Introducing a 12-Step Approach to Change: Three Broad Strategies for Graduate Education and Training

Foundational Evidence for 12-Step Approaches to Change

Across a range of disorders, self-help approaches to change are effective (Norcross et al., 2013). In many instances, their effectiveness approximates that of professionally delivered psychological services and commonly produces effects superior to no treatment at all (Barlow et al., 2000; Seligman, 1995). When the problem is substance use disorders and the change method involves 12-step approaches to addressing it, the research evidence mounts. This research establishes that this approach to change leads to specific and important outcomes, such as ceasing drug and alcohol use (Emrick & Tonigan, 2004; Fiorentine & Hillhouse, 2000; Humphreys et al., 2004; Moos & Moos, 2004; 2007; Tonigan et al., 1996). 

Much of what undergirds contemporary substance use disorder treatment systems has historically shared and borrowed from12-step approaches. For example, it only took three years for elements of the Alcoholics Anonymous (AA; Alcoholics Anonymous, 1976) program emerging from Akron, Ohio in 1935 to appear in the menu of programs being offered at the Public Health Service’s Federal Narcotics Farm in Lexington Kentucky. It was also recommended as a method of aftercare for individuals struggling with narcotic use upon release from the farm (Magura, 2007; Vogel, 1948; White, 1998). Such reciprocal relationships continue today and scholars note that contemporary outpatient, residential, and medical substance abuse treatment programs share and borrow aspects of 12-step approaches (DeLeon, 2004; DiClemente, 2007; McKay, 2009).

More recently, studies with increasingly complex and stringent analyses have compelled the field beyond debates about sample bias, demonstrating that the influence of 12-step approaches in achieving successful outcomes lies beyond self-selection (Humphreys et al., 2014; Humphreys & Moos, 2001). Some scholars have been busy unpacking the social, cognitive, and affective mechanisms of change that facilitate this approaches’ success (Kelly, 2016), while other scholars have conducted research demonstrating that even at follow-up, those involved in 12-step approaches to change have outcomes equal to those of professionally delivered services (Morgenstern et al., 1996; Ouimette et al., 1997; Wells et al.,1994).

Research also suggests that people participating in 12-step approaches experience benefits beyond remission of a substance use disorder, including increased psychological health through the promotion of effective social support and coping (Fiorentine & Hillhouse, 2000; Kelly, 2016; Tonigan et al., 1996). Finally, research also demonstrates that clinicians can influence the process of their client’s entry into 12-step approaches (Nowinski, et al., 1999). At the very least, clinicians should be making inquiry into client’s beliefs about their prior 12-step approach involvement. This line of inquiry represents an important clinical consideration for treatment planning and change (Timko et al., 2006; Tonigan et al., 1999).

Definition of Terms in 12-Step Approaches to Change

Understanding that the science supports people’s participation in this approach, while foundational, is only useful if students and their educators have a working definition of what is meant by 12-step approaches to change. Here we borrow from the seminal work of Miller and Thoresen (1999) who delineated an approach to spirituality. Their definition fits squarely within the wheel house of 12-step approaches as an interrelated set of practices, beliefs, and experiences. This definition is intentionally broad in order to consider addiction as a disorder of lifestyle and change as an unfolding process with many elements. It is also specific enough to allow students to delineate each element into measurable and describable parts, thus serving as a useful educational tool. 

A deeper analysis of the practices, beliefs, and experiences elements are provided in Magaletta and Leukefeld (2011). Briefly, practices are behavioral aspects of a person’s participation in 12-step approaches to change. Common practices might include attending meetings, speaking at meetings, reading 12-step literature, conducting the action and/or reflection suggested in a step, praying, meditating, helping a new 12-step member, etc. Beliefs point toward cognitions and cognitive change concerning substance use, recovery, and various aspects of lifestyle. A stellar review of beliefs and other cognitive changes and cognitive techniques used in 12-step approaches can be found in Bristow-Braitman (1995), McCrady (1994), and Steigerwald and Stone (1997). Experiences are the center of gravity in 12-step approaches to change, yet remain the most difficult to illustrate. They refer to the reflections of a person who finds themselves being able to do something that they had previously been unable to do. In the case of people with substance use disorders, this may initially mean to cease using, however, this is only the beginning. DeLeon (1997) describes this process:

The process of change is primarily understood by the participants themselves in subjective terms, through perceptions and experiences. Individuals not only must actively engage in the behaviors and attitudes to be changed but must feel the feelings associated with this engagement, understand the meaning or value of the change, and come to see themselves, others, and the world differently. (p. 11)

