12 Steps Beyond : Therapy: The self-help program designed for alcoholics is increasingly being adopted by people with emotional problems. Mental health experts question the method’s value.
Karen R. had done everything she could think of to overcome the heart-pounding, clothes-soaking panic attacks that struck out of the blue and eventually made her too afraid to leave her Ojai home.
She tried desensitization, in which a therapist each day tried to lead her a little bit farther out into the world. She tried cognitive therapy, in which the therapist helped her alter her thought patterns and belief systems. And hypnosis. And positive affirmations in which she repeatedly brought positive thoughts to mind. And more therapy.
Still, nothing worked. “For 10 years, it was like having heart attacks all the time and never knowing when the next one would come,” she said. “I thought there was no one in the world who understood what I was going through.”
Then a friend suggested a different approach. Why not try a weekly meeting with no professional involvement, no cost to participants and a format that for years has been used to treat alcoholics and addicts?
“All I know is that it changed my life,” Karen said. In January, she started the county’s first meeting of Phobics Anonymous at Vista Del Mar Hospital in Ventura. In keeping with the group’s traditions, she did not want her last name used.
“I’m not the only one who feels this either,” she added. “I know people who say they have tried doctors and therapists and everything else, but it wasn’t until they started applying the 12 steps to their panic attacks that they started getting better.”
Phobics Anonymous isn’t the first self-help group to borrow from the 12 steps of Alcoholics Anonymous, the organization started by two seemingly hopeless alcoholics in 1935 that now has millions of members worldwide. According to the nonprofit National Self-Help Clearinghouse, there are now more than 150 “anonymous” titles used by groups nationwide and the number is growing rapidly.
“There are new ones practically every day,” said Frank Reissman, the National Self-Help Clearinghouse’s director. “I just found out that there is now a meeting of Isolators Anonymous. I just wonder if they’ll talk to each other.”
Reissman of course, is kidding about what might go on in some of the newer 12-step meetings. But to a growing number of psychiatrists and psychologists, the subject isn’t funny.
Once, the majority of “anonymous” groups dealt with addictive substances such as alcohol, narcotics or tobacco. But in recent years, groups have formed to deal with problems other than substance abuse.
Dark outlook on life? Try Depressives Anonymous. Emotional instability? Try Emotions Anonymous. Suffer from dissociation, obsessions or compulsions? There is Neurotics Anonymous, Schizophrenics Anonymous or Obsessive-Compulsive Anonymous. Dealing with past sexual trauma? Incest Survivors Anonymous.
Sexual problems? Impotents Anonymous. Eating Disorder? Anorexic Bulimics Anonymous. Abuse your kids? Parents Anonymous. Abuse other people’s kids? Molesters Anonymous. Beat your wife? Batterers Anonymous. Can’t seem to stop? Repeat Offenders Anonymous.
And the list goes on.
But as more and more people turn to self-help groups to deal with problems other than chemical dependency, mental health professionals have begun asking some serious questions:
Are 12-step programs replacing the analyst’s couch as a place to deal with emotional, mental and sometimes physiological problems? Are principles designed to help alcoholics appropriate for people trying to overcome emotional disorders? And, if they are not, should the use of 12-step programs be limited in any way?
“For years, people kind of accepted that the 12 steps were OK, but now there is controversy,” said Marcia Ellis, a Ventura psychologist who has many clients who are or have been in 12-step groups.
“The 12 steps have helped a lot of people with alcoholism and related problems, but I’m not convinced that it translates well for other types of disorders. It’s hard to abstain from something like schizophrenia. This has caused some good discussion.”
But Frances Jemmott-Dory, executive director of California Self Help Center, said she sees the 12 steps as a complement to traditional therapy. “The goal is to cope one day at a time. It takes that daily renewal to manage the disorder, rather than the disorder managing you. But if you need medicine to be stable, then that’s an important part of therapy.”
Not surprisingly, the major area of debate in the mental health community surrounds the actual therapeutic value of some of the groups, most of which have a kind of buddy system to help members. The creed of Alcoholics Anonymous is “one alcoholic reaching his hand out to another,” and new group members are required to link up with another more experienced member, known as a “sponsor.”
Having a sponsor may be fine for people with drinking problems, many professionals say. But how useful is a sponsor at dealing with more complex problems--such as incest, eating disorders or schizophrenia?
“That’s the problem with any kind of self-help program,” said Chester Fretheim, a neuropsychologist and director of Carriage Neuropsychological Services in Oxnard. “Any time you deal with someone whose primary qualification for helping you is that they have gone through it themselves, it’s questionable how well they have actually resolved it.”
Jemmott-Dory says she finds it peculiar but understands how the steps can be of help to incest victims. “People find it very comforting to acknowledge that they are incest survivors, that they are innocent and didn’t do anything to bring this on. And there are things in their life, (the incest) that caused them to act in harmful ways to others.”
