In this quasi-religious programme, ‘working the steps’ is the remedy for any problem, but for me the cracks soon started to show
Eight of us sat together in a circle in a wooden shed, an outbuilding at a large country house, somewhere in the south of England. The door was ajar, and spring light flooded the room. “Can anyone name any treatment methods for addiction, other than the 12 steps?” asked a counsellor.
“Cognitive behavioural therapy?” offered a patient.
“These other methods come and go,” said the counsellor, with a wave of the hand. “But it’s only the 12 steps that truly work.”
I later found this to be questionable, to say the least. My 28-day stay in a 12-step rehab receiving treatment for substance misuse was defined by a series of moments in which I was told things that just didn’t sound right. But I wasn’t in a place to argue.
On check-in, I was told I have a disease that’s progressive, fatal and incurable, and that I have a one in three chance of dying from it. My life had fallen apart so dramatically over the course of the previous year that I was in desperate need of any solution.
The events that led me to rehab are hazy. There was a painful breakup, a redundancy. In October 2015, I was hit by a truck. Signed off work, with my hand in a cast, and tending to a set of difficult emotions, I turned to a coping mechanism I had discovered when I was 15. I had started drinking, then taking recreational drugs with friends to numb the pain I felt as my parents went through a divorce, and the confusion I experienced around being gay.
But crystal meth was to prove my nemesis. I’ve tried all the drugs, really. Meth, though, is something else. It has ripped through the gay scene, where it is used in conjunction with sex, in an epidemic known as “chemsex”. What started off as a bit of misguided fun very quickly got out of hand.
Now, aged 29, I had made a decision to move back in with my family – temporarily, I assured myself – in order to clean up. Before long, I was in the car outside the local drug recovery service, curled up in a ball, my face pressed against the window. I was dependent on Valium; it helped me carry on functioning, at least for a while. I tried to detox at home, but found myself sobbing, feeling as if I was falling apart. This triggered a return to using crystal meth as an analgesic, and bouts of severe paranoia. When someone finally suggested I might go to the Priory rehab clinic, I was all ears. Encouraged by my despairing family, I picked up the phone.
A woman answered. Running through my options, she said it would cost between £10,000 and £28,000 for a month’s stay. I was desperate, so I chose a small facility at the bottom end of the scale, at £13,000. I had an en suite room, and didn’t have to share a dorm. My parents arranged a “soft loan” from an extended family member. A privilege, I know; but one I have to pay back.
On the way to the clinic, I had the distinct feeling of being driven to my own funeral. My mum suggested we stop in Chichester for lunch. But I was not in the mood for a jolly meal. Checking in, I became aware that my situation was becoming pathologised. “Have you ever injected?” the doctor asked. “I have,” I replied.
Before my mum left, I asked: “Do you think I’ll be allowed a glass of wine with dinner?” The answer was no. Like most rehabs, this one enforced abstinence. I would spend the next 28 days with 25 or so other patients, each on their own seven-, 14- or 28-day journeys. I met some colourful characters, but it was mainly middle-aged alcoholics from the home counties.
I was a mess. There was an awful lot of work to do, and I was eager to get on with it. Weekdays consisted of six hours of group therapy. In the evenings, we might have acupuncture or yoga. The food was OK. After a cooked breakfast, we started the day in the living room, lined with bookshelves filled with ornaments. We’d sit on Chesterfield sofas in the glum half-light emanating from the north-facing windows, and share a reading from the Alcoholics Anonymous and Narcotics Anonymous Daily Reflections books, usually centred around big Christian themes expressed through metaphors of eagles swooping or geological features to be overcome. I had asked at check-in if I could have a Qu’ran to go with the Bible next to my bed (I heard it made for a better read, and I had a crush on a Muslim boy), but was told, in no uncertain terms, that the Bible was enough to be getting on with. (When contacted for this article, the Priory said that a Qu’ran is available at the clinic “on request”, adding that the “voluntary 12-step programme we run is open to people of all faiths and none … We fully respect a diversity of religious adherence.”)
Group therapy was more of the same. A copy of the 12 steps hung on the wall. Step one read: “We admitted we were powerless over our addiction and that our lives had become unmanageable.” Step three that we “turn our life and our will over to the care of God, as we understood him”. Step four that we make a “searching and fearless moral inventory of ourselves”. And step five that we admit “to God, to ourselves and to another human being the exact nature of our wrongs”. So it went on.
