Points to Ponder: Twelve Steps and Recovery
Twice, in recent weeks, I’ve encountered clients in recovery or recovered from an eating disorder that found recovery through 12-step programs. As a therapist with training in addictions and eating disorders, this caught my eye. In my own training, 12-step programs were controversial. Extreme viewpoints dotted both sides of the aisle when it came to debating effectiveness, science, and support for the 12-step method. In my training in eating disorders treatment, 12-step programs were met with a critical eye, as those who observed meetings came back with mixed reports about size shaming and blaming. But as I listened to my clients, I was forced to come to terms with my own jaundiced eye. This happens frequently, lest you think me narrow minded, and it is an experience I welcome with curiosity and warmth (and sometimes frustration, let’s be honest). It raises questions not just about 12-step, but about how we view health and healing, treatment and recovery. Bearing that in mind, here are some points to ponder.
History and Controversy
Twelve step programs originated in 1938 to address alcohol addiction. The founders, Bill Wilson (Bill W.) and Dr. Bob Smith (Dr. Bob) established the program as a fellowship for those struggling with alcohol addiction. About fifteen years later, in 1953, AA gave permission for NA, or Narcotics Anonymous, to build fellowship with the same steps and traditions in order to help those struggling with addiction to narcotics. Twelve step programs ask that those in fellowship recognize their powerlessness over their addiction and surrender it to a higher power. They then work through a process of behavioral, spiritual, and emotional changes to help promote sobriety and healing. Members can also find support through sponsors and sponsorship. Twelve step programs have expanded to incorporate various addictions, including substance dependence, eating disorders, sex addiction, gambling, hoarding, and others.
Controversy over twelve step programs centers primarily around efficacy. An article in Pacific Magazine by Maia Szalavitz in 2014 (see link below) argued that since its inception, twelve step programs have become the dominant treatment modality. In a critique of the preponderance of twelve step methodology in treatment, Szalavitz refers to several recently published books and articles that question the efficacy of the twelve step approach. It’s important to note, however, that efficacy studies applied to one group and subset of twelve step programs may not be applicable to others. In an organization where every meeting is run differently, experience and benefit are highly subjective and relative.
The fact that each experience is unique is another part of the controversy. Twelve step programs have come under fire for their propagation of their own ideals, morality, and views about addiction. Moreover, twelve step programs perpetuate themselves and these beliefs through the sponsor system and outreach, creating a self-sustaining system that, depending on the viewpoint of the research, may maintain systems of illness or systems of recovery. As a close system, twelve step programs fall under the same criticism as many other closed systems, that they are not open to outside perspectives. More extreme sides argue that twelve step programs are a cult, especially considering the spiritual aspects of the programs. In the end, the controversies and critiques are numerous, but so are the recovery stories. How then, do we apply this to eating disorders?
Twelve Step and Eating Disorders
Twelve step programs for eating disorders include Eating Disorders Anonymous , Food Addicts in Recovery, and Overeaters Anonymous. How is abstinence defined in these programs? As one person described their program to me, abstinence was about eating because it allowed them to be abstinent from their eating disorder. But abstinence from one eating disordered behavior can frequently lead to the development of another disordered behavior, especially when concerns regarding weight become involved. So then, how do these programs help members safeguard against this?
Eating Disorders Anonymous, for one, emphasizes nutrition and healthy balance. Food Addicts in Recovery offers a structured meal plan through sponsorship (sponsor and member work together on this). In speaking with clients regarding this, however, these meal plans aren’t established necessarily by registered dieticians (there is no requirement to have a nutritional education background in order to sponsor) and increasing or decreasing intake is largely based on doctor’s recommendations (reported by the member for anonymity), which are largely based on BMI, which we know is faulty. The idea being that increasing and decreasing intake will allow for the maintenance of healthy weight while at the same time decrease disordered behavior. But the emphasis is still, ironically, on weight.
And here’s where the jaundiced view comes into play.
In my training on eating disorders and treatment, there was a lot of movement and emphasis on mindfulness and intuitive eating and even more movement away from any discussion of weight (other than in weight restoration). So much so, in fact, that I recoiled when I heard “structured meal plan” and dove further into what that actually looked like. I admitted this immediately to my client, disclosing my viewpoints about intuitive eating and recovery. But my client humbled me when she explained that she just couldn’t do intuitive eating, that it never worked for her, and that, quite frankly, the program had saved her life. Our mutual disclosures helped build a rapport and helped get me thinking in ways I hadn’t thought about before.
Perhaps the biggest thought worm of the interlude was questioning how we view healing and recovery. In my narrowness, I realized that I was missing a potentially important tool to help others approach healing. Twelve step programs aren’t perfect, and it’s clear that there are some really important questions related to how they are structured to promote recovery, but the bottomline remains the same: No one treatment modality is going to work for every client. And the behavioral, emotional, and spiritual work of twelve-steps can be profoundly healing.
Time and again, clients come to me with different view about twelve steps. But for everyone that rejects the model, there’s always another that talks about the group of friends they have found, the connections they have made, and the invaluable support they have discovered. Eating disorders are very much disorders of isolation and shame. When it comes to healing, I had to ask myself, what was really important to help my clients into recovery? The answer was ultimately the same as it’s always been: community, hope, compassion, and caring.
In an article for Psychology Today, David Sack, M.D. questioned the hostility towards 12-steps, arguing that much of it, including the controversies over efficacy, were a result of misunderstanding the programs themselves. In the end, one thing is clear. Twelve steps, for all their controversies, provide something critical in recovery. They provide community. They also provide hope, compassion, and a safe place to work through the holistic struggles of these complex disorders. They help those struggling find another, better way to live for themselves in a way that works for them. As a healer, I can’t ask for more than that.
Interested in more info? Here are some links:
Eating Disorder Hope
Dr. Sack’s article:
Maia Szalavitz’s article:
Eating Disorders Anonymous:
Food Addicts Anonymous: