12-Step Facilitation of Treatment
Adrianne L. Johnson, State University of New York at Oswego
As explored in the previous chapter, groups are a highly effective modality for the treatment of addictions, and have a long and successful history in the field of chemical dependency. Twelve-step groups may be more appropriately titled “self-help groups” (because not all self-help groups have exactly 12 steps). The terms will be used interchangeably throughout the chapter.
The primary focus of self-help groups is to provide emotional and practical support and an exchange of information. Such groups use participatory processes to allow people to share knowledge, common experiences, and problems. Through their participation, members help themselves and others by gaining knowledge and information, and by obtaining and providing emotional and practical support. Traditionally, self-help groups have been in-person meetings, but more recently, Internet self-help groups have become popular.
One of the most widely recognized groups for the treatment of addictions is Alcoholics Anonymous (AA). Miller and McCrady (1993) note that Alcoholics Anonymous is the “most frequently consulted source of help for drinking problems” (p. 3). In fact, approximately 1 in every 10 adults in the United States has attended an Alcoholics Anonymous meeting at least once (Doweiko, 1999; Miller & McCrady, 1993; Zweben, 1995). Concurrently, affiliation with 12-step groups has been consistently linked to the achievement of abstinence among persons experiencing alcohol and other drug problems (Laudet & White, 2005). It is highly recommended that counselors, even if they do not regularly incorporate these groups into their counseling practice, should at least be familiar with them. The goal of this chapter, then, is to help counselors meet the following objectives:
1. To have a basic understanding of the foundation, history, and development of the 12-step model of treatment for addictions;
2. To gain a basic knowledge of the advantages and disadvantages of these groups, and how to use this knowledge to make appropriate referrals; and
3. To understand how to incorporate 12-step groups into culturally sensitive and client-appropriate addiction treatment for the most effective outcome.
History: Development of 12-Step Groups
As will be discussed later, Alcoholics Anonymous (AA) is one of the most widely recognized 12-step groups, and has been an instrumental force in the establishment of other groups using its model. Alcoholics Anonymous was founded on June 10, 1935, when Dr. Robert Holbrook Smith, an alcoholic physician, had his last drink (Doweiko, 1999). His cofounder, Bill Wilson, a failed Wall Street stockbroker, had previously been affiliated with the New York Oxford Group, a nondenominational group of Christians committed to overcoming a common drinking problem. The two men met coincidentally in Ohio while Wilson was seeking support to stay sober during a business trip (Miller, 2005). The plan for the group was devised by the two men, with a shared aim to spread the supportive message of sobriety to other alcoholics.
During its early years, AA worked to find a method that would support its members in their struggle to both achieve and maintain sobriety. Within three years of its founding, three AA groups were in existence, yet, “it was hard to find two score of sure recoveries” (Twelve Steps and Twelve Traditions, 1981, p. 17). The then-new organization was unable to establish exactly how and why the message of the group worked for some members, but not for all. Since then, several dynamics have been identified that will be discussed later in this chapter. The new organization continued to grow to approximately 100 members in isolated groups by its fourth year (Doweiko, 1999). The early members decided to write about their struggle to achieve sobriety in order to share their discoveries with others, leading to the principles of the now well-established foundation. In the half century since its founding, Alcoholics Anonymous has grown to a fellowship of 87,000 groups including chapters in 150 countries, with a total membership estimated at more than 2 million (Doweiko, 1999; Humphreys & Moos, 1996). The first edition of Alcoholics Anonymous was published in 1939, detailing the well-known Steps and Traditions that now serve as the established guide to addictions recovery and maintenance among group members. The organization took its name from the title of the book, which has since come to be known as the “Big Book” of AA (Twelve Steps and Twelve Traditions, 1981).
1. We admitted we were powerless over alcohol—that our lives had become unmanageable;
2. Came to believe that a Power greater than ourselves could restore us to sanity;
3. Made a decision to turn our will and our lives over to the care of God as we understood Him;
4. Made a searching and fearless moral inventory of ourselves;
5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs;
6. Were entirely ready to have God remove all these defects of character;
7. Humbly asked Him to remove our shortcomings;
8. Made a list of all persons we had harmed, and became willing to make amends to them all;
9. Made direct amends to such people wherever possible, except when to do so would injure them or others;
10. Continued to take personal inventory and when we were wrong promptly admitted it;
11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out; and
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.
1. Our common welfare should come first; personal recovery depends upon A.A. unity.
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.
3. The only requirement for A.A. membership is a desire to stop drinking.
4. Each group should be autonomous except in matters affecting other groups or A.A. as a whole.
5. Each group has but one primary purpose—to carry its message to the alcoholics who still suffers.
6. An A.A. group ought never endorse, finance, or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose.
7. Every A.A. group ought to be fully self-supporting, declining outside contributions.
8. Alcoholics Anonymous should remain forever non-professional, but our service centers may employ special works.
9. A.A., as such, ought never be organized; but we may create service boards or committees directly responsible to those they serve.
10. Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy.
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.
12. Anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities.
According to Al-Anon’s Twelve Steps and Twelve Traditions (1985), wives would often wait while their husbands were at the early Alcoholics Anonymous meetings. While they waited, they would talk about their problems and struggles. At some point, they decided to try applying the same 12 Steps that their husbands had found so helpful to their own lives, and the group known as Al-Anon was born (Al-Anon’s Twelve Steps and Twelve Traditions, 1985; Doweiko, 1999). In the beginning, each isolated group made whatever changes it felt necessary in the Twelve Steps. By 1948, however, the wife of one of the cofounders of Alcoholics Anonymous became involved in the growing organization, and in time, a uniform family support program emerged. This program, known as the Al-Anon Family Group, borrowed and modified the Alcoholics Anonymous Twelve Steps and Twelve Traditions to make them applicable to the needs of families of alcoholics (Doweiko, 1999).
Co-Dependents Anonymous (CoDA) was founded in 1986 in Phoenix, Arizona, and is a 12-step program that strives for healthy relationships, from a point of departure of codependence on someone with an addiction. CoDA adheres to 12 steps and traditions similar to those of AA. Each group is allowed to function autonomously to meet its own needs, as long as it has no other affiliation except CoDA, and does not affect other groups of CoDA as a whole (CoDA World Fellowship Website, 1998). There are approximately 1,200 CoDA groups in the United States, and it is active in more than 40 countries.
Narcotics Anonymous (NA)
In 1953, a self-help group patterned after AA was founded, and called itself Narcotics Anonymous (NA). Although this group honors its debt to AA, the members of NA feel that:
We follow the same path with only a single exception. Our identification as addicts is all-inclusive in respect to any mood-changing, mind-altering substance. “Alcoholism” is too limited a term for us; our problem is not a specific substance, it is a disease called “addiction.” (Narcotics Anonymous, 1982, p. x).
To the members of NA, it is not the specific chemical that is the problem, but the common disease of addiction. There is an important distinction to be made between AA and NA: The language of AA speaks of alcoholism, whereas NA speaks of “addiction” or “chemicals.” Each offers the same program, with minor variations, to help the addicted person achieve sobriety (Doweiko, 1999).
By 1957, in response to the recognition that teenagers presented special needs and concerns, Alateen was established after modifications to Al-Anon. These members follow the same 12 Steps outlined in the Al-Anon program, but the goal of the program is to provide teenagers the opportunity to share experiences, discuss current problems, learn how to cope more effectively, and offer encouragement to each other (Facts about Alateen, 1969).
Other Support Groups
Rational Recovery (RR) was founded in 1986 by Jack Trimpey, a California licensed clinical social worker, and is a source of counseling, guidance, and direct instruction on self-recovery from addiction to alcohol and other drugs through planned, permanent abstinence. This concept is designed as an alternative to AA and other 12-step programs (“Groups Offer Self-Help,” 1991). The program closely follows the cognitive-behavioral school of counseling, and views alcoholism as reflecting negative, self-defeating thought patterns (Ouimette, Finney, & Moos, 1997). While RR and AA promote abstinence, the programs use different strategies. There are approximately 600 RR groups in the United States (Doweiko, 1999; McCrady & Delaney, 1995).
