How Treatment Coopts 12-Step Practices
Last week's review of Rehab: An American Scandal brought us to a topic I was already considering for a post: the relationship between 12-step groups and substance use treatment.
As I wrote, the 12-step model is unworkable for many people, and has problems both in theory (such as the imperative to believe in a higher power) and in practice (such as meetings or communities that are only safe for certain people). Critics of the treatment industry are right to complain that so many facilities are 12-step-based, as it leaves few options for people seeking something different. Treatment facilities may also introduce and refer patients to 12-step meetings without presenting any of the other (spiritual or secular) forms of peer support available for substance use issues. Such options include LifeRing, Recovery Dharma, SMART Recovery, Women For Sobriety, Celebrate Recovery, Moderation Management, and SOS (a network of secular groups).
I believe an additional factor making 12-step groups look bad, however, is how the treatment industry has coopted their ideas. Cooptation, in this case, means that a concept or practice that treatment facility managers wanted to use anyway (for their own purposes) gets dressed up in language from the recovery community. The actual concept or practice gets fundamentally corrupted from its 12-step form, but the veneer of recovery wisdom makes it harder to argue with.
Two basic elements on which the treatment industry relies– coercion and financial optimization– have absolutely no place in 12-step life. 12-step literature is clear that no one can be forced into recovery and that all the program's necessary funds come from members' own voluntary contributions. Thus wherever 12-step ideas are invoked with a backdrop of forcing patients through treatment or making (or saving) money for the facility, I see cooptation.
Specific examples:
1) Identification as having a "disease" or being an addict/alcoholic. In 12-step culture, this must be done by each individual for themselves. In treatment, however, patients have to submit to a disease label that is determined for them by a professional authority. And from there, anything they do or say may be attributed to this essential, immutable quality of being addicted.
2) The group format. Facilities providing all treatment in groups is about efficiency, period. But they can point to AA as the original group model and claim that patients' support for each other is more valuable than individual counseling. Meaningful support and healing relationships certainly can occur in group treatment; I've seen it. But the fact is that many patients would prefer individual counseling (and, in my opinion, would benefit more from individual as well). They simply cannot have it.
Rosalie Genova
3) Moral inventory and consultation. A foundation in step work is the "searching and fearless moral inventory" of one's own conduct (step 4). Following that, members practice taking accountability and making direct amends for harm done. This process may repeat in small daily inventories or by completing the 12 steps many times over a lifetime.
Feedback from others, particularly one's program sponsor (a peer mentor in recovery) is another essential mechanism of accountability. Hands-on, no-bullshit sponsors are in high demand; the most common trait patients tell me they want in a sponsor is one who will proactively "call them out" when necessary.
But 4th step inventories are voluntary, and sponsors are freely chosen (and can be freely fired). No money is changing hands. This is a far cry from treatment, which involves little to no choice in programming or providers. Practices of "confrontation" often amount to shaming, and are done by people whose feedback the patient never necessarily wanted.
Concepts of peer support and mutual aid. 12-step groups are longstanding, largely successful examples of both. Peer support involves people with shared lived experience (in this case, experience of addiction) supporting each other, as opposed to professional intervention. Mutual aid is likewise non-hierarchical, with peers providing each other various forms of assistance, as opposed to "charity" or "philanthropy" models that privilege givers over receivers.
This is the form of cooptation that most appalled me when I worked in treatment centers. When patient needs arose that the facility wasn't going to meet, managers claimed patients should meet these needs for each other– you know, "peer support"! "Mutual aid"! One example was concerns about physical safety in our facility. My supervisor said we should assume some patient or other would step up to protect everyone else in the event of violence. Another example was people using substances on premises or arriving intoxicated. When patients expressed a wish for a sober environment, managers told me those patients should see themselves as mentors or role models to their actively using peers. Again, concepts that were developed for a free, all-voluntary program are being deployed in professionalized, billed treatment that is often mandatory.
Again, I agree with most of the criticisms of 12-step practice pervading substance use treatment. Patients should have more options both in treatment approach and referrals to peer support. But 12-step practices are actually much more person-centered than most addiction treatment. When we look past what treatment passes off as 12-step, we see what these programs and communities really have to offer.