This didn’t feel right. I’d spent a lifetime cultivating self-acceptance. Now I was being told that the root of my problems was my own moral failings. And my only salvation from this life-threatening situation was to establish a relationship with God.
I sat in that shed and took it in turns with my fellow inpatients to read aloud from worksheets that we completed every night and every morning. We would feed back to one another on the problems we had: broken homes, failed marriages, misspent youth. The counsellors, most of them “12-steppers”, interjected with words of encouragement and examples of when, for them, it had felt as if things were going wrong and then, ultimately, something had provided: a solution appearing from between the clouds. “Working the steps,” was prescribed as the remedy for every problem.
I was given shots of vitamin B12 in my backside every night for the first week: useful, apparently, for alcoholics. We all smoked a lot. As one fellow inpatient put it: “I came in with a drink problem, and I’ll leave an ‘alcoholic’ – and a smoker.” The walls of the smoking shed were adorned with messages of support and empty platitudes from our forebears. Here we told tales of our former lives, providing glimpses into the worlds we had left behind. The gallows humour in rehab is immense, I’ll give it that: the one unifying factor of those present was that we had all messed up our lives so severely, or were on the verge of doing so, that the only thing left to do was laugh. I’ll never forget the story one patient told about the time she got so drunk she mistook a household appliance for her boyfriend and snuggled up to it on the floor. She’s dead now, I think.
The ancillary staff – nurses-cum-carers-cum-security, some of whom were recovering addicts themselves – smoked with us. They, too, would extol the virtues of the 12 steps. One night, I sat in the shed with a nurse on his night shift. Holding a stick-thin roll-up, he reminisced about the good old days of mental health care when the golden rule, he recounted with a soft chuckle, was: “When in doubt, knock ’em out.”
“But if I have a disease,” I asked, looking at step one, “why do I admit it? Surely I’m not guilty of anything?” I was willing to kick up a fuss. But it’s amazing how quickly one adapts to a thought system when everyone around you is extolling it. Rehab counsellors are often provided with “12-step facilitation” manuals, instructing them how to counter dissenting patients. In this case, one of the counsellors merely gestured to me to zip my lips and swallow the key. Later, a counsellor would take me aside and tell me that the more questions I asked, “the less this will work”. The experience, generally, was gruelling. Filling out yet more worksheets, I was reminded of a family member rubbing the nose of my childhood kitten in its own shit. “Describe how your using caused you harm,” the worksheet asked. “Describe three times your using led you to break your own moral code.” A lot of the time, stumped for answers, I would shoehorn in anything, hoping the act of confession alone would keep me clean.
Accepting a higher power was fundamental to my chances of staying clean, I was told. That “higher power” could be anything. The counsellors advised we “turn our will and our lives over to God” by checking every life decision we ever made with another recovering addict, or a 12-step therapist. This seemed unwieldy. But, as a straight-A student with his life on the line, I was willing to give it a go; I was particularly keen to get this right.
Despite extensive research, there is very little reputable evidence to show that the 12-step programme works better than other interventions. There have been two Cochrane reviews, the gold standard for assessing medical research, in 2006 and 2020. The first review found no evidence that the method helped recovering alcoholics. In the second review, the results of which superseded the first, AA adherents were slightly more likely to be sober after a year than those following other methods, including cognitive behavioural therapy, but they did no better on a number of other metrics, such as a reduction in the severity of drinking among people who did not find full recovery, and mitigation of the negative side-effects of excessive drinking.
In 2017, the Department of Health and Social Care published a report known as The Orange Book, featuring research into how best to treat addiction. It mentions the 12 steps a handful of times, but only as a treatment offered to willing patients as part of a “menu” of other options for them to choose from. I asked Dr Emily Finch, one of the 28 addiction experts who worked on the report, why they received scant mention. “There is very little evidence to show that they work,” she says. “This is not to say they don’t work. The active ingredient for most people in 12 steps is not necessarily about the theory, it’s about things like the social skills it teaches people. It helps people to use their time more productively. I have plenty of patients who say the steps have worked for them, but that’s not borne out necessarily in the scientific evidence.”