Rational Recovery (RR) specifically adheres to the following tenets:
· RR does not regard alcoholism as a disease, but rather a voluntary behavior;
· RR discourages adoption of the forever “recovering” drunk persona;
· There are no RR recovery groups;
· Great emphasis is placed on self-efficacy;
· There are no discrete steps and no consideration of religious matters.
Secular Organizations of Sobriety (SOS) was also founded in 1986; Dorsman (1996) estimates that approximately 1,200 SOS groups meet each week in the United States. SOS emerged as a reaction to the heavy emphasis on spirituality found in AA and NA (Doweiko; 1999; “Groups Offer Self-Help,” 1991); the guiding philosophy of SOS stresses personal responsibility and the role of critical thinking in recovery (Doweiko, 1999).
Women for Sobriety (WFS) was founded in 1975 (“Groups Offer Self-Help,” 1991), and McCrady and Delaney (1995) estimate that approximately 325 WFS groups meet in the United States. Doweiko (1999) states that this organization is specifically designed for and comprised of women, and is founded on the theory that the AA program fails to address the very real differences between the meaning of alcoholism for men and women (p. 485). For this group, however, there are 13 statements, not 12.
Women for Sobriety (WFS) is specifically designed for and comprised of women, and is founded on the theory that the AA program fails to address the differences of the meaning of alcoholism between men and women (Lewis, 1994). Additionally, WFS focuses on negative thought patterns, tendencies of guilt, relationships, and spiritual and personal growth. These points are delineated in the Thirteen Statements of Acceptance (Kirkpatrick, 1990; Miller, 2005):
1. I have a life-threatening problem that once had me.
2. Negative thoughts destroy only myself.
3. Happiness is a habit I will develop.
4. Problems bother me only to the degree I permit them to.
5. I am what I think.
6. Life can be ordinary or it can be great.
7. Love can change the course of my world.
8. The fundamental object of life is emotional and spiritual growth.
9. The past is gone forever.
10. All love given returns.
11. Enthusiasm is my daily exercise.
12. I am a competent woman and have much to give life.
13. I am responsible for myself and my actions.
Alcoholics Anonymous for Atheists and Agnostics (Quad A) tends to draw heavily from the traditional Alcoholics Anonymous (Rand, 1995), but with one important distinction: Quad A tends to downplay the emphasis on religion inherent in the traditional AA foundation. In fact, this organization tends to remove the power given to a higher force than the members themselves, instead stressing the forces in the individual’s life that support recovery (Doweiko, 1999).
Moderation Management (MM) was established in 1994 as a free-of-charge, nonprofit support group that welcomes anyone concerned about their drinking, regardless of level of consumption. The founder, Shirley Kishline, states that the goal of MM is to “provide a supportive environment in which people who have made the decision to reduce their drinking can come together and to help each other change” (Kishline, 1996, p. 55). MM is a controversial group because moderation is the goal, not abstinence (Kishline, 1996). MM emphasizes that individuals will be most successful at attaining their goals with alcohol when these goals are chosen by the individual, and proposes that individuals should be responsible for their behavior and can change lifetime habits with a program of support.
National Association for Children of Alcoholics (NACoA) was formed in February 1983 in California, after two groups of professionals from across the country met twice during 1982 to share their concerns, knowledge, and experiences regarding children of alcoholics. One group included clinicians concerned with the needs of adults whose mental health problems stemmed from a childhood in an alcoholic family. The other group included counselors and social workers who primarily worked with young children experiencing a broad range of problems in families with parental alcoholism. The 22 physicians, psychologists, social workers, and educators who attended these meetings concluded that a national membership organization was needed to identify and address the unique problems of children of alcoholics and to provide them with a means through which to voice their concerns (Wenger, 1997). NACOA provides support and information through their confidential telephone, letter and email helpline, and via their Web site.
The Group Process: How 12-Step Groups Work
As with other counseling groups, 12-step addictions groups have established goals for members to work toward, which help them in their main goal of achieving addiction recovery. In a survey of outpatient drug abuse programs (Mejta, Naylor, & Maslar, 1994; Price et al., 1991), the following treatment goals that share similarities with other treatment modalities were identified:
· Abstinence from alcohol and other drugs;
· Steady employment;
· Stable social relationships;
· Positive physical and emotional health;
· Improved spiritual strength; and
· Adherence to legal mandates/requirements as applicable.
