A twelve-step program is a set of guiding principles outlining a course of action for recovery from addiction, compulsion, or other behavioral problems. Originally proposed by Alcoholics Anonymous (AA) as a method of recovery from alcoholism,^[1] the Twelve Steps were first published in the book, Alcoholics Anonymous: The Story of How More Than One Hundred Men Have Recovered From Alcoholism in 1939.^[2] The method was then adapted and became the foundation of other twelve-step programs such as Narcotics Anonymous, Overeaters Anonymous, Co-Dependents Anonymous and Debtors Anonymous. As summarized by the American Psychological Association, the process involves the following:^[1]

• admitting that one cannot control one's addiction or compulsion;
• recognizing a greater power that can give strength;
• examining past errors with the help of a sponsor (experienced member);
• making amends for these errors;
• learning to live a new life with a new code of behavior;
• helping others that suffer from the same addictions or compulsions.

Overview

Twelve-step methods have been adopted to address a wide range of substance abuse and dependency problems. Over 200 self-help organizations–often known as fellowships–with a worldwide membership of millions, now employ twelve-step principles for recovery. Narcotics Anonymous was formed by addicts who did not relate to the specifics of alcohol dependency.^[3] Similar demographic preferences related to the addicts' drug of choice has led to the creation of Cocaine Anonymous, Crystal Meth Anonymous and Marijuana Anonymous. Behavioral issues such as compulsion for, and/or addiction to, gambling, food, sex, hoarding, debting and work are addressed in fellowships such as Gamblers Anonymous, Overeaters Anonymous, Sexual Compulsives Anonymous, Clutterers Anonymous, Debtors Anonymous and Workaholics Anonymous. Auxiliary groups such as Al-Anon and Nar-Anon, for friends and family members of alcoholics and addicts, respectively, are part of a response to treating addiction as a disease that is enabled by family systems.^[4]

 History

Alcoholics Anonymous (AA), the first twelve-step fellowship, was founded in 1935 by Bill Wilson and Dr. Bob Smith, known to AA members as "Bill W." and "Dr. Bob", in Akron, Ohio. They established the tradition within the "anonymous" twelve-step programs of using only first names "at the level of press, radio and film."^[5]

As AA was growing in the 1930s and 1940s, definite guiding principles began to emerge as the Twelve Traditions. A Singleness of purpose emerged as Tradition Five: "Each group has but one primary purpose -- to carry its message to the alcoholic who still suffers."^[6] Consequently, drug addicts who do not suffer from the specifics of alcoholism involved in AA hoping for recovery technically are not welcome in "closed" meetings unless they have a desire to stop drinking alcohol.^[7] The reason for such emphasis on alcoholism as the problem is to overcome denial and distraction. Thus the principles of AA have been used to form many numbers of other fellowships for those recovering from various pathologies, each of which in turn emphasizes recovery from the specific malady which brought the sufferer into the fellowship.^[8]

In 1953 AA gave permission for Narcotics Anonymous to use its Steps and Traditions.^[9]

 Twelve Steps

These are the original Twelve Steps as published by Alcoholics Anonymous:^[10]

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.
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.

In some cases, where other twelve-step groups have adapted the AA steps as guiding principles, they have been altered to emphasize principles important to those particular fellowships, to remove gender-biased or specific religious language.^[11][12][13]

Twelve Traditions

The Twelve Traditions accompany the Twelve Steps, the Traditions provide guidelines for group governance. They were developed in AA in order to help resolve conflicts in the areas of publicity, religion and finances.^[14] Most twelve-step fellowships have adopted these principles for their structural governance.^[15] The Twelve Traditions of Alcoholics Anonymous are as follows.^[5]

1. Our common welfare should come first; personal recovery depends upon AA 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 AA membership is a desire to stop drinking.
4. Each group should be autonomous except in matters affecting other groups or AA as a whole.
5. Each group has but one primary purpose—to carry its message to the alcoholic who still suffers.
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.
7. Every AA 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 workers.
9. AA, 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 AA 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.

 Process

In the twelve-step program human structure is symbolically represented in three dimensions: physical, mental, and spiritual. The problems the groups deal with are understood to manifest themselves in each dimension. For addicts and alcoholics the physical dimension is best described by the allergy-like bodily reaction resulting in the compulsion to continue using substances after the initial use. For groups not related to substance abuse this physical manifestation could be more varied including, but not limited to: compulsive hoarding, distractibility, eating disorders, dysfunctional enabling, hyperactivity, hypomania, insomnia, irritability, lack of motivation, laziness, mania, panic attacks, psychosomatic illnesses, poor impulse control, procrastination, self-injury and suicide attempts.^[16][17] The statement in the First Step that the individual is "powerless" over the substance-abuse related behavior at issue refers to the lack of control over this compulsion, which persists despite any negative consequences that may be endured as a result.^[18]

