Rule 1 asks the individual first to connect with some type of recovery community that is based around the healing and recovery from your particular addiction and then to do something every day that involves this group. This could mean attending a regular meeting, carrying a message of hope and sobriety to others who ar
What causes an addiction? There is no quick and complete answer to the question in spite of many years and decades discussing it. The psychiatric hypotheses have not been helpful at all to the field. The twelve step faith-based groups have been the most helpful, but even this group only reaches a small percentage of sufferers, and then only seems to help a small percentage of those. To its credit, at least the 12-step groups do not base their claims in hypotheses rather they have been based on research in action - observing what actually works.
To recover from drug addiction, one needs regular support from individuals like themselves who have been through related experiences. The research on this is crystal clear. To a large extent, drug and alcohol abuse becomes a disease of disconnection from humanity. Over a slow and insidiously progressive course of disease, the individual gradually drifts further and further away from connection with other human beings and more and more into the dark mire of substance abuse. When he is finally lifted from this - that is to say, the drugs and alcohol are removed - the extent of this disconnection is painfully experienced, although he/she may not recognize it as a cause.
In the mid 1930s, a group of alcoholics, who were otherwise deemed hopeless by their society, discovered the miraculous power of being around and talking with alcoholics like themselves while trying to help others who were still suffering. Substance abusers by temperament tend to be highly defiant character types with a generally low sense of self-worth that one must work continuously to disguise. For this reason it is very difficult for this individual to be accepting and open to the ideas and treatment suggestions of someone with whom he can not identify. For example, a helpful or compassionate intention from a friend or family member is often misinterpreted as a patronizing and condescending tone. However, when the message is coming from an individual who has had the same problems and appears to be recovering from them, the sufferer's mind suddenly opens up and the seed of hope and willingness gets planted.
This became the foundation upon which Alcoholics Anonymous and the subsequent 12-step offshoots (e.g. Narcotics Anonymous, Cocaine Anonymous, Crystal Meth Anonymous...) are based. These groups are considered to be the most effective programs in the world for helping recovering drug abusers and alcoholics stay sober. In fact, to help another sufferer stay sober is each organization's primary purpose.
Particularly in the early months of sobriety, fellowship with these groups could be the difference between continued abstinence and relapse. The mood fluctuations and emotional upheavals common in early sobriety become nearly impossible to navigate through on one's own. Rules two through twelve will not be strong enough on their own to carry the newly sober individual through this period. Talking with and receiving encouragement from other people is invaluable and trying to help a newer person trudge through his/her own difficulties may be the only true sense of purpose one finds in those early months.
For many reasons, not least being the individual's stubborn belief that he does not need the help of other people, many drug abusers do not find these programs on their own. Today's treatment regimen, however, is typically designed to expose the individual to one of these organizations while in treatment and stresses the importance of immediate involvement with a group following completion of the final level of care. Most newly sober individuals need to attend twenty to thirty meetings before they begin feeling comfortable in the groups and develop a sense of their importance.
Perhaps the greatest strength of a 12-step fellowship is hearing another sober group member share an experience to which he can relate. The relief one experiences from realizing that he is not alone is incalculable. This allows one to become more comfortable sharing his own experiences and thus relieving much of the latent tensions wrapped up in such experiences. This reduces the internal tensions that build up over years of active addiction, thereby reducing the risk of relapse.
Most in the field agree that drug addiction is a three-fold disorder and a successful recovery needs to address the disease of the individual physically, mentally, and spiritually. A spiritually -based program is the best known place to address and repair the missing spiritual component in the individual's recovery. Although the twelve-step groups are the most common and prevalent, there are other options available, as well, including Christian Recovery, Women for Recovery, SMART Recovery, and LifeRing. Aligning oneself with a fellowship that accepts the need for spiritual regrowth is essential.
The growing prevalence of drug and alcohol addiction decades after the social acceptance of these twelve-step programs, which have been lauded by some as the only true way to arrest the disease, reflects a fundamental ignorance and careless disregard of the individual's need for physical and mental repair.
The substances commonly abused today, for example, are different than those commonly abused twenty or thirty years ago, therefore the nutritional approach to reversing some of the long-term damage is not the same. In twelve step groups, there is often a message being promulgated (often sternly) by the older members of the group that substance abuse is one big disease and what works for one individual will work for another if he simply does what he's told. The fall-out from this message is that when the user returns to a substance of abuse, he is embittered with the belief that it is his moral weakness that has precipitated the relapse, and the last thing an active drug abuser needs is anything to exacerbate the already burdensome feelings of intense guilt and shame.