It is reasonable to assume that most 12-step groups incorporate these general goals into their general treatment foundation (a noted exception being Moderation Management, as discussed in the previous section), although individual groups differ in membership composition, individual aims and goals, and foundational beliefs. For example, the primary purpose of AA is twofold. Members strive to “carry the message to the addict who still suffers” (The Group, 1976, p. 1) and the organization seeks to provide for its members a program for living without chemicals. Doweiko (1999) notes that this is accomplished by presenting the individual with a simple, truthful, realistic picture of the disease of addiction; and by sharing their life stories, public confession of lies, distortions, self-deceptions, and denial that supported his/her own chemical use (p. 477).
The Twelve Steps and Twelve Traditions
Alcoholics Anonymous pioneered the 12-step model from which most other 12-step groups now operate. Each group of Alcoholics Anonymous is self-supporting, not-for-profit, and is “in cooperation with but not affiliated with” with the professional community (Alcoholics Anonymous World Services, 1991). All Alcoholics Anonymous groups are guided by the Twelve Steps and Twelve Traditions, which serve as a basis for many other groups as well.
Alcoholics Anonymous is not officially associated with any particular religious denomination, political affiliation, or organization, and notes that it “does not discriminate against any prospective member” (Alcoholics Anonymous World Services, 1991, p. 1), including those with addictions other than alcohol; it therefore welcomes nonalcoholics to open meetings. Alcoholics Anonymous does explicitly state, however, that while some professionals refer to alcoholism and drug addiction more generally as substance abuse or chemical dependency, the group makes the clear distinction that only those with alcohol problems are allowed to attend closed meetings (Alcoholics Anonymous World Services, 1991). There are six noted types of 12-step meetings (Miller, 2005); the counselor should be familiar with all types, and should invest time in attending some to gain a better understanding of the powerful dynamics at work:
1. Open meetings generally involve one recovering person speaking to the group about his/her addiction and recovery story. Nonaddicts are invited to attend and listen, and these meetings are generally helpful for those who want to learn more about addiction.
2. Closed meetings involve addicted individuals only.
3. Discussion meetings typically focus on a topic discussed by those addicts in attendance. Note that these meetings are called “participation meetings” in California.
4. In speaker meetings, one addicted person speaks to the audience about his or her addiction and recovery story, and the meeting may be open or closed.
5. In step meetings, the topic for discussion is one of the 12 steps, and these meetings are typically for addicted individuals only.
6. In Big Book meetings, a chapter from Alcoholics Anonymous is read and discussed.
It is important to note that, while the aforementioned Steps and Traditions have been the foundation for many other self-help groups, other groups have diverged due to differences in individual needs or in the belief systems of group members. More attention will be given to this later in the chapter.
Group Dynamics as Applied to 12-Step Groups
There are many different types of groups, as well as many different theoretical approaches to groups. Among the many varieties of group counseling, there is an enormous diversity in format, goals, and roles of the leader (McKay & Paleg, 1992). There are also many ways to select the members of a group. For example, they may be homogeneous by type or by age. There are advantages and disadvantages to every combination (Lawson, Lawson, & Rivers, 2001), and those aspects of diversity, composition, theoretical orientation, base, and foundation all play enormous roles in the outcome of the groups’ efficacy. In their exploration of why certain self-help groups are so effective, Roots and Aanes (1992) identified eight characteristics that seem to contribute to a group’s success:
1. Members have shared experience, in this case their inability to control their drug/alcohol use;
2. Education is the primary goal of Alcoholics Anonymous membership;
3. Self-help groups are self-governing;
4. The group places emphasis on accepting responsibility for one’s behavior;
5. There is but a single purpose to the group;
6. Membership is voluntary;
7. The individual member must make a commitment to personal change; and
8. The group places emphasis on anonymity and confidentiality.
As will be discussed later in this chapter, clinicians often choose to include groups as part of the treatment plan, and make that decision based on the assessed needs of the client and his or her fit with the potential group. Although most treatment programs include both group and individual counseling, Lawson et al. (2001) found that often, it is in a group that the client makes the most progress toward significant therapeutic movement and suggests that as social beings, we are influenced more by a group of people than by just one person for any number of contextual, environmental, or personal reasons.
