Why does the 12-step therapy work for quitting alcohol?

BarcelonaWe've seen it in countless movies: "Hello, my name is so-and-so and I'm an alcoholic." We know the acronym Alcoholics Anonymous (AA) and what it represents. But what we might not know is that behind these initials –and this recurring phrase– lies a twelve-step therapeutic method created by two men from Ohio in 1935, which has since helped millions of people worldwide. This method is now applied in 68 countries, including Spain, where there are up to 586 active Alcoholics Anonymous (AA) groups. A study by Harvard Medical School and Massachusetts General Hospital concluded in 2020 that this AA twelve-step therapy "is more effective than other established treatments for increasing abstinence" and improves outcomes, especially "in the long term," helping people stay sober for longer. The survival and constant global expansion of this system for nearly a century also attest to its effectiveness.

However, when reviewing the twelve specific steps proposed by the method, some of them clash from a scientific point of view. The first step is clear: "admitting we were powerless over alcohol," a necessary step for any therapy (admitting there is a problem). But the second is not so much: "believing that a Power greater than ourselves could restore us to sanity." And other steps –not all of them– also exude a religious air inherited from its origin: the more rural United States of the early last century. "The program was created by two men who were religious, but it's not about making you believe in God or go to mass; in the end, it's about adopting an idea of a higher power as you conceive it, whether it's God, Allah, or anything else," explains by phone the general secretary of the AA service board in Spain, who assures that it's not necessary to be religious or spiritual to follow this therapy, which "serves everyone." And he insists on a basic premise of the program: "No one is forced to do anything here."

In fact, one of the factors that explain the success of the method, according to psychologists, is not the steps themselves, but the fact of sharing the process with people who have gone through or are going through the same thing. There are no professionals or psychologists; it is the alcoholics themselves who organize themselves. "It is the paradigm of self-help," explains Josep Maria Suelves, a psychologist at the Public Health Agency of Catalonia and a member of the Working Group on Addictive Behaviors of the Official College of Psychology of Catalonia. "One cannot judge AA without taking into account its origin: it was born in the 1930s in the United States in a very religious society and at a time when the moralistic perspective was dominant. Alcoholics were not seen as if they were sick but as people who did not know how to control themselves, they were socially rejected, and the medical system offered them no solution," explains Suelves, highlighting group therapy as "the great contribution" made by the creators of AA in the last century: "At least in the treatment of alcohol, they were the first to use group therapy."

In an AA meeting, there are figures such as the coordinator, the secretary, or the treasurer, all volunteers, but "anyone can moderate the session" and there are no strict rules; simply "there is a round of words where everyone's turn to speak is respected, and no one enters into debate or discussion," explains the general secretary of the group in Spain. It also usually includes the reading of one of the so-called twelve traditions, which are the reflections that accompany each of the twelve steps, in order to guide reflections towards this topic. But the spokesperson assures that following these steps is not a strict formula that requires a specific order or time for each one. "The most important thing is the first point, because you have to be honest with yourself, and then you go through the other steps almost without realizing that you are doing them," he explains.

Helping others

Another element of the AA program is the figure of the "godparent", someone who has already managed to overcome alcoholism and who helps or accompanies the person who is starting the process. "It's all suggested, nothing is mandatory, but it's a person who understands you because they've been through the same thing and gives you advice to stay sober", explains the AA spokesperson, and adds: "The most important thing is that you realize that no one here will criticize you or scold you for anything". In fact, one of the main objectives of the program is that any member can become a godparent, and here lies another psychological benefit of the therapy: helping others is comforting and also helps to stay sober.

"Many times giving up alcohol means leaving your social network and many people are left alone. AA also fulfills the function of a group or community that makes this person feel more supported", also highlights Óscar Pino, coordinator of an adult mental health center and spokesperson for the Official College of Psychology of Catalonia. He also points to a possible explanation for the success of a method that has this spiritual or religious component: "There are mental health studies that show that religious people overcome psychological problems better because they pass control to divine will and that relieves them of possible guilt".

"There are people who have tried many other methods and have not succeeded, who have reached very problematic situations due to alcohol consumption, and who finally with the support of AA make a click and truly find the path to recovery", says Suelves. However, he makes it clear that participation in AA groups should not exclude professional medical intervention. "Alcohol withdrawal syndrome can be lethal, it can cause phases of delirium tremens and requires professional medical treatment", he recalls.

Fortunately, today's society is very different from that of a century ago, and now it is indeed aware that alcoholism is an illness and not a weakness of character or moral failing, as was thought a century ago. "Alcohol consumption causes changes at the brain level that, at a certain point, lead to a real addiction and the illness is considered chronic," states Pino. The general secretary of the AA board assures that the link between the association and public health services, at least in the Spanish state, is total. "We are very linked, we need each other," he affirms, and also explains that members of the group go to schools to give prevention talks for adolescents: "Our main objective is to bring the message to any alcoholic who is suffering to tell them that recovery is possible".