So the need to fellowship with other's like oneself is critical - so critical, in fact, that we have made this Rule 1. However, there are still eleven rules after this one. Fellowship is important and will do a world of good helping individuals feel welcomed, part of something beneficial and useful, while helping relieve feelings of intense loneliness and isolation.
Once the alcoholic or drug addict is provided some understanding of his disease and what it may take to stay sober, a moral obligation does come into play. Because he now knows. If he follows the rules of recovery, he will likely stay sober and begin to recover to good purpose. If he willfully deviates or neglects parts of the plan, he will likely relapse into old behaviors and inflict the illness back onto himself. Once physically detoxed (that is, at least 30 days sober), he now has a clear choice: get better or to stay sick,. And it is on him to make this choice.
A.A. is far and away the most tried and proven program for helping alcoholics to stay sober. Its primary purpose is to stay sober and help other alcoholics to achieve sobriety. Members are there to support one another, helping other members to recognize that he is licked by his disease and unable to fight it on his own. A.A. offers alcoholics a fellowship and association with other sober alcoholics to support one another as each member "trudges the road to happy destiny."
Almost without exception, people who come into sobriety did not fully develop the living skills that other non-addicted people have. Belonging to this type of fellowship helps the alcoholic start to piece together a new lifestyle and how to maturely and successfully handle certain situations. Millions of alcoholics can attest that the program does work.
You may come into recovery with the belief that everyone you know would want you to get sober and recover to good purpose. In fact, most people will likely say those exact words. The family and social dynamics of addiction are amazingly complex and deeply laced in pathological behavior. In the book Alcoholics Anonymous, the author states that years of living with an alcoholic is sure to make any spouse or child neurotic - the whole family is to some extent sick.
Generally speaking, physical and mental health are dependent upon positive attitudes, whereas poor health, both physical and mental, is associated with such negative attitudes as resentment, jealousy, hostility, self-pity, fear, anxiety, etc. This explains why treatment facilities are so averse to releasing a patient right back into his previous environment. Whether or not one is living with or among others who have addictive tendencies of their own makes little difference. A household which fosters such negative attitudes as listed above is an unbelievably difficult environment for one to begin recovery. One does not get over pessimism by associating with cynics; the age-old truism that you are defined by the company you keep has some clinical basis.
The term “family illness” is widely accepted both by professionals in the field and deeply understood by loved ones with enough honesty and courage to look at how they themselves fit into the clinical picture. The energy and attitudes one gives off can be thought of as an invisible element which becomes a constituent of the very air one breathes. Therefore, just as one takes in hydrogen, nitrogen, and oxygen from the air, as one breathes, the energy from an individual becomes a part of the very life force that is being permeated into the body.
Everyone has known individuals who seem to be floating in a bubble of toxic energy; they simply attract conflict at every turn. These are individuals who will inevitably destroy every close relationship around them while being completely unaware of the pattern. Through every form of rationalization and self-justification, even if made aware of the trend, will be entirely convinced that he/she has not once been at fault. The neuroses that are at play in this individual are well beyond the scope of this article, however the identification is an important one. Many recovering substance abusers were once themselves and/or closely associated with individuals of this type. The discipline and courage required to identify and distance oneself from these types of relationships can prove paramount to the prognosis of recovery.
We know that stresses (internal or external) are the primary triggers for addictive craving, therefore minimizing these will go a long way in establishing a stable internal balance that is more resistant to disruption. In the 12-step groups this involves making amends where appropriate, and in the initial treatment setting may involve family counseling.
So, how can one determine if an individual is supportive or destructive of one's recovery? Here is a good test: do you routinely feel worse after speaking to or being in this individual's presence? If the answer is yes, it is recommended to intentionally put some distance between yourself and them.
For all of the strengths of a twelve-step fellowship, they are not without their shortcomings. Any discussion of the benefits of these groups would be unfair and incomplete without at least addressing the arguments on the other side. Because we personally endorse and support these programs as a whole and are therefore naturally bias in their favor, we will attempt to present the other side in as objective a manner as possible.
The only subject more touchy than medication use in the recovery community is the effectiveness of the twelve step groups. If you want a heated argument where neither side will ever concede to the other, bring up this topic. Nothing would make us happier than to avoid this discussion all together, but we would be choosing to do so only out of fear of public blowback, and any pursuit of truth that is avoided simply out of fear of other people's opinions is cowardly and not virtuous. Therefore, we have to address these issues at the outset.
