taught, understood and learned. Steps 10 and 11 inform a daily practice of a nonjudgemental, carefully considered review (mediation) of emotions, thoughts and events, and planning for the day ahead, based on the principles of steps 3, 4, 8 and 9.
“WHEN WE RETIRE AT NIGHT, WE CONSTRUCTIVELY REVIEW OUR DAY…with the 12 STEPS;
On awakening, let us think about the twenty-four hours ahead”.4 The intention is to non-judgementally identify where motives rather than principles continue to inform behaviour and to proactively correct errors before they occur or are allowed to escalate.
STEP 12: The result of the 12 step lifestyle is a personality change (spiritual awakening) to a happier, more capable individual who is able to grow and flourish. Assisting and guiding other recovering alcoholics to achieve the same provides a sense of purpose and meaning that supports long-term sobriety.2,4-6
Participation in 12 step-based social groups, such as Alcoholics Anonymous or Narcotics Anonymous, provides valuable support for long-term sobriety. Although a 12 step process may not be appropriate for all addicts, it is helpful for clinicians to have an informed working knowledge of the 12 step process so that they may encourage it where it is appropriate and support those who are already participating in such groups.12 STEPS
References 1. Belleau C, DuPont RL, Erickson CK, et al. What is recovery? A working definition from the Betty Ford Institute. The Betty Ford Institute Consensus Panel. J Substance Abuse Treat 2007; 33: 221-228. 2. Moos R, Timko C. Outcome research on twelve-step and other self-help programs. In Galanter M, Kleber HO (Eds.). Textbook of substance abuse treatment (4th ed). Washington, DC: American Psychiatric Press; 2008. pp. 511-521. 3. Robinson MJF, Robinson TE, Berridge KC. Incentive salience and the transition to addiction. In Miller P (Ed). Biological Research on Addiction (1st ed). Amsterdam: Academic Press; 2013. 4. Alcoholics Anonymous (4th ed). New York: 12 STEPS Alcoholics Anonymous World Services, Inc; 2001. 5. Twelve steps and twelve traditions. New York: Alcoholics Anonymous World Services, Inc; 2009. 6. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016: pp 2-1 – 2-26; 5-8 – 5-10. 7. Mendola A, Gibson RL. Addiction, 12-Step programs, and evidentiary standards for ethically and clinically sound treatment recommendations: What should clinicians do? AMA Journal of Ethics 2016; 18(6): 646-655. 8. Schultz W. Dopamine reward prediction error coding. Dialogues Clin Neurosci 2016; 18: 23-32. 9. Berthet P, Lindahl M, Tully PJ, et al. Functional relevance of different basal ganglia pathways investigated in a spiking model with reward dependent plasticity. Front Neural Circuits 2016; 10:53. doi: 10.3389/fncir.2016.00053 10. Morita K, Kawaguchi Y. Computing reward-prediction error: an integrated account of cortical timing and basal-ganglia pathways for appetitive and aversive learning. Eur J Neurosci 2015; 42: 2003-2021. 11. Ostafin BD, Palfai TP. When wanting to change is not enough: automatic appetitive processes moderate the effects of a brief alcohol intervention in hazardous-drinking college students. Addict Sci Clin Pract 2012; 7: 25. http://www. ascpjournal.org/content/7/1/25 12. Gardner EL. Addiction and brain reward and anti-reward pathways. Adv Psychosom Med 2011; 30: 22-60. 13. Nestler EJ. Cellular basis of memory for addiction. Dialogues Clin Neurosci 2013; 15: 431-443. 14. Volkow ND, Koob GF, McLellan T. Neurobiologic advances from the brain disease model of addiction. N Engl J Med 2016; 374: 363-371. 15. Jazaieri H, Jinpa GT, McGonigal K, et al. Enhancing compassion: A randomized trial of a compassion cultivation training program. J Happiness Stud 2013; 14(4): 1113-1126.