The promise of — and problems with — 12-step programs

Thousands of Ontarians with substance-use issues turn to Narcotics Anonymous. Many credit it with turning their lives around — but others see it as a barrier to recovery.
By Daina Goldfinger - Published on Jul 23, 2019
Empty red chairs arranged in a circle.
Narcotics Anonymous meetings are offered in more than 100 communities across the province. (iStock.com/SolStock)

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“We admitted that we were powerless over our addiction, that our lives had become unmanageable … We came to believe that a Power greater than ourselves could restore us to sanity … We made a searching and fearless moral inventory of ourselves.” Those are just three of the 12 steps that participants in Narcotics Anonymous work their way through as part of their recovery process — a process that’s undertaken by many Ontarians, but that experts say may not give everyone the support they need.

The 12-step approach and philosophy are used at meetings and treatment centres nationwide — NA meetings are offered in more than 100 Ontario communities. Participants speak about their experiences, make amends to those their addiction has harmed, work with a sponsor, and try to abstain from the use of substances.

The 12-step program helped David — a 48-year-old whose last name is being withheld to protect his privacy — recover from the abuse of multiple substances. Originally from Australia, he now lives in Victoria Harbour, about 35 minutes north of Barrie, and has been in recovery for eight years. David was on the methadone program while he was using cocaine and fentanyl intravenously. After waiting five months in 2010, he got into a concurrent-disorder residential program — a curriculum that treats people with both mental-health and substance-abuse problems. He stayed there for four months and was gradually weaned off the methadone. Once he finished the program, he was sent to a residential treatment centre that used the 12-step curriculum. He was there for eight months. “That place saved my life — no doubt about it,” he says.

But some experts say the method isn’t backed up by evidence — and may not represent the best way forward for everyone. In The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, for example, retired Harvard Medical School psychiatry professor Lance Dodes analyzed dozens of studies and found that the success rate for 12-step programs is between 5 and 10 per cent.

“That [12-step] approach, as sort of an uncomplicated understanding of what’s going to happen to you and what you need to do to prevent it, is certainly attractive for some people because it gives them hope,” says Karen Urbanoski, the Canada Research Chair in substance-use, addictions, and health-services research, a scientist with the Canadian Institute for Substance Use Research and an assistant professor in public health and social policy at the University of Victoria. “However, it doesn’t describe the experience of everyone who has addiction issues.”

One element of the method that critics say can be problematic is its emphasis on abstinence. In NA, this means completely refraining from using any mood- or mind-altering substances, including alcohol. The use of cigarettes and coffee is considered to be a personal choice — but, officially, the program has no opinion on prescribed medications.

NA stresses abstinence because “it comes from our Basic Text, which is what we follow,” says Bob Shott, a public-relations assistant at NA World Services. “It’s proven that it’s worked.” Shott points to NA’s 2015 voluntary survey, which found that 92 per cent of respondents indicated that their family relationships had improved, and 75 per cent indicated that their employment status had improved.

But Benjamin Schutt, a 35-year-old from Hamilton who attended a 12-step program for about four months in 2014, didn’t get much from its philosophy. “It’s horrible as far as stigma and things like that go,” he says, adding that he doesn’t believe in abstinence, as there are many other drugs that people consume regularly, such as coffee. “These are people, who, as far as they’re concerned, their lives have been ruined by drugs,” Schutt says. “You can’t find a room full of people that hate drugs as much as NA anywhere, which makes being harm reduction all the more isolating.” Schutt says that the 12-step program’s binary system of abstinence — of being either “clean” or “dirty” — is problematic and that harm-reduction choices, such as using clean needles, can be more helpful for people with addictions.

“If you just frame it as ‘you’re either with us or against us,’ ‘you’re either sober or you’re not,’ you just turned away a whole bunch of people that otherwise you probably would have been able to give some sort of help to,” he adds.

Althea Blu, 42, who is originally from Port Stanley and is in recovery from opiate addiction, doesn’t believe in abstinence either. (Blu’s real name has been withheld to protect her privacy.) She attended 12-step meetings several times but says they didn’t work for her. “In all 12-step-based programs, if you use again, you’ve failed,” she says.

NA “seems to work for the people it works for. But if it’s not working, the idea is that you are not working the program hard enough — if you were working it hard enough, you would recover,” says Urbanoski.  “I don’t think that’s true.”

Blu says that she drinks wine with dinner and smokes pot. “Do I shoot heroin and cocaine and smoke crack? No. In my head, am I absolutely, 100 per cent in recovery? Absolutely. Have I relapsed? Nope, because I haven’t touched heroin.”

After Spencer Lachapelle, 31, got off opiates in February 2017, the native of Vineland, about 20 minutes west of St. Catharines, attended 12-step meetings regularly. He still finds them helpful but says that he’s faced attitudes there that almost caused him to quit NA.

He had been taking Suboxone, an opioid-replacement medication. “A lot of people were against taking me through the steps, and there were a lot of people that were very open about how they didn’t like the way I was getting clean,” Lachapelle says. “People were telling me I wasn’t clean because I was on Suboxone, and it’s like taking somebody’s hope away.”

Marshall Smith, the chair of the British Columbia Recovery Council, says that 12-step programs remain the most accessible and effective way for people with addictions to start practising wellness. “They’re highly effective, and millions of Canadians across the country credit their participation in those programs as saving their lives,” Smith says.

But experts say that there are many other treatment options that people can benefit from, including cognitive therapies, motivational interviewing, individual and group counselling, residential treatment, and methadone and Suboxone maintenance.

“An effective addictions treatment program is multi-varied,” says Mark Haden, an adjunct professor at the University of British Columbia’s School of Population and Public Health and a former addiction worker. “There’s no one thing. Yes, 12-step programs should be supported because some people find them to be absolutely wonderful. Some people need cognitive-therapy programs. A diverse and rich program is the appropriate response.”

Urbanoski agrees: “There are a lot of treatment approaches that are evidence-based, and what is likely going to set them apart is not whether they’re more or less effective than the next one, but what is it about them that makes them effective with this individual,” she says. “It’s about the fit of the individual with a particular type of service, as opposed to that service being wholly effective or not effective.”

Haden wants to see an integrated addiction-treatment system, one in which services work in tandem. Currently, he notes, abstinence-based treatment programs may not be supportive of supervised-injection sites — but the two serve different purposes, both of which are critical.

“We should be providing, with absolutely no conflict and controversy, a variety of services, from supervised injection to abstinence-based treatment, and they should all be seen as an integrated system of care, without any conflict anywhere in the system.”

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