AA isn’t the only way to change your relationship with alcohol. Here are other options

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Chances are, you or someone you know has gone to an Alcoholics Anonymous meeting.

The recovery program is by far the most ubiquitous form of support for those looking to change their relationship with alcohol. As of 2020, AA had more than 2 million members in 118,000 groups across 180 countries. The 12 steps have helped an untold number of people.

In the U.S., especially in communities that aren’t in metropolitan areas, going to AA can sometimes feel like the only path to recovery. The first resource you’ll be offered if you’re talking to a friend or a doctor or a therapist about your substance use will most likely be a list of local AA meetings. And most treatment facilities in America are at least partly based on the 12 steps.

But AA isn’t a good fit for everyone. Maybe you have intense social anxiety and the group model doesn’t work for you, or you feel uncomfortable with how God is invoked throughout the program. Maybe AA’s hard line on what counts as recovery — lifelong abstinence from alcohol and all other drugs — has actually made it harder for you to change your relationship to drinking. AA also endorses the disease model of substance use problems, which could feel dismissive if you know that your drinking is the most effective way you’ve learned so far to soothe the wounds of trauma.

A Group Therapy reader asked about different ways of thinking about substance use treatment that have developed since AA was founded in 1935: “I went through recovery during COVID. I believe there is so much information to distribute about addiction and how to get to the other side. Recovery has evolved far beyond inpatient treatment and AA. Both are great options for recovery but there are so many other resources available.�

In this newsletter, we’ll explore why AA has been successful in helping so many people, the principles of harm reduction, and recovery models that can be used instead of — or in tandem with — AA.

AA works for many, but not everyone

A lot has been written about AA over the past eight decades, and fans of the program often cite these trademarks of the 12 steps when they explain what keeps them returning to meetings: community and releasing their struggles with alcohol to a higher power.

Many people who don’t consider themselves religious or spiritual still adopt the concept of a “higher power� — in part because AA is the most available form of support out there, and handing over your troubles to a God-like entity is what it prescribes. But it also can really work for people. In her book “The Recovering: Intoxication and its Aftermath,� writer Leslie Jamison explains how the AA-instilled belief that she was simply not in control of her drinking helped her to stop:

“When people in the program talked about a Higher Power, they sometimes simply said “H.P.,� which seemed expansive and open, a pair of letters you could fill with whatever you needed: the sky, other people in meetings, an old woman who wore loose flowing skirts like my grandmother had worn,� Jamison wrote. “Whatever it was, I needed to believe in something stronger than my willpower. This willpower was a fine-tuned machine, fierce and humming, and it had done plenty of things — gotten me straight A’s, gotten my papers written, gotten me through cross-country training runs — but when I applied it to drinking, the only thing I felt was that I was turning my life into a small, joyless clenched fist. The Higher Power that turned sobriety into more than deprivation was simply not me. That was all I knew. It was a force animating the world in all of its particular glories: jellyfish … pineapple upside-down cake, my friend Rachel’s laughter.�

While AA’s spiritual messaging helps some people, they find that the program works for them for a different reason.

One of the major threats to recovery is that people who have an unhealthy relationship with drinking or drugs usually hang out with other people who use, John Kelly, an addiction researcher at Harvard Medical School, told Vox.

AA meetings provide both a social network that’s supportive of recovery and a way to socialize without drinking. Perhaps most crucially, it’s a place where, ideally, your pain will be witnessed without judgment, said Thérèse Jacobs-Stewart, psychotherapist and author of “Mindfulness and the 12 Steps.�

“The community of people who can understand what you’re going through — that’s a big draw of AA,� she told me. “I frankly don’t know of any other treatment or recovery paths that have that strong an element of community.�

But the very elements of AA that attract so many — spirituality and a group setting where you’re expected to freely share your most private thoughts and emotions — repel others. So, too, does the idea that the only way to change your relationship with drinking is through complete abstinence of all alcohol and drugs. Abstinence is absolutely a crucial part of recovery for some people who struggle with substance use, but research shows that abstinence isn’t essential for everyone. Yet many addiction providers will expel clients for relapsing.

This leaves a lot of people behind for whom abstinence just doesn’t work. As addiction expert Gabor Maté has said: “Abstinence is just not a model you can force on everybody. There’s nothing wrong with it for those of whom it works. But when it comes to drug treatment there’s an assumption that one size fits all. And if you’re going to wash your hands of people who can’t go the abstinence route, then you’re giving up.�

To be clear, AA will not kick you out for relapsing. But repeatedly failing to adhere to its abstinence-only rules is seen as a personal failure in some 12-step circles. It’s a mind-set embedded in the Big Book, AA’s bible. It states: “Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way.�

Alternatives to AA

Over the past few decades, new recovery programs have emerged that provide an alternative to AA.

However, you should know that most of these also use an abstinence-only model. If you or a loved one finds that such a framework isn’t the right fit, I encourage you to look for local programs that emphasize harm reduction, which, put simply, are practices that meet people where they are, whether that’s a need for abstinence or something else. Harm reduction recognizes that all pathways to recovery are valid.

