12-Step Facilitation is the eighth most frequently used therapeutic approach in treatment facilities

~ Jason Schwartz

There are a lot of problems in addiction treatment, but 12-step hegemony is not the problem that advocates and media coverage would lead one to believe.

There’s a widely held belief that 12-step culture exerts a smothering pro-abstinence stranglehold on public health and policy responses to substance use. It’s a strange phenomenon when one considers that AA explicitly endorses moderation for people who are able to do so, cannabis is being legalized and commercialized, alcohol consumption is up in recent years, experiments with decriminalization, the spread of public health campaigns that depart from the tobacco abstinence messages with new messages about safe fentanyl use, and that the most visible public health responses to the opioid crisis are efforts to flood the zone with naloxone and low threshold buprenorphine.

Further, 12 step isn’t even a hegemonic force in the treatment space. The 2020 National Survey of Substance Abuse Treatment Services found 12-step facilitation to rank 8th out of 14 therapeutic approaches. (Keep in mind that 12-step facilitation is an evidence-based treatment.)

It’s worth asking why this is so frequently misrepresented.

National Survey of Substance Abuse Treatment Services (N-SSATS): 2020

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Published by Jason Schwartz

I have been an addiction professional and social worker since 1994. I started blogging in 2005 as the Clinical Director at Dawn Farm. I currently serve as the Director of Social Work and Spiritual Care for a healthcare system. I've also served as the Director of Behavioral Health at another hospital. I'm also a lecturer at Eastern Michigan University’s School of Social Work. Views expressed here are my own. Keep in mind that the field, the contexts in which the field operates, and my views have changed over time.

7 thoughts on “12-Step Facilitation is the eighth most frequently used therapeutic approach in treatment facilities”

  1. Jason- loved your key points-
    I so agree- lots of mixed messages-
    I didn’t know 12 step facilitation was
    an EBT
    Thanks and keep up the critical thinking-
    Bob

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  2. I’ve been in the Addicition Medicine (yes, I still call it that) field for over 32 years and yes, I provide 12-Step Facilitation (along with other Therapeutic approaches) AND I’m also abstinence based. For years now all I will have to do is state that I’m a 12-Step guy AND/OR I’m an abstinence based guy and I usually will get. “Oh, you’re one of those…” It’s not being said as a compliment. I would venture to say that many would not agree with or know that 12-Step facilitaion is an EBT. In all those years only one other Clinician has even asked me what I meant by “abstinence based” (a Doc working in a MAT Clinic.) I stated what I mean by that is no mood altering substances except for those medications that are properly prescribed, taken, and monitored by a an appropriate Healthcare Provider. I added, if the person served is not looking for that approach, determined on initial contact, I refer them to a local provider that is more in alignment to what they are looking for. If they don’t know what they are looking for, I will discuss it with them. The response I got back from said Doc was “Oh, that’s our protocols for providing MAT and what we do on initial contact too.” Nobody, and I mean nobody, has ever asks what is 12-Step Facilitation. Most of the rest usually just frown and walk away. Some feel a need to call me names such as dinosaur or criminal. I have no idea if they even know what 12-Facilitaion is. I just know that they apparently have an opinion on it. My other guess is that many think that abstinence based equals anti mediciations. Hard to do before Hip Surgery….

    Respectfully,

    Don Mrdjenovic, CADC, CCS

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  3. TSF is a manualized protocol. In my 36 years I’ve met almost zero addiction counselors that ever used the protocol or had any familiarity with it. Or even knew where or how to get a copy of the manual if they were so inclined.

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  4. I’ve come to understand the perception of 12-step being hegemonic not as a function of the literature or its actual use in treatment (i.e., TSF) but as a reaction to other forces prevalent in both 12-step and treatment. These are forces of exclusion, and while they are not likely any more predominant in 12-step or TSF than in society at large, people with addiction are at their most vulnerable when looking for help. Exclusionary forces are numerous, but one of those that lead to this perception is worth noting. The most influential would be the attitude, still prevalent in addiction treatment and 12-step, that if the person with an addiction has a disease that is incurable and if they don’t do what they are told, they are damned to an infinite cycle of relapse and death. This is a deficit-based approach and is simply not true; most people recover, and most recover without treatment or 12-step. Granted, people with higher chronicity and severity are more likely to benefit from both treatment and 12-step, but they are also the most vulnerable. In my research and clinical observations, people thinking about treatment or entering into 12-step programs are often met with this attitude- that the person’s strengths and inherent resiliency are irrelevant to their potential for success. We can imagine, therefore, how people who are intersectionally marginalized at multiple levels might experience this phenomenon as hegemonic — because it is the dominant belief of society at large. Until all treatments and 12-step shift to a predominantly strengths-based approach, they will continue to be associated with the idea that people are lacking, unworthy, and flawed, which naturally makes people feel as if they are in a struggle against a hegemonic force–because they are, it’s just not the prevalence of 12-step but rather the prevalence of the attitude that some are flawed and unwilling and that there is only way to recover.

