Addiction and Psychotherapy — Why AA Alone Is Not Always Enough
I am in long-term recovery from addiction. I have attended 12-step meetings. I trained at the Hazelden Foundation. I have supervised the clinical teams at PROMIS Recovery Centre and Cardinal Clinic. And I have, in 25 years of clinical practice, watched people attempt to recover from serious addiction using the 12-step programme alone, without psychotherapy, and I have seen what that produces.
The 12-step programme saves lives. It provides a structure, a community, a set of practices and a framework of meaning that, for many people, makes sustained recovery possible. I am not arguing against it.
I am arguing that it is not psychotherapy, and that asking it to do what psychotherapy does — while declining to do psychotherapy — produces, for a significant proportion of people in recovery, a result that is described as sobriety but which is, more accurately, white-knuckle abstinence.
What the evidence shows
The Recovery Research Institute has reviewed what the research actually shows about residential versus outpatient treatment. Its conclusion is striking: some studies found that people who attend intensive outpatient programmes fare just as well as those in residential treatment. The evidence that residential treatment produces better outcomes than well-structured intensive outpatient care is weaker than the clinical consensus suggests.
What the 12-step programme does and does not do
The programme offers structure, community, accountability, sponsorship and a framework that includes a spiritual dimension. For many people, this framework is transformative.
What it does not offer — and was never designed to offer — is an exploration of the psychological conditions that gave rise to the addiction. The traumatic history. The attachment patterns. The specific psychological function that the substance or behaviour served.
“I have worked with people who had five years of sobriety from AA and were, in many important ways, still completely organised around the addiction. The substance was gone. What had driven them to the substance — the terror, the shame, the unbearable internal state — was still entirely untouched. The programme had given them a way to not pick up. It had not given them a way to live.” — Philippe Jacquet
The psychological work that sobriety requires
Recovery requires addressing what the addiction was doing. Every addiction serves a function — it manages an internal state that the person could not manage otherwise. Understanding that function — specifically, not in the abstract — is the beginning of building something to replace it.
This is psychotherapy. It requires a trained clinician, a regular therapeutic relationship, and time. I offer intensive bespoke outpatient treatment as an alternative to residential rehab for many clients — the same depth of clinical work, while the person remains in their life.