Twelve-step fellowship groups are not treatment centers and are not composed of individuals trained in the field of medicine, psychiatry, psychology, nutrition, or behavioral health. As a whole, the quality of recovery typically found in a given group of an anonymous program is questionable at best (after all the only requirement for membership is a desire to be sober). Perhaps this principle is no where better illustrated and articulated than the famous article in the July 1976 article of "24 Magazine" titled, Gersham's Law and Alcoholics Anonymous. The article discusses the observation that as Alcoholics Anonymous grew in size and popularity, it became possible to remain sober for significant lengths of time simply based upon the fellowship alone without necessarily achieving any spiritual growth that would have previously been suggestive of a successful recovery - he calls this type of sobriety the "weak cup of coffee." The author observes that this type of sobriety will almost inevitably become so uncomfortable and unsustainable to the individual that it will eventuate in a catastrophic, if not fatal, descent back into active addiction. This "weak cup of coffee" sobriety, we could say, describes the most common type of sobriety experienced in twelve-step group members today and is one of the primary reasons for creating the 12 Rules for Recovery.
Given the limitations of these groups, they are typically not enough by themselves to propel a substance abuser into a full, healthy, and comfortable recovery. Some members are able to remain abstinent for a period of time, but without significant growth and personal development - that is to say physically, mentally, and spiritually - long-term recovery is not likely.
Regardless of its true value, we have to agree that the twelve-step fellowships - Alcoholics Anonymous (AA) in particular - have become a household name and part of the main fabric of the recovery world. AA started 85 years ago and very quickly (within about 10 years) became widely accepted as the go-to treatment for alcoholism. Since that time, all sorts of sub-groups were granted permission to use the twelve-step format to treat other chronic afflictions (cocaine, narcotics, marijuana, gambling, over-eating, sex, shopping, co-dependency, etc.). The biggest problem that the medical community has with these organizations is a continuing lack of evidence-based research. In fact, we can not think of any other chronic, progressive illness that is so incredibly lacking in this area. It appears that the actual success rates (defined here as continuous abstinence over 3 years) are between 5-8% (Dodes, Lance, MD, 2014). It is generally accepted that spontaneous recovery from a substance addiction is usually in the 4-5% range, therefore AA by itself doesn't appear to be much better statistically speaking than doing nothing for the majority of people.
The Cochrane Collaboration is the prestigious scientific research organization that is trusted to carry out the long-term clinical reviews of the most common disease states. The long-term reviews are needed mostly to control costs so we know where to focus the treatment dollars and what to recommend as common treatment guidelines. The organization did a comprehensive review of Alcoholics Anonymous from 1966-2005 and reached a startling conclusion: "No experimental studies unequivocally demonstrated the effectiveness of AA in treating alcoholism."
This was the largest and most organized review of AA ever conducted. The conclusions were obviously met with unbelievable hostility from not only the AA community but the treatment community given that most of the multi-billion dollar rehab industry relies heavily upon the twelve-step method. Regardless of the fact that the Cochrane Review's findings in virtually any other area of health and medicine are taken so seriously that they literally change treatment guidelines, in this particular instance, we mostly discarded the findings. We don't suggest anything malicious going on here. The more pragmatic minded people in these communities usually respond with: "So AA isn't a perfect treatment, but what do you know that works any better?" That is a fair point. We do not know anything long-term that works better or for more people than a twelve-step fellowship. This is why rule number one is to join one of these groups. Particularly in the very early stages, it seems to be absolutely necessary to listen to and be around other people with whom you can identify. There is utility in these groups, and I believe it could make the difference especially in the rocky months of the first year of sobriety.
During my undergraduate and doctoral education, I learned about disease states, their current treatment guidelines, and the methods whereby these guidelines are continuously updated, reviewed, and upon which they're improved. One of the primary methods we use to evaluate the effect of a medication, for example, is to measure the patient adherence. That is to say, if a tablet to treat an auto-immune disorder is prescribed to be taken once daily in the morning with food, is the patient actually doing that? If we study 1000 patients prescribed to that tablet and 950 of them stop taking it after one week, we will look at the treatment and consider why 95% of people stopped taking it so quickly. We would certainly not conclude that there is something wrong with those 950 people and that they must not really want to get better like the other fifty. We wouldn't say they are constitutionally incapable of taking the medication at the right time. Now imagine the fifty people who took the tablet as prescribed started to see some improvement and started going all around as often as possible claiming there was something wrong with the 95% who didn't adhere to the treatment. This would never happen, of course, in traditional medicine, but why is the treatment of addiction any different. Twelve-step fellowships, unfortunately, take the other approach. In other words, the program doesn't fail; you fail.
In grade school, we learned about the scientific method. In short it says that to verify if something is true, we need to come up with a hypothesis and then test that hypothesis by controlling for every other possible confounding variable. If we're changing multiple things, we run the risk that the results observed were caused by that other 'thing' and not by what we are observing. In human studies, we try our best to always use a control group. This is a group where the only statistically significant difference between it and our study group is the exact item we are attempting to study. The other type of study is an observational study done without interventions or controls and we look to draw conclusions from the study. The problem is that the conclusions we draw from these studies tend only to point to a general correlation and not to a true causation. Unfortunately, these studies usually come up with great headline-capturing conclusions so they play very well in the media. It happens all the time and because of the power of suggestion, they can have a significant impact on the masses.