Three Broad Strategies to Impart Knowledge of 12-Step Approaches to Change for Graduate Education and Training

As demonstrated above, evidence supports the effectiveness of 12-step approaches to change, and can be defined as an interacting set of practices, beliefs and experiences. How can this all be transmitted to graduate students? Within a broad generalist training curriculum there are three equally broad strategies that can be used to impart knowledge of 12-step approaches into education and training. These strategies can be woven into various courses or aspects of training that students receive and can be considered didactic material, can be woven into ongoing supervision, or can be integrated into a student’s work during a practicum or internship training experience. Considered together, these strategies can provide both educators and students an opportunity to learn about 12-step approaches to change through demonstration, participation, and facilitation.

Strategy 1: Demonstrate through readings and/or assignments the elements of the 12-step approach as they appear in 12-step literature.

This first strategy challenges students to think from an implementation standpoint and demonstrates that 12-step literature provides individuals who want to change a description of the practices, beliefs, and experiences that lead to change. Similar to training clinicians toward fidelity within a particular model, people who participate in 12-step approaches to change often use 12-step literature (e.g., Alcoholics Anonymous, 1953; 1976) to guide their process and adhere to the approach. Not only can the stories of recovering individuals from this literature be scoured by students to answer questions about detecting substance use disorders, but they can also be used to highlight the peculiar mental twists that emerge when someone tries to change but remains unsuccessful. The 12-step literature can also be used to elucidate various theories of change that underlie various counseling practices. Using the practices, beliefs, and experiences definitional framework allows students to begin their readings with purpose. In unpacking the term 12-step approaches and in using the literature, illustrations of the complexities of both substance use and recovery phenomena emerges. And, if questions about a client’s substance use arise later in treatment, students may recall that such reading resources are available to them and their client. While there are many examples of effective 12-step literature, below are two different ways that educators can use 12-step literature to demonstrate 12-step practices, beliefs, and experiences. 

• The first chapter of the book, Alcoholics Anonymous (1976) provides robust diagnostic material from the life of Bill Wilson, an AA co-founder. It is replete with examples of the mental and physical features of alcoholism, features which map well onto the diagnostic criteria described in medical classification systems. For this reason, the reading is a perfect supplement for various active learning exercises in the application of knowledge for a general psychopathology or a diagnosis and assessment course. Individually, or as a group, students can pull out the diagnostic criteria and apply them to aspects of Bill’s decent into alcoholism.  Specifically, after a lesson on these addictions criteria, an instructor may have a copy of the chapter and ask students to read the story out loud in class while others list or discuss the diagnostic criteria they hear being read.  his strategy makes available to students the experiences, beliefs and practices of others who have or are participating in the 12-step approach. This particular story also provides a historical review for the emergence of the approach in the form of a story.
• Similarly, a theory of change or counseling techniques class might benefit from assignments with the chapter called “How It Works” (Alcoholics Anonymous, 1976).  This particular chapter, as well as the remainder of the Bill Wilson Story mentioned above, can supplement a lesson on the 12-steps themselves as both chapters provide the reader an overview of how individuals approach the beliefs, practices and experiences of the 12-step approach. For example, in a psychotherapy class a person’s recovery story, amply available in 12-step literatures, can be read to illustrate cognitive changes that people experience both on the decent into substance use disorder and also the ascent to recovery. Such explanations are especially powerful when considered from the perspective of how the 12-step approach might relate to techniques proposed within various counseling theories. 

Strategy 2. Participate in 12-step approaches by creating or supporting experiential opportunities for students via active learning assignments.

This strategy allows students to co-create their own experience learning directly from others who are changing or trying to change using 12-step approaches.

• For example, students can be offered an opportunity to learn by assigning attendance at an open 12-step meeting. This is the easiest and quickest method for students to begin understanding the experiences element defined above, via reflection upon their own experiences. Here special consideration should be paid to the assignment sequence, with the following being recommended: 1. Complete readings that outline evidence for the approach and a definition of terms.  2. Learn how to find a meeting to attend and attend it. 3. Come to class ready to discuss meeting attended.  4. Attend a second meeting.  5. Write up a brief summary / reflection paper.  This type of assignment can serve as an addendum within a psychotherapy, strategies and techniques, or family therapy courses.

