mythsThere is no doubt that Alcoholics Anonymous and the follow-on twelve step programmes like Narcotics Anonymous, have helped millions of people world wide to overcome addiction to alcohol and drugs.

Their success rate however, is only between 5% and 10% of the total people who enter the programme.

Why is this, and what can we do to help those hundreds of thousands, or possible millions of people who are battling addiction, for whom the Twelve Step Programmes do not work?

Lance Dodes MD has been treating people with addictions for more than thirty years. He is a Training and Supervising analyst emeritus at the Boston Psychoanalytic Society and Institute and recently retired assistant clinical professor of psychiatry at Harvard Medical School.

In his book – The Sober Truth, he examines why Alcoholics Anonymous does work for between 5% and 10% of people who enter the 12-step programme. And importantly, why it does not work for the remaining 90% – 95%.

“Myths have a way of coming to resemble facts through repetition alone. This is as true in science and psychology as in politics and history. Today few areas of public health are more riven with unsubstantiated claims than the field of addiction.

Alcoholics Anonymous has been instrumental in the widespread adoption of many such myths. The organization’s Twelve Steps, its expressions, and unique lexicon have found their way into the public discourse in a way that few other “brands” could ever match. So ingrained are these ideas, in fact, that many would be hard-pressed to identify which came from AA and which from scientific investigation.

The unfortunate part of this cultural penetration is that many addiction myths are harmful or even destructive, perpetuating false ideas about who addicts are, what addiction is, and what is needed to quit for good.


This common myth essentially says that a person needs to reach a point of absolute loss or despair before he or she can begin to climb back toward a safe and productive life.

The most common objection to this myth is simple logic: nobody can possibly know where their “bottom” is until they identify it in retrospect. One person’s lowest point could be a night on the street, while another’s could be a bad day at work or even a small personal humiliation. It’s not unusual for one “bottom” to make way for another following a relapse. Without a clear definition, this is a concept that could be useful only in hindsight, if it is useful at all.

A bigger problem with this notion is the idea that addiction is in some fundamental way just a matter of stubbornness or stupidity—that is, addicts cannot recover until they are shown the consequences of their actions in a forceful enough way. This is a dressed-up version of the idea that addiction is a conscious choice and that stopping is a matter of recognizing the damage it causes. If consequences alone were enough to make someone stop repeating an addictive behavior, there would be no addicts.
One of the defining agonies of addiction is that people can’t stop despite being well aware of the devastating consequences. That millions of people who have lost their jobs, marriages, and families are still unable to quit should be a clear indication that loss and despair, even in overwhelming quantities, aren’t enough to cure addiction. Conversely, many addicts stop their behavior at a point where they have not hit bottom in any sense.

There is a moralistic subtext at work here as well. The notion that addicts have to hit bottom suggests that they are too selfish to quit until they have paid a steep enough personal price. Once again we get an echo of the medieval notion of penance here: through suffering comes purity. Addicts no more need to experience devastating personal loss than does anyone else with a problem. Yes, it can be useful when a single moment helps to crystallize that one has a problem, but the fantasy that this moment must be especially painful is simply nonsensical.

Finally, the dogmatic insistence that addicts hit bottom is often used to excuse poor treatment. Treaters who are unable to help often scold addicts by telling them that they just aren’t ready yet and that they should come back once they’ve hit bottom and become ready to do the work. This is little more than a convenient dodge for ineffectual care, and a needless burden to place on the shoulders of addicts.


Here we have a pillar of the Oxford Group, AA’s theological forerunner, which preached salvation through surrender to God. In” Alcoholics Anonymous,” this idea is implied, if not expressly stated, in steps 1 and 3, which respectively recommend admitting powerlessness and making a decision “to turn our will and our lives over to the care of God as we understood God.”