The mental obsession is described as the cognitive processes that causes the individual to repeat the compulsive behavior after some period of abstinence, either knowing that the result will be an inability to stop or operating under the delusion that the result will be different. The description in the First Step of the life of the alcoholic or addict as "unmanageable" refers to the lack of choice that the mind of the addict or alcoholic affords concerning whether to drink or use again.^[19]

The illness of the spiritual dimension, or "spiritual malady," is considered in all twelve-step groups to be self-centeredness. This model is not intended to be a scientific explanation, it is only a perspective that twelve-step organizations have found useful.^[16][17] The process of working the steps is intended to replace self-centeredness with a growing moral consciousness and a willingness for self-sacrifice and unselfish constructive action.^[17] In twelve-step groups, this is known as a spiritual awakening or religious experience.^[20] This should not be confused with abreaction, which produces dramatic, but ephemeral, changes.^[21] In twelve-step fellowships, "spiritual awakening" is believed to develop, most frequently, slowly over a period of time.^[22]

It is suggested that members regularly attend meetings with other members who share their particular recovery problem. In accordance with the First Step, twelve-step groups emphasize self-admission by members of the problem they are recovering from. It is in this spirit that members often identify themselves along with an admission of their problem, e.g. "Hi, I'm Wendy and I'm an alcoholic." Such catchphrases are now widely associated with support groups. Some meetings are known as dual-identity groups, which encourage attendance from certain demographics, so that some areas have for example, women's groups; men's groups; and gay, lesbian, transgendered groups. There are also in some areas beginner's groups as well as "old-timer" groups that limit who can share, or speak during the meeting, by the length of time the members have in that fellowship.^{[citation needed]}

 Sponsorship

A sponsor is a more experienced person in recovery who guides the less-experienced aspirant ("sponsee" or variously, "sponsoree") through the program. New members in twelve-step programs are encouraged to secure a relationship with at least one sponsor.^[23] Publications from twelve-step fellowships emphasize that sponsorship is a "one on one" relationship of shared experiences focused on working the Twelve Steps.^[24][25][26] According to Narcotics Anonymous:

Sponsors share their experience, strength, and hope with their sponsees... A sponsor's role is not that of a legal adviser, a banker, a parent, a marriage counselor, or a social worker. Nor is a sponsor a therapist offering some sort of professional advice. A sponsor is simply another addict in recovery who is willing to share his or her journey through the Twelve Steps.^[27]

Sponsors and sponsees participate in activities that lead to spiritual growth. These may include practices such as literature discussion and study, meditation, and writing. Completing the Twelve Steps implies being competent to sponsor to newcomers in recovery.^[23] Sponsees typically do their Fifth Step, review their moral inventory written as part of the Fourth Step, with their sponsor. The Fifth Step, as well as the Ninth Step, have been compared to confession and penitence. Many, such as Michel Foucault, noted such practices produce intrinsic modifications in the person—exonerating, redeeming and purifying them—it unburdens them of their wrongs, liberates them, and promises their salvation.^[28]

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 "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.^[23]

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, but that there were few short-term benefits for the sponsee.^[29][30]

Effectiveness

Alcoholics Anonymous is the largest of all the twelve-step programs, followed by Narcotics Anonymous; the majority of twelve-step members are recovering from addiction to drugs or alcohol. The majority of twelve-step programs, however, address illnesses other than addiction. For example, the third largest twelve-step program, Al-Anon, treats codependence. About twenty percent of twelve-step programs are for addiction recovery, the other eighty percent address a variety of problems from debt to depression.^[31] It would be an error to assume the effectiveness of twelve-step methods at treating problems in one domain translates to all or to another domain,^[32] therefore readers are directed to relevant sections in each group's article.

 Criticism

The criticisms of twelve-step groups are as varied as the pathologies they address. People have attended twelve-step meetings, only to find success eluded them. Their varied success rate and the belief in a Higher Power suggested in them, are common criticisms of their universal applicability and efficacy.^[33]

Confidentiality

The Twelve Traditions encourage members to practice the spiritual principle of anonymity in the public media and members are also asked to respect each other's confidentiality. However, the programs rely on 'obedience to the unenforceable' and there are no legal consequences or sanctions within the program to discourage those attending twelve-step groups from revealing information disclosed during meetings. Statutes on group therapy do not encompass those associations that lack a professional therapist or clergyman to whom confidentiality and privilege might apply. Physicians who refer patients to these groups, to avoid both civil liability and licensure problems, have been advised that they should alert their patients that, at any time, their statements made in working through the Twelve Steps might be disclosed.^[34]