One such organization is the Harm Reduction Therapy Center, which primarily serves people experiencing homelessness in the San Francisco Bay Area. Though HRTC offers harm reduction therapy in more than a dozen locations, it’s best known for its mobile vans, or “clinics without walls.� These sites provide not just drop-in therapy, but water, food, first-aid supplies and harm reduction equipment like safe injection kits. Jason Brown, a staff therapist at HRTC, said that he might say hello to someone who grabs food at the van for a year before they’re ready to talk about their substance use.

“There’s an assumption that someone will make a therapy appointment and be ready to get everything out,� Brown said. “Especially for people with a very difficult day-to-day lived experience, opening up all those doors can be really hard. We need to let those relationships develop over time, to show up consistently with the same energy and attitude of openness, because some people will need that amount of time to get comfortable enough to access our other services.�

Likewise, therapists at HRTC don’t compel people to stop using drugs or alcohol completely. “If I come at them with the perspective that what they’re doing is wrong, and tell them to make immediate changes, we’re completely ignoring why they’re doing it. I need to understand what it’s doing for them, and support them in making changes that help them. If all I’m doing is forcing them to move away from the thing that provides relief, I’m doing harm,� Brown said.

“In the stages of change, people contemplate making a change for the longest. Forcing someone into abstinence ignores this period that they need to be in,� he said. “Harm reduction can step into that space and ask, ‘How do we help you stay safer while you’re thinking about what you’d like to do differently?’�

Compared to abstinence-only recovery programs, those that take this sort of expansive approach are few and far between. With that said, here are some popular alternatives to AA:

• SMART Recovery doesn’t base its program on spiritual principles of steps, nor does it see problematic substance use as a disease. Instead, SMART encourages people to feel empowered to overcome alcohol or drug use that’s become harmful. SMART incorporates interventions like cognitive behavioral therapy (CBT) and emphasizes four areas in the process of recovery: building motivation, coping with urges, problem-solving and lifestyle balance. The program offers mutual support meetings facilitated by trained volunteers and is an abstinence-only program.

• Women for Sobriety is a secular recovery group for women struggling with substance use. It was created by sociologist Jean Kirkpatrick in 1976 as an alternative to the 12-step model. The program is built on 13 affirmations that are intended to support members in changing their self-image and worldview. As is practiced in SMART Recovery, WFS members are encouraged to not label themselves as alcoholics and addicts. WFS encourages complete abstinence from alcohol.
  
• LifeRing Secular Recovery is a nonprofit organization that provides peer-run recovery groups. LifeRing encourages members to stay abstinent from drugs and alcohol, and its doctrine holds that everyone has a “sober self inside them.â€� Members are free to incorporate ideas from sources they find useful, like materials from other addiction recovery groups like AA or religious texts.
  
• Moderation Management provides peer-run support groups for anyone who would like to reduce their alcohol consumption, and acknowledges that not everyone wants to (or can) completely stop drinking. Moderation Management was founded in 1994 as an alternative to abstinence-only programs and allows members to set their own drinking goals with certain guidance, like goal-setting techniques and a cognitive-behavioral change program.
  
• Recovery Dharma was founded 2019 with the mission of supporting peer-led groups using Buddhist practices and principles for recovery. The program stresses renunciation (abstinence), meditation, meetings, understanding the Four Noble Truths and Eightfold Path of Buddhism, engaging in a structured process of self-reflection with others, and supporting others in the program through mentorship.

. . .

If you’re someone who’s changed your relationship with alcohol or drugs, we would love to hear about your journey, wherever you are in it. We might share your note (with your permission) in a future newsletter.

Until next week,

Laura

If what you learned today from these experts spoke to you or you’d like to tell us about your own experiences, please email us and let us know if it is OK to share your thoughts with the larger Group Therapy community. The email [email protected] gets right to our team.

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More perspectives on today’s topic & other resources

In her book “The Recovering: Intoxication and its Aftermath,� writer Leslie Jamison writes about addiction (and the stories we tell about it) in a way that reinvents the traditional recovery memoir. Jamison blends literary criticism, journalistic reportage, cultural history and her own experiences with drinking to demonstrate that the story of recovery can be as electrifying as the train wreck itself.

Why some people swear by Alcoholics Anonymous — and others despise it. This Vox piece draws in interview with experts who’ve researched 12-step facilitation treatment and AA, as well as people who attended the programs. “My goal was to see whether the 12 steps really do help people overcome their alcohol addictions,� wrote German Lopez. “The answer: It’s complicated.�

Other interesting stuff

Love it or hate it, self-care has transformed from a radical feminist concept into a multibillion-dollar industry. In this excellent podcast episode of the “Ezra Klein Show,� Dr. Pooja Lakshmin argues that when you practice real self-care, beyond superficial, individualistic actions like buying a new candle or taking a bubble bath, you not only take care of yourself, but you can also plant the seeds for change in your community.