So how have we ended up in a place where a quasi-religious treatment method is taken as gospel, especially in the US, when it comes to treating addiction? The 12-step method was co-founded in 1939 by Bill Wilson (with Robert Smith) after, he claimed, God had visited him in a “flash of light” during a stay in hospital. The method provided a convenient remedy, in a puritanical society just out of prohibition, for the issue of “problem drinkers”. Based on the principles of the Oxford Group, a fundamentalist Christian organisation of which Wilson – a salesman, with no medical training – was a member, Alcoholics Anonymous, the 12 steps’ first iteration, was at the time labelled “a curious combination of organising propaganda and religious exhortation,” by the American Medical Association. On the AA website, it states: “There is room in AA for people of all shades of belief and non-belief,” adding that while many believe in a God, others are atheist or agnostic. The 12-step model continues to proliferate today, with at least 50 “fellowships” catering to everything from overeating to sex addiction, gambling and procrastination.
The idea of addiction being a disease was first introduced in 1960 by a scientist and 12-step adherent, EM Jellinek, bringing the method pseudo-medical respectability. The mismatch between medicalisation and a “spiritual” solution jars, says Maia Szalavitz, author and journalist, who is a former 12-step member. She says: “If you went to treatment for depression, cancer or schizophrenia and someone told you to get on your knees, find a higher power, take moral inventory and make amends, you’d think you’d found a quack.”
US addiction specialist Dr Lance Dodes describes the perception that the 12 steps works as a “sampling” bias. “You don’t hear from those who fail,” he says. Dodes estimates the success rate of 12-step fellowships to stand at roughly 5-8%. That means for every person you see at a meeting, there are 18 or 19 who have sat there before, and for whom the method hasn’t worked. Yet 12-step fellowships hold an enduring place in the public consciousness, not least thanks to Marty Mann, an early adherent and PR woman who took the method to Hollywood, where it would feature in films such as Billy Wilder’s 1945 classic The Lost Weekend and many since.
Dodes argues that the approach of turning our will and lives over to the care of God, when we should be seeking psychotherapeutic help, has “caused a great deal of harm to a great many people”. The biggest danger for him is the 12-step programme’s insistence that relapse is down to the individual failing to take responsibility. “At 12-step fellowships, they will say, ‘It works if you work it’,” says Dodes who, along with his son Zachary wrote The Sober Truth, aimed at debunking the science of AA. “But if it doesn’t work, whose fault is it? It’s your fault.” He warns that people “lose years, decades of their life to the programme”, and develop additional problems such as OCD. I spoke to at least one former 12-stepper who had left AA after developing severe OCD, something I identify with since trying to live by the unrealistic demands of “the programme”, constantly worried that I might do something “wrong”.
Yet 12-step rehabs continue to thrive. Addiction rates are soaring. In a review into drug treatment services, Dame Carol Black warned that publicly provided drug recovery services are “on their knees”, while drug-related deaths in England and Wales are at an all-time high. Across England, many local authorities have seen their budgets for addiction services slashed since 2015 as councils struggle to balance the books.
The Priory defends the use of the 12-step model in its clinics. “The 12-step set of guiding principles is recognised around the world, and has been used successfully for more than 80 years to help millions overcome problems including drug and alcohol addiction,” a hospital spokesperson tells me. “It is simply wrong to suggest that it leads to frequent relapse. It is recognised, however, that recovery from addiction can be difficult and, sadly, relapses can happen for some. We have robust aftercare groups and these show that the programmes do work for many people.”
Today, there are 118 private residential substance misuse services in England registered with the Care Quality Commission (CQC). A spokesperson for the CQC told me: “Providers must make sure that they obtain consent lawfully … Staff should provide sufficient information about treatment options and risks, and ensure service-users have capacity to make an informed decision.” Yet this is exactly what I feel I did not do. Informed consent involves patients being provided with a variety of treatment options, along with information about expected outcomes, in order for them to choose what they feel is best, and right, for them. Not to do so makes for ineffectual treatment. A spokesperson for the Priory says: “Patients are entitled to question all or any element of the programme, or indeed discharge themselves from treatment and find an alternative which they feel is more appropriate to their needs and beliefs.”