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    1. I’m not sure what I think about this. I’ll have to sit on it. There’s a lot in your comment.

      There’s no doubt that one-way-ism exists in 12-step and in treatment. I don’t know how prevalent that is but it’s not the norm in my experience.

      Are 12-step groups exclusive? Yes. The offer a particular pathway to a particular destination for a particular problem. NA’s existence is due to AA’s decision to exclude primary problems other than alcoholism.

      They don’t profess to be the only way or the solution to all problems. In fact, AA explicitly endorses moderation for those able to achieve it. I’ve seen people be jerks but I’ve seen a lot more people be relentlessly supportive with people who struggle. Are there deficit-based messages? Yes. But there are also a lot of strength-based messages about their importance, their capacity for service, their capacity for growth and success, the mutual need between old-timers and newcomers, etc.

      There is also one-way-ism among professionals but, as you indicate, it’s not confined to providers who default to facilitating 12-step involvement.

      I see peers whose personal recovery is in 12-step get accused of being closed-minded and insufficiently empowering even when they express pretty sophisticated attitudes toward other pathways and ongoing cannabis use.

      This invites the question, why target 12-step with these claims? Why not CBT and the other 7 approaches that are more prevalent?

      My gut instinct is that the accusations of hegemony are rooted less in 12-step’s conduct and more in the failure to develop other pathways to levels providing similar access and support. When some people look for communities of recovery around them, they are disappointed with the lack of diversity. 12-step isn’t monopolistic. If there’s anyone to blame for this state of affairs (and I’m not interested in blaming anyone), it’s the advocates, treatment providers, and others who serve people in need of other mutual aid.

      STAT recently accused 12-step groups of a “war on recovery” and I wrote the following in response.

      NA has their own definition of recovery for their fellowship, but they are not engaged in any policy advocacy and do not engage in any activity to prevent access to care with medications.

      NA is a mutual aid group that was created during a period when people with addiction were abused and neglected by medical, legal, and public health systems. They self-organized to recover and help others recover.

      There’s something ironic about a medical publication villainizing a group of people with opioid addiction organizing themselves and developing pathways to recovery when medical systems had failed them and often abused and abandoned them.

      It’s entirely appropriate to note that NA doesn’t meet the needs of millions of OUD patients and that inappropriate referrals can be harmful.

      It’s also appropriate to ask why there isn’t a thriving counterpart to NA that supports or integrates the use of medications for OUD. With buprenorphine now FDA-approved for more than 20 years, 16 million prescriptions per year, millions of Medicaid recipients (plus Medicare and private insurance recipients), and billions spent on the problem, why haven’t MOUD providers successfully cultivated the development of community-based mutual aid (rather than demanding NA change to accommodate their patients)?

      Sincerely, thank you for the good faith comment. My response represents me thinking out loud. Thanks for challenging me to think!

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      1. Thanks, Jason, I agree that its a problem of perception and not necessarily of reality, but in the world we live in today, perception is often confused with reality. It’s also my experience that when you’ve been to one meeting, treatment center, or used one modality, you have an ‘n’ of one. Having been bouncing around for the last eight years, the flavor of NA (and treatment facilities I’ve toured or worked in) in MA, NY, AZ, CA, NM, and a couple of places I’m forgetting is quite different. While some feel very welcoming, some absolutely do not. I suspect this perception is informed by these limited experiences in some locales and not others. In other words, it all depends on where you are and the cultural characteristics of that place more than the characteristics of treatment or 12-step generally. One last thought: I don’t think the modality drives the experience nearly as much as the institutional culture. This is to say something quite obvious but necessary, some people are more likely to have a negative experience in a treatment center that doesn’t have adequate policies protecting minoritized people than others; ergo, we are not going to detect a legitimate minority perspective when looking at national data sets. But that’s on us; we need to strive for a welcoming culture of recovery for all, and figuring out why a minority doesn’t agree is an essential task.

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  5. I appreciate this blog so much it helps me navigate and recalibrate my clinical contribution with my 12 step lived experience. I get so much out of these deep conversations around recovery and how I am to evolve and adapt to contuas learning. Thank you your service and your ability to stay in the solution of the variety of recovery pathways.

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