It is most important to prepare students so that they know what to expect and to look for, prior to attendance, via readings. Ask the students to listen for beliefs, practices and experiences among those in attendance. Other instructional tips that may prove important include teaching students to select an open meeting, one that is available not just to those with addictions. They will also need to understand that there are different types of meetings – including speakers meeting which feature a person in recovery telling their story; literature meetings where participants read from 12-step literature and discuss it; and discussion meetings where a topic is selected and commented upon. In some meetings everyone may be given a chance to talk (volunteer), but no one is forced.  Students attending a meeting may or may not have a chance to introduce themselves.  If they do, an appropriate introduction might be “Hi.  My name is _______, and I am here to learn more about 12-step approaches to change. I pass.”  This would mean that the student is finished and someone else in the meeting can now speak. Students should not to bring a tape recorder or paper for note taking during the meeting. They may find that listening actively, but silently, takes a lot of concentration and will require their utmost attention. Although there are no rules, it is uncommon for students to ask questions during a meeting. It would be best to ask a question, if they are compelled, after the meeting. If students are already a member of a 12-step meeting they should be encouraged to attend a differently focused 12-step meeting with which they are less familiar. It is essential that students not ever reveal anyone’s identity. Further, they should understand that they are there for their own learning experience of how others approach the 12-steps. 

• An important element for learning to occur in experiential methods, is reflection. For this reason, after the first meeting is attended, a large class discussion should be generated with the question, “what about attending that meeting was most important to your learning” (Stanier, 2016). This allows for the necessary reflection upon the experience that allows students to begin applying or unpacking this experience – and to carry this learning forward as “experiences” when they attend a second meeting. After this second attendance, they have an experiential frame of reference and can begin translating this into their reflection paper. 
• In order to extend and structure learning the following elements of the paper are suggested: Develop and pick a title for the paper, one that reflects the essential lesson learned. Begin the paper with a brief, general summary of the meetings attended. Students should review impressions of the meetings and whether or not they would refer a client to that meeting. They should consider the type(s) of people they think might do well in this particular group and describe how they, as a newcomer to this group felt. How do they think a new comer to this meeting might feel? If the majority of their learning occurred in one meeting (i.e., they attended the same meeting two different times), then they might focus upon that. In their reflection, students should integrate concepts already learned in class perhaps counseling theories or stages of change models or skills such as active listening, the 12-step approach beliefs, practices and experiences framework, or diagnosis and assessment of substance abuse and dependence. 

Strategy 3. Facilitate professional outreach – learning to link professional communities with people practicing 12-step approaches.

Properly armed with an understanding of the practices, beliefs and experiences inherit in the approach, students can begin to patrol the border between professional service delivery systems and the people and organizational elements of the 12-step approach system.

• For example, you can courage students to explore and understand how the 12-step approach can be understood organizationally, having them explore and propose how they would facilitate links or bring a 12-step meeting into their clinic, practica or internship site. This teaches basic skills such as learning about where meetings occur, and also teaches students to consider aspects of their current practice organization – what will and will not be done to support volunteer programs? If on practica or internship, does the setting already host meetings?  If not, why not? Are there other policies beyond the volunteer policy that must be understood before initiating such links? Does the setting have restrictions on volunteers or types of volunteers that can be tapped to host events within the setting? This is practicing the administration and management of service delivery lines and promotes students exposure to and familiarity with the “organization” of 12-step groups and an experiences. It aids in understanding the nuances of working with such groups in closed settings where students may someday be employed. 
• A similar facilitation practice would be to encourage a presentation by 12-step members for a class or part of a panel of presentations for a recovery month or other educational series in a given practice setting. Such community wide educational events can be used to educate other students and/or employees (if in a practica or internship setting) on how 12-step approaches can be used to support employees, colleagues, and others. Recognizing that many individuals and families face a multitude of difficulties when substance use disorders strike, and that these difficulties quite often spill over into the workplace and wider community, this type of presentation can reach a broad audience. 

Conclusion

The perspective of service delivery through a workforce must be linked to and inclusive of the reality that many people can change on their own. The approaches these individuals use to recover are an important optimizer for the promotion of psychological health. Ultimately, service delivery and guided self-change approaches, both together and separately, are required to impact the substance use crisis and to support individuals along their path toward recovery. Now is the time for graduate training and education to become a part of that story. Each strategy presented here provides opportunities for exposure to the practices, beliefs, and experiences that form the 12-step approach to change. When educators and students are exposed to this influential framework, they are in the best position to increase access, reduce barriers, and encourage optimal use of this psychological health resource among those they will serve.