The first problem with this idea is its overt religious flavor. I have covered the many ways that addiction is a problem of the mind and not of the spiritual soul. “Surrendering,” in the sense that addiction organizations commonly understand it, means abdicating power to a presence greater than oneself to attain guidance. It’s not surprising that many addicts chafe at this notion, not least because it requires a belief system that may not jibe with their own.

A bigger problem is that surrendering is tantamount to agreeing that one is incapable of managing one’s own life. AA’s literature ties this idea once again to a moralistic adage: “Our whole trouble had been the misuse of will power.”

Surrendering becomes a way to toss out a useful sense of selfhood or agency precisely when it’s needed most.

And of course the very notion of surrender is problematic when viewed through the prism of a more psychologically sophisticated understanding of addiction.


The emotion that precipitates addiction is helplessness.

Addicts find certain forms of helplessness utterly intolerable, and the addiction is an effort to reverse that. Asking them to surrender their free will in response to this problem is diametrically opposed to what they need to do: feel empowered. The dissonance created by this emphasis on surrender is one of the big reasons so many addicts don’t get better in AA [or other twelve step programmes].


Enter any conversation about AA with addicts “recovering” in AA, and they will likely be able to tell you the precise number of years, months, and days they’ve been sober. This is an integral part of Alcoholics Anonymous and its offshoots: a tally system designed to discourage backsliding by turning sobriety into something additive, an ever-expanding reward system. The AA tradition of giving out tokens or chips for days of sobriety is intended to be a helpful reminder of what people have accomplished, and a way to discourage them from falling off the wagon.

The dark side of this practice is what happens when addicts take a drink or slip in some way: they must go back to zero and lose everything they’ve gained. It’s obvious that this system can cause a great deal of pain, and the humiliations that come with it can be manifold.

Giving up tokens and esteem feels like—is intended to feel like—wiping out all the hard work that has come before and starting over. The moralistic dimension of this is hard to miss; some recovering addicts even use the tsk-tsk acronym SLIP (for sobriety loses its priority). If you are in AA and slip, you cannot avoid feeling like a failure, because that’s exactly what the system is designed to tell you.

Yet slips are hardly rare and not remotely apocalyptic. Most people will experience some lapses as they grapple with their addiction. This is completely predictable, given the fact that addictions arise from deeply personal emotions and experiences that can take months and years to work through. To suggest that having a drink or placing a bet should “undo” all the progress a person has made to date is absurd. That progress happened. And its benefits are no less cumulative for the interruption.

In fact, lapses can be turned into something useful.

They can be a window into the personal nature of addiction that might guide addict and therapist toward a new understanding of what drives the behavior. If an addict’s efforts at sobriety have been unbroken until a particular moment, then it is always worth digging into that moment in some detail to understand what precipitated the relapse.

People with addictions often feel empowered by this ongoing process of investigation and liberated by the insights it yields.

In my practice – we find looking at why a patient has relapsed can be an extremely valuable process and experience.


This language is AA’s own, and lies at the heart of its one-size-fits-all treatment philosophy.

In a sense, the word “drunks” is meant to be comforting, communal, a collective identity that defuses the terror of addiction and gives people a sense of belonging and a chance to laugh at their struggles.

Unfortunately, the word is also reductive, and understandably disliked by many addicts. Its frequent use is designed to break down the barriers between group and self and to take down a peg those who come to meetings feeling that they don’t really belong lumped in with everyone else. Individual identity of this sort is frowned upon in 12-step culture; “drunks” gives everyone the same deprecating title and the same implied prognosis for recovery.

It is not surprising that the word also serves the AA mission. Because this is a Programme where everybody receives the same treatment, it makes sense to call everyone by the same word. The word “drunks” also defines addicts by their addiction, further reinforcing the notion that addicts are somehow different from the rest of us, as if addiction is an innate quality rather than an acquired behavior.

In the world of Alcoholics Anonymous, where alcoholics all supposedly suffer with the same character flaws and problems, addiction is not something you do, it’s something you are.