Twelve-step groups such as Alcoholics Anonymous (AA), Cocaine Anonymous (CA), and Narcotics Anonymous (NA) consider that helping others makes recovery possible. This helping component relies on the exchange of dialogue, reinforcing behavior, and encouraging messages of recovery through efforts modeled by the leader, which then filter throughout the group, often resulting in a successful outcome. Some studies suggest that AA and similar groups help individuals recover through common process mechanisms associated with enhancing self-efficacy, coping skills, and motivation; and by facilitating adaptive social network changes (Kelly, Magill, & Stout, 2009).
The Role of Sponsors in Recovery
Sponsorship reflects the structure of AA and functions on two levels. A sponsor is a more experienced person in recovery who guides the less-experienced “sponsee” through the program (Alcoholics Anonymous World Services, 1991). Level I Sponsorship is concerned with sobriety; the sponsor helps the “sponsee” to become or to stay sober. With Level II Sponsorship, the sponsor counsels the sponsee through the Twelve Steps so that recovery can be achieved (Brown, 1995).
The personal nature of the behavioral issues that lead to seeking help in twelve-step fellowships results in a strong relationship between sponsee and sponsor. As the relationship is based on spiritual principles, it is unique and not generally characterized as a “friendship.” Fundamentally, the sponsor has the single purpose of helping the sponsee recover from the behavioral problem that brought the sufferer into twelve-step work, which reflexively helps the sponsor recover (Twelve Steps and Twelve Traditions, 1981).
The focus of the relationship, for both sponsor and sponsee, is on the Twelve Steps, with the sponsor serving as a guide and facilitator of the recovery process. The AA model encourages a gradual transition from primary dependence on the sponsor to a focus on the process itself. This shift demonstrates increased confidence and courage in the recovering addict working through the Steps, and allows for progress to be qualitatively evaluated by both the sponsor and the sponsee (Brown, 1995; Knack, 2009).
Do 12-Step Programs Really Work?
As already stated, 12-step groups have a long and successful history in the field of chemical dependency treatment. Lawson (2003) found that participation in 12-step groups during and after formal treatment has been associated with positive outcomes among substance users, and Donovan and Wells (2007) found that involvement in 12-step self-help groups, through both attending meetings and engaging in 12-step activities, is associated with reduced substance use and improved outcomes among alcohol- and cocaine-dependent individuals. Not surprisingly, a higher intensity of involvement has been associated with better drinking outcomes (Emrick et al., 1993; Zemore et al., 2004). For example, individuals who are heavier substance users and have more substance-related problems are more likely to affiliate with 12-step self-help groups and less likely to drop out after treatment than less impaired clients (Connors et al., 2001; McKellar, Harris, & Moos, 2009; Tonigan, Bogenschutz, & Miller, 2006). Research also suggests that early 12-step attendance might help to maintain better long-term alcohol abstinence for adolescents aged 13–15 years. Sterling, Chi, Campbell, and Weisner (2009) found that adolescents who attended 10–20 meetings within a period of 6 months had alcohol and drug abstinence rates significantly higher than adolescents who attended fewer meetings.
Other findings have consistently concluded that 12-step participation can enhance treatment outcomes among problem drinkers (Emrick, Tonigan, Montgomery, & Little, 1993; McIntire 2000; Tonigan, Toscova, & Miller, 1996; Zemore, Zaskutas, & Ammon, 2004); and scientific reviews of available data indicate that AA and related 12-step treatments such as Narcotics Anonymous are at least as helpful as other intervention approaches. Likewise, research on Narcotics Anonymous typically supports the efficacy of this approach (Alford, Koehler, & Leonard, 1991; Christo & Franey 1995; Johnsen & Herringer 1993; Kelly, Magill, & Stout, 2009; Toumbourou, Hamilton, U’Ren, Steven-Jones, & Storey, 2002; Zemore et al., 2004).