While roughly half of the rehabs in the UK offer only 12-step treatment, the other half more closely follow the guidance of The Orange Book, and the principle of informed consent, by providing patients with a range of therapeutic options. That isn’t to say these institutions should be immune to criticism. Until 2014, the sector was unregulated: anyone could set up a “rehab”. In 2017 the CQC issued a report outlining serious concerns with the industry. It warned that 49 out of 68 clinics inspected contravened the Health and Social Care Act 2o12. One rehab, not run by the Priory, was struck off when it was found to be unaware of how to support clients through an opiate or alcohol detox. The Priory points out that the clinic I attended has a CQC rating of “good”, and that 86.5% of its healthcare sites in the UK are rated as good or outstanding. It adds that it will “take on board” my concerns about the treatment I received “in order to improve the patient experience at the clinic”.
Ironically, many in the 12-step community shun rehabs, complaining they charge for something that should be “given freely”. “Rehabs are the definition of a rip-off,” says Szalavitz, “paying for what you can get at 12-step meetings for free.”
I stayed clean for 13 months after I left rehab. I followed the advice I had received there to a T. I checked in with the counsellors by phone and stuck to the schedule I had made: five 12-step meetings a week. I did a “90 in 90”: attending a 12-step meeting every day for the first three months. By the end, I could no longer see the wood for the trees: I had internalised “the programme”. I drove to rehab every Wednesday for aftercare. Before long, I noticed those I had been in with dropping away. After eight months, I attended an aftercare session and realised that only three of the 25 I shared time with there were still in attendance.
It wasn’t long before the cracks started to show for me, too. I had moved back to London, into a flat I shared with a friend. Before long, I was closeted in my room, reluctant to see people for fear of a relapse. I continued to attend meetings; I prayed, at the suggestion of a Narcotics Anonymous mentor. But I also became pious and controlling. The undiagnosed eating disorder I had as a teenager came back. I cut out sugar, wheat and dairy. I became fastidious about exercise. Life was joyless. And all the while, I disappeared further down a dark rabbit hole, hoping that a “spiritual awakening”, as promised by the programme, was just around the next bend.
As my old life fell away, I entered a very dark place. After a three-week spell in which thoughts of killing myself looped in my head, I told the mentor that I was suicidal. He told me this showed my step two – the requirement to find faith in a “higher power” – wasn’t strong enough. I needed to reinvest myself in the programme, attend more meetings. I felt broken. But worse, I felt alone.
I remember thinking at the time that if I did kill myself, and my parents asked what had gone wrong – perhaps of the rehab centre – they would have been told: “It was the disease that got him.”
Rather than kill myself, I went on a bender. First wine, then crystal meth. I was conscious of two things: that I had promised myself I would never drink or take drugs again; and that since leaving rehab, I had thought only of recovery – the 12-steps; what I was doing right, what I was doing wrong.
I bounced in and out of 12-step meetings for a year after that. Finally, I started seeing a therapist and focused on the issues that had led to me using in the first place. I told her I felt I was “in recovery from recovery”; I took antidepressants for the first time in my life. I went through a period of great cognitive dissonance as I off-boarded the faulty thinking instilled in me by 12-step programmes. The damage done to my life during that period is immense: personal finances, friendships, employment prospects all went through a trapdoor. As a gay man, I feel the idea of being “diseased” was particularly difficult for me to take on board. I had grown up with the threat of HIV, and knowing that even after being legalised, homosexuality had been classified as a mental disorder until 1987.
As well as the audacity of diagnosing people with a life-threatening disease that I don’t believe exists, I feel that the treatment I received stood in the way of accessing care that suited me. If I had been provided with genuine choice as a patient, I would have saved myself an awful lot of time and money. I’ve had to work through the trauma of my rehab experience: the unwieldy, dispassionate way the method of the 12 steps was delivered to me, and the apparent insistence that it was the only way I could live.
In the UK, Action on Addiction is available on 0300 330 0659. In the US, SAMHSA’s national helpline is at 800-662-4357. In Australia, the National Alcohol and Other Drug Hotline is at 1800 250 015; families and friends can seek help at Family Drug Support Australia at 1300 368 186.
This article was amended on 6 and 9 December 2021. An earlier version said there was very little reputable evidence to show that the 12-step programme works; this should have said there was very little reputable evidence to show the programme works better than other interventions. It was also revised to make clear that the Cochrane review of 2020 superseded the findings of the 2006 review.
In this quasi-religious programme, ‘working the steps’ is the remedy for any problem, but for me the cracks soon started to show