Following a model laid out by Alcoholics Anonymous (AA) in the 1930s, 12-step programs and support groups have become a mainstay of addiction treatment, helping people tackle dependencies on everything from drugs to overeating to sex. But while they’re ubiquitous, 12-step programs aren’t universally accepted: studies of their effectiveness are limited and equivocal and for many people, they won’t be the best, or only, path to abstinence.
What are 12-step programs?
12-step programs are peer-led mutual support groups for people seeking to overcome addiction or other harmful behaviors, modeled on Alcoholics Anonymous (AA).
They center around a 12-step journey, as the participant confronts their addiction and its damaging effects on their life, surrenders to a God or another higher power atones for the harm they’ve caused others, learns to live by a new code of behavior, and commits themselves to serve others struggling with the same addiction.[1]
Related: The 1st step of AA
Participants are guided through these steps and held accountable at free, anonymous, and confidential meetings. At these meetings, attendees share their experiences of addiction and recovery, while others listen, and learn about the 12 steps of the program. Thousands of these meetings are held weekly worldwide, at community centers, libraries, churches, prisons, and online.[2]
A sponsor also assists participants, someone who has walked the path to recovery before them and can be a confidant, teacher, and source of accountability.[3]
What 12-step programs are available?
The 12-step formula has been applied to more than 300 addictions and psychological disorders.[4]
Among the most prominent are:[5]
- Narcotics Anonymous (NA): for addictions to substances of abuse besides alcohol
- Cocaine Anonymous
- Marijuana Anonymous
- Gamblers Anonymous
- Sex Addicts Anonymous
- Overeats Anonymous
- Debtors Anonymous
- Al-Anon: for the family and friends of alcoholics
- Nar-Anon: for the family and friends of drug addicts
Why are 12-step programs so popular?
The government’s 2021 National Survey on Drug Use and Health found that two million individuals had attended self-help groups, many of them 12-step programs, for substance abuse in the previous year, making it the most popular venue to receive addiction treatment.[6]
Alcoholics Anonymous says it has 65,000 groups meeting regularly in the U.S., and a total of 2 million members convening at 120,000 meetings worldwide.[7] Narcotics Anonymous says it hosts 70,000 meetings in 144 countries.[8]
National surveys have found that 72% of addiction treatment facilities employ 12-step programs to some extent.[9]
The immense popularity of 12-step programs has been attributed to their accessibility and low barrier of entry, their no-cost model, their rooting in the community, and their promise of anonymity and confidentiality.[10] People who may not have the resources or confidence to seek out professional treatment, or may be too ashamed to do so, can discretely attend meetings and begin their 12-step journey. Even in recovery, many people continue to regularly attend meetings, seeking out a sober community and accountability.
These advantages have made 12-step programs the default answer to drug addiction in some communities. However, they’re not a cure-all, and may not be the answer, or the only answer, for some people facing addiction.
Are 12-step programs effective?
Research into the efficacy of 12-step programs has long been hampered by the program’s closely-guarded confidentiality and by selection bias: the people who stay in AA and participate in the studies are the ones who find the model helpful. The studies that have been performed show ambiguous results.
A 2020 review of 27 studies of Alcoholics Anonymous, covering more than 10,000 participants, found that “clinically delivered and manualized” 12-step programs can lead to higher rates of continuous abstinence than other treatment approaches including cognitive behavioral therapy (CBT) and motivational interviewing. Overall, 42% of AA participants were completely abstinent one year later, compared to 35% who had received CBT. The review also found that AA might perform just as well as other treatment approaches at reducing drinking intensity, negative alcohol-related consequences, and the severity of addiction, and at a lower cost.[11][12] However, it distinguished peer-led groups and 12-step facilitation, where the program is delivered by a professional, and found the latter superior.
Additionally, the authors of the review were reluctant to attribute AA success to anything embedded in the 12-step program itself and said the benefit may come chiefly from its creation of a sober community for recovering addicts. “I don’t think it’s something unique to AA, as if it’s got some sort of magic,” John Kelly, a Harvard researcher who led the review, told Vox. “It’s rather that the magic of AA is that it’s everywhere and mobilizes these therapeutic mechanisms in a very strong, socially supportive network of recovery support.”[13]
Evidence is sparser for other applications of the 12-step model. A 2017 systemic review of 12-step programs found that they’re no better or worse than other psychosocial interventions, including CBT, dialectical behavioral therapy (DBT), and motivational interviewing, at preventing illicit drug use.[14]
A 1999 longitudinal study tracked participants in AA and NA for 24 months and found a strong correlation between continuing to attend meetings and staying abstinent. At 24 months, 77% of the participants still attending NA meetings at least once weekly reported being clean, compared to 63% of dropouts and 48% of people who’d never attended.[15]
However, dropout rates are consistently high across 12-step programs. Alcoholics Anonymous has a reported dropout rate of over 50% in the first three months and by some accounts, just 13% of initial attendees will stick with the program for the long haul.[15][16]
The upshot? 12-step programs can work for a self-selecting group, who continue to attend meetings. But they’re not a good fit or effective for others.
Anecdotally, researchers say that there’s often a “rule of thirds” that applies to AA and similar programs. One-third of participants will reach sustainable recovery through AA, another third will derive some benefit from it but need other interventions, while the remaining group won’t be helped at all.[13]
Why aren’t 12-step programs a good fit for some people?
12-step programs aren’t a fit for everyone. While some people may be able to get sober through a 12-step program alone, for most people these self-help groups form just one part of a wider treatment plan that includes professional therapy, medication, and detoxication.
12-step programs might not be the answer—or at least not the only answer—for you if:
- Need to detox: Withdrawing from some substances, such as alcohol and opioids, can be uncomfortable and even life-threatening and may need to be done under medical supervision, such as in a hospital or detox facility. When you’ve safely medically detoxed, a 12-step program might then be appropriate.
- Are put off by spirituality: Spirituality suffuses 12-step programs. In one step, participants turn to God and ask to be freed from their addiction. Although many people substitute a different deity or an unspecified higher power for God, some people are alienated by religiosity.
- Have co-occurring mental health conditions, which require counseling from a professional and medication. For many people, mental health conditions and addiction are closely intertwined and sobriety is difficult to sustain unless they tackle the underlying issue (eg. anxiety, depression, PTSD).
- Want to use medication-assisted treatment (MAT), such as disulfiram (Antabuse) for alcoholism or methadone or buprenorphine for opioid abuse. AA and NA don’t have official positions on medication-assisted treatment and let autonomous groups set their own policies. But in some groups, the use of MAT is frowned upon, despite the enormous help it can offer.
What are the alternatives to 12-step programs?
If you didn’t like the format of a 12-step meeting or couldn’t get sober through meetings alone, don’t despair. There are many paths to recovery. These include:
- Therapy from a professional, such as CBT, dialectical behavior therapy (DBT), psychodynamic therapy, etc.
- Medication, such as disulfiram and naltrexone for alcoholism, and methadone and buprenorphine for opioid use disorder
- Medical detoxification
- Support groups following other models, such as SMART Recovery
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