If this is the case, why run any other type of group? While specific advantages and disadvantages will be discussed later, some of the challenges of self-help groups are addressed here. First, it is unclear just how many people respond to self-help groups. Laudet (2003) suggests that the effectiveness of 12-step groups may be limited by high attrition rates and low participation. It may be safe to assume that some members who attend one or more of these groups do not attend consistently, do not reach group or therapeutic goals, or do not maintain sobriety. By the same measure, it may also be safe to assume that some members of these groups are sober, yet not happy or fully functioning. It is also important to remember that self-help groups are self-selective; because of this, membership consists of people who want to be members and who are willing to follow the guidelines of the group. This may explain the high degree of success reported among members (Lawson et al., 2001).
Although AA has been a social force in the United States for more than half a century, there has been surprisingly little empirical research into what elements of this and other 12-step programs are effective (Emrick et al., 1993), or for what types of people the 12-step model might be most useful (Galanter, Castaneda, & Franco, 1991; George & Tucker, 1996; McCaul & Furst, 1994; Tonigan & Hiller-Sturmhofel, 1994). Laudet, Magura, Cleland, Vogel, and Knight (2003) found that the following characteristics among group members are associated with the greatest long-term group retention, often leading to successful recovery: Older age; more lifetime arrests; more psychiatric symptoms but not taking psychiatric medication; being more troubled by substance abuse than by mental health; having a greater level of self-efficacy for recovery; residing in supported housing; and being enrolled in outpatient treatment at follow-up. And while a study of sponsorship as practiced in Alcoholics Anonymous and Narcotics Anonymous found that providing direction and support to other alcoholics and addicts correlates with sustained abstinence for the sponsor, the study also found that there were few short-term benefits for the sponsee (Crape, Latkin, Laris, & Knownlton, 2002).
Specific Advantages and Disadvantages of 12-Step Groups
There are many advantages to incorporating 12-step groups into treatment. First, as discussed earlier, certain dynamics that can facilitate personal growth are more likely to exist in groups than in individual counseling. Kelly, Magill, and Stout (2009) suggest that AA-related changes occur via intrapersonal, behavioral, and social processes. The group setting offers support for new interaction dynamics, and encourages experimentation and behavioral rehearsal which is useful in generalizing to the world beyond the group. Additionally, they suggest that participants are able to explore their style of relating to others and to learn more effective social skills (Corey & Corey, 1992). AA provides a social outlet for its members. The 12-step group offers a safe, predictable, chemical-free place in which members can learn or relearn important social skills while experiencing a shared sense of purpose and belonging.
Predictability, consistency, universality, the opportunity to build social skills without chemical dependence, and the learning of coping skills are all factors present in self-help groups that lead to effective outcomes. There is a re-creation of the everyday world in some groups, particularly if the membership is diverse (Corey & Corey, 1992). The 12-step group allows its members to recognize that their problems are not unique, and members have the opportunity to learn about themselves through the experience of others; to experience emotional closeness and caring that encourage meaningful disclosure of the self; and to identify with the struggles of other members. This universality normalizes the recovery experience.
Another primary strength may lie in a group’s ability to provide free, long-term, easy access and exposure to recovery-related common therapeutic elements (Kelly, Magill, & Stout, 2009). Lawson et al. (2001) suggests that economically, groups are a logical choice because a counselor can see approximately three times the number of clients in groups than in individual counseling. For counselors, this is an important point; incorporating self-help groups into treatment helps clients build skill that would be fundamentally lacking in individual sessions, and counselors who engage themselves in the self-help group process as leaders (if the group allows this) have the opportunity to reach a greater number of clients in single sessions.
For many addicted clients, economic concerns far outweigh the potential benefits of treatment, especially among culturally diverse, minority, and marginalized populations. Self-help groups offer a free opportunity to achieve treatment goals; Tonigan et al. (1996) found that affiliation with 12-step groups such as AA and NA, both during and after treatment, was identified both as a cost-effective and useful approach to promoting abstinence among persons experiencing alcohol- and other drug-related problems. Additionally, meetings are often held at multiple locations and times in order to reach a wider client base, so clients have frequent, regular opportunities to attend meetings between individual counseling sessions.
