Do the 12 Steps Belong in Addiction Treatment?
Spiritual programs like AA have long served as the mainstay of addiction treatment. So have people who are recovery successes. That's the problem.
A friend recently asked what I’ve got against spirituality in addiction treatment, citing my opposition to the inclusion of 12-step work in rehab and my insistence that medical experts—not people in recovery—be in charge of addiction care that gets insurance or government reimbursement. He asked: do I think that the existential need for meaning and purpose plays no part in addictions? And why do I deny the importance of recovering people to the field?
My answer is complicated. I certainly believe that recovery for many people is a spiritual experience and that treatment often fails because people cannot find a way to have a meaningful or even bearable life without drugs. My own recovery certainly felt like a spiritual rebirth: I was in awe of how close I’d come to death and my physical turnaround alone seemed like a miracle.
The support I got from other recovering people in 12-step groups truly felt like God’s grace. Going from being an 80-pound wreck dotted with tracks to a healthy young woman whom no one would believe had once been very ill was as extreme a change as reliving puberty, far stranger and more mystifying than any psychedelic trip I’d ever taken.
However, I am extremely uncomfortable with attempts by treatment providers to force particular visions of spirituality—often explicitly religious ones—on patients, especially those who are coerced into the treatment system. While 12 step–based programs like Hazelden, the Caron Foundation and Betty Ford Center aren’t explicitly religious, the word God remains in the steps, complete with His male pronouns and implicit Christianity, which is often made explicit in sharing by patients and even discussions by counselors of their own paths. The idea that spirituality is the only way to meaning is also troubling.
If you allow people to use treatment to teach the 12 Steps, why not Christianity, Islam, Judaism, Scientology or the Great Spaghetti Monster?
The problem is this: if you allow people to use treatment to teach the 12 Steps—which, according to every state Supreme court that has ever looked at the question, is unconstitutional because the program is deemed religious—why not Christianity, Islam, Judaism, Buddhism, Scientology or the Great Spaghetti Monster? And if addiction really is a disease, why is it the only one where having it makes you qualified to treat it?
For no other medical disorder is meeting and praying considered reimbursable treatment: if a doctor recommended these religious or spiritual practices for the primary treatment of cancer or depression, you would be able to sue successfully for malpractice. Similarly, people who have those medical conditions and recover from them may have valuable experience and information to share. But they have not graduated from medical school and would never escape legal scrutiny if they decided to set up a medical practice.
Given that, I think that professional treatment that is covered under Obamacare or any other insurance system should be exactly that: professional. The historical isolation of addiction from the rest of mental health care, and from the health care system in general, results from stigma—and reinforces it. Integrated treatment requires practitioners who know about far more than addiction and addiction counseling.
All of this said, I do think that recovering people have a critical role to play in the field and that being in a community of people who have overcome addictions offers a powerful source of hope and support. Referral to 12-step or other support groups, encouragement of such attendance, providing information about what to expect and even having such meetings available on-site for those who wish to attend is helpful, not problematic. I certainly found inspiration in hearing people who’d successfully climbed Mt. Recovery before me.
However, I don’t think people should get paid to essentially act as sponsors who indoctrinate people in the 12-step belief system: not only does this violate AA’s traditions, it also winds up making patients pay for self-help knowledge they could get for free. Neither treatment nor the 12-step community is improved by this conflict of interest.
Nonetheless, because recovering people can serve as such powerful role models, I do think they should be given special help to overcome educational barriers that might otherwise prevent them from getting properly qualified to work in the field. I also think that recovering people who get those qualifications should be given preference in hiring over those without such experience: we want the enthusiasm and passion that comes with good recovery. If their only knowledge is of getting better through one self-help path, however, it’s unfair to patients or insurers to pay such people as counselors, except perhaps in well-defined situations where it is made clear that this is their only source of authority.
When we emphasize addiction as a uniquely spiritual problem, we reinforce the idea that it’s not a medical issue but, in fact, a sin.
Nor do I think discussions of spirituality have any more place in professional addiction treatment than they do in psychological counseling for depression or other disorders. If someone wants to explore their relationship with a higher power, there are plenty of places outside the medical system that can help with that, again, for free and without constitutional issues of separation of church and state. As in cancer care or in hospices, pastoral care should be an adjunct to treatment for those who want it, not a substitute or requirement.
Of course, with data increasingly showing that meditation and exercise can be effective in dealing with multiple psychological problems, I see nothing wrong with programs that incorporate these powerful tools into treatment: indeed, I think they should be encouraged. Still, I don’t think that addiction should be seen as a “special case” where spirituality is any more essential to recovery than it is for other conditions. We need to recognize that not all healing is medical: some of the most potent spurs to health are social. But when friends are the best medicine, we shouldn’t have to pay for them.
Like depression, addiction can be a response to an existential crisis, and treatment providers need to empower addicted people to find ways to make a meaningful life for themselves. To recover from either problem, finding a purpose—whether through relationships, work, altruism or, yes, spirituality and religion—is often critical. That, however, can only come from within each individual, often through a network of social ties. Attempts to impose it via a treatment system are too often counterproductive, intrusive, offensive or all three.
Finally, when we emphasize addiction as a uniquely spiritual problem, I think we not only subtly reinforce the idea that it’s not a medical issue, but, in fact, suggest that it is a sin. The health care system is no place to enforce morality: to protect both spirituality and addiction care, I think we need to keep God or whatever higher power we choose (or don’t choose) outside of formalized treatment and within our own personal belief and support systems.
Maia Szalavitz writes the biweekly "On the Contrary" column and a new advice column, "Ask Maia," for The Fix. She is also a health reporter at Time magazine online, and the co-author of four other books on subjects ranging from empathy to polygamy.