Yet, 12-step members concede there are pitfalls. One woman said she has come across sponsors who, though in a group for less than a year, already are advising others on how to run their lives.
“But there is a tradition that takes care of that, if the groups really adhere to it,” she said. “It says, ‘Our leaders are but trusted servants, and they do not govern.’ ”
Fretheim, as with a number of professionals contacted, said he also considers 12-step programs a “useful adjunct” to therapy, but wouldn’t recommend that they take the place of it.
“These days we have shorter-term and more realistic treatment options for a lot of these problems,” he said. “I’d hate to see someone end up for life in something like a Phobics Anonymous group, who could have resolved it in three months of psychotherapy.”
The flip side of that argument, of course, is that many people in the 12-step groups cannot afford traditional therapy, or they already have tried it to no avail.
“One woman had tried to commit suicide, tried therapy, tried everything, and it wasn’t until she joined Emotions Anonymous that it worked for her,” said Carol Eisman, associate director of the California Self-Help Center based at UCLA. “Often, these people have hit bottom when they try these groups. . . . There is something about the program that works where all these other services have failed.”
Some of the success, say many members, comes from the religious element in 12-step programs. But that is another sticking point for critics.
Six of the 12 steps refer to a “higher power” and, according to AA writings, the effectiveness of the program as a whole rests on how well and earnestly individuals can “turn our will and our lives over to the care of God as we understood Him.”
Jemmott-Dory explained that a participant might benefit by invoking a force greater than himself. “He might say, ‘It’s not just about me as a person who lacks willpower. It’s about something that is bigger than me.’ ”
To psychologist Stanton Peele, author of “Diseasing of America: Addiction Treatment Out of Control,” that aspect is the most disturbing when it comes to dealing with emotional problems.
“There is no problem with people having religious conversion experiences. The only problem is mistaking that for therapy,” Peele said in a newsletter funded by the California Department of Mental Health. “It is a dangerous precedent to start mistaking religious conversion for objective psychological treatment.”
Proponents of the programs, however, see no conflict. “The 12-step approach is totally different than organized religion,” says Reissman of the National Self-Help Clearinghouse. Reissman agrees that the groups are not a substitute for therapy, but he also believes they do more good than harm.
“It gives people a sense of caring, of nurturing,” he said. “Do they get confused sometimes, too? Possibly. But I think it’s very valuable.”
Some progressive political groups also have criticized the 12-step format when used to treat complicated disorders, primarily because it focuses on individual problems instead of looking for underlying causes.
For instance, feminists have argued that women with eating disorders have succumbed to a distorted societal definition of beauty resulting in self-loathing and compulsive behavior. Without undergoing a fundamental change about how they see themselves as women, the thinking is that any “progress” in 12-step groups will be cosmetic.
Groups such as Anorexic Bulimics Anonymous, on the other hand, say they encourage members to alter their behavior and then go back and figure out what caused it if they want to.
Many members believe it is that simplicity of the approach that has made the 12-step programs so successful.
“Listen, a lot of us have analyzed everything to death before we even got in here, and we don’t need to do it any more,” said Ellen G., a member of Emotions Anonymous who said she struggled for years with depression and feelings of worthlessness. “I mean, what’s the point of understanding that you’re screwed up because your parents emotionally abandoned you if it doesn’t help you to feel any better?”
It may be impossible to ever know how well 12-step programs work. Although there are no studies or surveys, Alcoholics Anonymous generally estimates that the success rate for its members is about 10%. Because of anonymity issues, there is no way of gauging how well people with emotional problems do in the groups.
“I’ve heard it said that we are a nation of people who define themselves by their illnesses, but I don’t know if that is true or not,” said Marina Ross, director of Primary Purpose Alcohol and Drug Treatment Program in Oxnard. “There obviously is a great need for some principles of living, which is what the 12 steps are all about.
“But the real question, I think, has to be: Are these groups doing harm? I don’t know the answer to that. And to the best of my knowledge,” she said, “I don’t think anyone else does either.”
SELF-HELP BASICS FROM AA
The 12-step program used by individual self-help groups is based on the one designed by Alcoholics Anonymous. “They change a little bit to make it applicable,” said Carol Eisman, associate director of the California Self-Help Center at UCLA, “but basically they are all the same.”
Here is the AA version.
1: We admitted we were powerless over alcohol--that our lives had become unmanageable.
2: Came to believe that a Power greater than ourselves could restore us to sanity.
3: Made a decision to turn our will and our lives over to the care of God as we understood Him.
4: Made a searching and fearless moral inventory of ourselves.
5: Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6: Were entirely ready to have God remove all these defects of character.
7: Humbly asked Him to remove our shortcomings.
8: Made a list of all persons we had harmed, and became willing to make amends to them all.
9: Made direct amends to such people wherever possible, except when to do so would injure them or others.
10: Continued to take personal inventory and when we were wrong promptly admitted it.
11: Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12: Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.