The word thus ignores the tremendous variety of people who become addicts. Addiction appears within every possible socioeconomic level and in people who run the gamut of emotional health. To reduce this variety to just one word is to ignore the widely divergent experiences that can lead to addictive behavior. The core issues that lead to feelings of overwhelming helplessness, and thence to addiction, are as varied as the people who experience them. For some, this underlying distress may be about failing in competition; for others it may be about the loss of an important person, or an inability to protect themselves in a relationship. That all these people become “drunks” is almost beside the point. Their lives are what is significant. Using one word to describe them all shrugs off the individual treatment they require.

(A corollary to this label is the notion that people with addictions are pleasure-seekers: “Drunks” are people who can’t keep themselves from the pleasure of getting drunk. But true addiction has almost nothing to do with a tendency to gorge on that which we find enjoyable; it persists long after the pleasure is gone.)


This famous slogan encapsulates the outside-in, behaviorally oriented nature of AA and its offshoots. AA members are constantly discouraged from thinking too far ahead, lest they become overwhelmed or disheartened. In a sense, this is an echo of the notion that addiction is innate—a steady and implacable force, not unlike gravity, that requires constant, effortful pushback. AA members do not speak of a cure because they view their addiction as fundamentally incomprehensible—not something to be understood and resolved, but something to be resisted. When addiction is seen this way, every day is more or less like every other day. Looking ahead offers no benefits.

The notion of taking things one day at a time is also rather infantilizing, as it suggests that addicts cannot bear the burden of considering weeks or months without addiction.

This would make sense if abstinence were like lifting weights or running a marathon: it’s useful to hang on to the “just one more” ethos to get through something that becomes increasingly difficult over time.

But abstinence doesn’t have to feel that way.

A more appropriate metaphor would be learning a new instrument: you may start out one note at a time, but before long you are learning minuets and sonatas.

The biggest mistake with “One day at a time” is that it’s backward. One of the truly useful things about understanding addiction from a psychological perspective is that this view breeds a kind of precognition: people become adept at predicting when the urge will arise. In fact, thinking ahead is one of the most powerful tools in treatment, as it gives addicts a chance to head off their addictive urges long before those feelings actually occur.

Purposely keeping one’s head down and refusing to think about the future is a formula for getting blindsided by powerful and unfamiliar feelings.


The idea that our peer group influences our behaviour is not unique to AA. This is way of encouraging members to seek out positive role models in the programme, but its unwanted consequences can be painful and isolating. Speaking only with people who have “gotten sober” is a good way to miss out on hearing or learning from the great majority who do not find AA useful.


Many new AA members are instructed to follow this slogan, which has informally arisen outside of AA’s founding text. Its purpose is to break the routine of addicts and get them instantly and deeply involved with the programme and to help shake the destructive cycle they’re in.

However this particular prescription is essentially arbitrary, Like the thirty days (o2 21 days) almost universally recommended for rehabilitation centres the ninety day period is something pulled out of thin air, based on the intuition that three months should be enough time to get started on the right foot.


This homily (often apocryphally accredited to Albert Einstein) has found its way into popular culture. Thos people who work in clinical psychiatry could tell you that this isn’t remotely close to the definition of insanity. Doing the same thing over and over again and expecting a different result is, at worst, a symptom of self-deception or perhaps unfounded hope.”

What any twelve-step programme fails to address, is what is now widely considered to be an inextricable link between Trauma and Addiction. And perhaps unless that trauma is uncovered and addressed, there is little hope of long-term recovery.

Trauma leads to a sense of helplessness. And feelings of helplessness lead to frustration, anger, hurt, fear and many other destructive feelings These feelings often persist over a lengthy period of time for many addicts. And the person finds ways of soothing these feelings by using their drug of choice.

We said earlier, that the 12 step programmes work for many people. If you are battling with addiction, there are other alternatives. Its worth examining those because an untreated addiction, does not end well. Also see our article about the myths of alcohol rehabs in South Africa.

Vaughan Pankhurst – Addictions Counsellor – Recovery Direct