While there are numerous advantages to self-help groups, there are significant disadvantages as well. Laudet and White (2005) point counselors to the lack of consistent empirical support for their effectiveness, as well as a general lack of trained professionalism (e.g., groups that are not led by counselors); the risk that members may become overly dependent on the group; that members may, and sometimes do, get bad advice from other group members; and that the usefulness of these groups is limited in time (i.e., only needed in early recovery) or in scope (i.e., deals with only one substance while some clients have multiple issues). Certainly, the boundaries of any group are dependent upon the amount of structure present, and that structure is dependent upon the ability of members to provide the necessary motivation and commitment to keep the group operating. Without appropriate modeling from a trained professional, there is the risk that boundaries will be violated and structure will be lacking, and harm or attrition may result. Further, addictions are often superficial, albeit damaging, problems. Clients with addictions may engage in replacing one problem symptom for another, without ever confronting or challenging the real issue(s) beyond the group process.
Lawson et al. (2001) also note that there is often a subtle pressure to conform to group norms, values, and expectations. Participants sometimes unquestioningly substitute a groups’ values and norms for those they had unquestioningly acquired in the first place. In other words, members may be susceptible to replacing detrimental values, norms, and even behaviors with equally detrimental ones exhibited and observed in the group. This is especially salient when referring clients with possible Axis II disorders; clients may choose to abandon the chemical for a similar dependence on an observed behavior, an adopted value, or even another individual.
Hence, not all people are suited to all groups. The screening process for self-help groups is limited, and in most cases, especially in open groups, non-existent. Some individuals are inappropriate for groups (e.g., too suspicious, too hostile, or too fragile) and do not benefit from a group experience. As a result, some individuals are psychologically damaged by attending certain groups. Inevitably, some make the group a place to ventilate their miseries and be rewarded for their engagement in the catharsis process. Others use groups as vehicles for expressing their woes, in the hope that they will be understood and totally accepted, and make no attempt to actually effect substantial change in their lives (Lawson et al., 2001). Before an individual is referred to a group, all these factors need to be carefully weighed by both the counselor and the client, to increase the likelihood that the person will benefit from the self-help group experience.
An even stronger point of resistance to the incorporation of self-help groups into treatment by counselors is based on the fact that many groups operate from a foundation of Christianity. 12-step literature explicitly encourages helping as part of the recovery process, a point reinforced dramatically by Alcoholics Anonymous’ twelfth step: ‘having had a spiritual awakening as a result of these steps, we tried to carry this message to other alcoholics, and to practice these principles in all our affairs’ (Alcoholics Anonymous World Services (1991), as cited in Zemore, Zaskutas, and Ammon, 2004). Twelve-step groups have been historically controversial for this very reason, and several aspects of the recovery program have been identified as potential stumbling blocks for both substance users and clinicians (Chappel & DuPont, 1999; Laudet, 2000). This is due to a multiplicity of factors, and a main criticism includes the lack of cultural sensitivity inherent in the foundation of many groups. Further, Davis and Jansen (1998) suggest that the [twelve-step model’s] emphasis on spirituality, surrender, and powerlessness contradicts contemporary dominant western cultural norms of self-reliance and widespread secularism.
It is important for counselors to be culturally sensitive and aware of the predominantly white, middle-strata, male-defined view of addictions upon which most 12-step programs are founded. Heyward (1992) suggests that for women in particular, it is difficult to listen to religious language which may be interpreted as sexist from a dominant cultural standpoint. Further, the reliance on external support, and particularly on spiritual support as one of the cornerstones of the 12-step program, has been identified as a potential point of resistance to these organizations from certain ethnic groups (Laudet, 2003; Peteet, 1993; Smith, Buxton, Bilal, & Seymour, 1993). Bell (1993) suggests that African-American clients, for example, as well as people in other nondominant cultures, tend to see addiction issues as secondary to such problems as illiteracy, racism, and poverty. The reliance on the spiritual component of the group, therefore, may not be as relevant—and not as helpful—when considering the hierarchy of immediate needs of nondominant groups.