One example of many is when it was reported that people who drink diet soda have a higher incidence of depression. This study was conducted by the National Institute of Health - a reliable source - and it understandably had a great impact on soda sales. Unfortunately, the follow up research will never get the front page headlines, therefore it is usually left forgotten in the wind. In this case, it turns out that people who chose diet soda tended to be more critical of their own weight and appearance and more prone to obesity. The depression arises physiologically from the effects of obesity such as sleep apnea, diabetes, etc. [note: we do not recommend diet soda - or any soda - as a rule, but not because it causes depression].
Everyone with a scientific education background understands that a huge problem when interpreting public health research is what is known as the compliance effect. It can spoil even carefully created scientific studies.
The basic idea suggests that people who follow recommendations faithfully and regularly for their own well-being (e.g. exercising, taking multi-vitamins, eating nutritiously) are actually fundamentally different from people who do not. In other words, people who comply with medical advice are more likely to care for themselves in other ways as well.
For example, if we recommend a new vitamin and recommend it to a population of people, we might conclude that over a given length of time, the people who took the vitamin regularly saw improvements in the areas we were studying. But is it accurate to conclude that this improvement in the group who took the vitamin is related to the vitamin itself, or is it simply that these people who can follow a recommendation simply took better care of themselves?
This idea has come up when scientifically discussing the benefit or lack-thereof from the twelve step fellowship groups. The efficacy of the programs isn't fully understood, but it appears to be somewhere in the 5-10% range (See WHAT IS SUCESS below). Did these people improve because they "worked the program" or were these simply the small percentage of people who were already ready to get sober and therefore were willing to follow direction?
No good analysis of the twelve step fellowships could be made without coming to the obvious question of: how do we define success? After all, success could be measure a number of different ways. Should we measure number of total days sober? Number of consecutive days sober? Number of days without a "severe episode"? If someone stays sober 11 months, slips for one night, then resumes sobriety for the rest of the year? Are they given any credit for that? What if someone remains abstinent from drugs and alcohol, but ruins the financial stability of the family after developing a crippling gambling addiction. Is that counted any differently?
Each study that interprets the effectiveness of these programs uses a slightly different definition of "success", therefore it is very important to consider this end point before evaluating any of the data.For general purposes, we like to use the definition of complete and continuous abstinence for one year.
In the field of medicine, when considering the course of a chronic, progressive disease, there is a term spontaneous remission that is often used. It's most common in the world of cancer research. It needs to be considered and included in any calculation of treatment efficacy if the results are to be considered credible and accurate. For example, if a drug is being brought to market to treat a certain type of undifferentiated arthritis, and it claims to effect a remission of the disease in 30-40% of the population, this claim would not be worth much because the disease tends to spontaneously regress at this exact rate.
This brings us to the twelve step data. A large study done at the Beth Israel Medical Center in New York in 1990 concluded that alcoholism, for example, has a spontaneous remission rate of between 3.5 - 7.5%, meaning with no help at all. That is to say, if we look at twenty alcoholic individuals who do not seek any treatment for their condition, nineteen of them will progressively get worse over time, and one of them will stop drinking on their own and stay stopped.
When we consider the 5-10% success rates of twelve-step fellowships along with a 5% spontaneous remission rate, the benefits of the programs seem even bleaker.
If the medical research is accurate, and the success rates are as poor as they appear to be, how can we recommend these groups as our very first rule for recovery? The answer is two-fold: first, although the results are not impressive for the majority of people as a stand alone therapy for addiction recovery, there is still no better option. There may come a time when a great modern-day breakthrough forever changes our first-line treatment recommendations, but like the founders of AA wrote in their self-titled book, "Science may one day accomplish this, but it hasn't done so yet." And because addiction is chronic, progressive, and increasingly fatal, we don't have the luxury to wait around for this mythical "one day."
Secondly, it is our belief that addiction is a disease of loneliness. I do not not know an alcoholic or drug addict who after getting sober has not admitted to a life-long deeply impressed feeling of loneliness. It would be nice if the feeling would go away once we get sober, but if we believe that the substance use was at least partially a self-treatment for loneliness, then we'd expect that it might get worse after getting sober. Unfortunately, this is what happens for a lot of people in early sobriety. Initially, the only way we know to treat this intense loneliness is to fellowship with other people like ourselves. It is an experience you won't want to miss.