Alex, a 44-year-old man with severe alcohol use disorder, tells you he “doesn’t do religion” when you bring up 12-step programs. He was recently discharged from an inpatient withdrawal management program, has only tenuously engaged in outpatient treatment, and is worried about going back to drinking. You want to help him find a local support program, but he shuts down at any mention of the possibility.

Twelve-step programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are among the most widely used supports for people with substance use disorders (SUDs). But many clinicians have a limited understanding of what actually happens in these programs and are not able to effectively talk about them with patients. This lack of familiarity can lead to missed opportunities for engagement and referrals that feel hollow or perfunctory. 

This article explains how 12-step programs work, reviews the evidence, and shows you how to talk about them with patients in a way that encourages engagement.

What are 12-step programs?
The 12-step model originated with AA and has since been widely adapted to address various SUDs, such as through programs like NA or Cocaine Anonymous. Some programs even address behavioral addictions such as compulsive eating or sex addiction. 

The core elements of 12-step programs include attending meetings, working through the steps (often with a sponsor), and making a long-term commitment to abstinence. Along the way, participants are encouraged to build a new life grounded in honesty, accountability, and community. 

What happens in a meeting?
When referring patients to a 12-step meeting, first explain what they should expect. Some patients may fear they’ll have to speak or reveal personal details in front of strangers. Reassure them that there’s no pressure to talk. 

Meetings are either open (attendance available to anyone) or closed (reserved for those who want to stop using substances). Most meetings begin with a welcome, a moment of silence, the Serenity Prayer, and a reading of the program’s 12 steps or 12 traditions. What follows depends on the meeting format:

• Speaker meeting: One member shares their recovery story while others listen.
• Discussion meeting: A topic is introduced, and members take turns sharing thoughts or experiences.
• Step meeting: The group focuses on one of the 12 steps, discussing its meaning and application.
• Beginners meeting: Designed for those new to recovery with a focus on foundational steps.

Meetings typically end with a group reflection or prayer. Many groups also hand out sobriety “chips” to mark milestones in recovery—these can be a motivating and symbolic gesture for many participants. 

The 12 steps and their underlying principles
At the heart of these programs are the 12 steps themselves. They guide participants through admitting powerlessness over addiction (step 1), moral self-inventory, and finally, helping others (step 12). While each step has distinct language and focus, the overall structure of the steps is meant to encourage accountability, engagement, and personal reflection.

Another key theme is making amends—repairing relationships damaged by addiction. These steps help individuals take responsibility for their actions and begin to rebuild trust with others. 

Some patients find the spiritual language used by the 12 steps to be a barrier. More than half of the steps refer to a “higher power” or “God as we understand Him.” While this language can be off-putting, it’s important to clarify that 12-step programs themselves are not religious and have no church affiliation. Participants are free to define “higher power” in personal terms. Some may choose nature or the group itself rather than a traditional God. An atheist or agnostic may identify reason, rationality, or a sense of purpose. The idea is humility and connection, not theology.

For a list of the 12 steps as they were originally written and to get additional details about each step, visit www.tinyurl.com/c97spa6c.

Sponsors and “90 in 90”
Sponsorship is a core part of 12-step programs. Sponsors are experienced members who have worked through the steps themselves and can guide newer participants. Patients aren’t required to obtain a sponsor, but having one is a strong predictor of engagement and retention.

Newcomers are frequently encouraged to attend “90 meetings in 90 days.” This daily commitment helps stabilize early recovery, reduce cravings, and establish a routine. You might frame this for patients as a therapeutic trial, much like the way we evaluate medication response over four to six weeks.

Evidence for effectiveness
Although 12-step programs have been criticized for a lack of rigorous outcome data, there is research suggesting that these programs may be beneficial, at least indirectly, when patients actively engage. 

One large comprehensive review found that 12-step facilitation (TSF), a structured approach to connecting patients with meetings, significantly improved continuous abstinence and was even associated with lower health care costs (Kelly JF et al, Cochrane Database Syst Rev 2020;3(3):CD012880). For more about TSF and how it relates to 12-step mutual help groups, see our interview with Dr. Nowinski in CATR July/August/September 2025.

Importantly, active involvement, such as having a sponsor, working through the steps, and attending meetings regularly, correlates with better outcomes than passive attendance alone (Chi FW et al, Subst Abus 2013;34(1):33–42).

Addressing common patient concerns
When introducing 12-step programs, clinicians should anticipate and normalize common reservations. Spirituality and religion are among the most frequent concerns. Reassure patients that belief in a traditional God is not required, and that “higher power” can mean different things to different people.

Other patients may be reluctant because they dislike group therapy. Clarify that 12-step meetings are peer support groups, not therapy groups. There’s no requirement to speak; listening is fine. For patients who say 12-step programs haven’t worked for them, explore what aspects were unhelpful. Emphasize that not all meetings are the same, and that trying a different one may result in a better experience.

Some patients may worry about other members judging them should they return to use, sometimes called “relapse stigma.” Reiterate that returning to meetings after a relapse is not only accepted but encouraged—many members have relapsed at some point, and the programs are structured to support people through that process. 

Getting to in-person meetings can be challenging for some patients. If transportation is a concern for your patient, suggest that they seek out one of the many online meetings that can be found with a quick internet search. 

Finally, groups differ in terms of their attitudes toward various treatment approaches. Some are warm and accepting, while others favor “tough love.” Importantly, some groups—NA in particular—may discourage the use of medication. If medication is an important part of your patient’s treatment plan, encourage them to find another group. Tell patients, “Every meeting is different. If you don’t like the culture or content of one, try another.”

Talking with patients about 12-step programs
You don’t have to be a 12-step expert; just a basic understanding will help you make a referral that feels informed and thoughtful. Normalize hesitation and offer to help patients find a local or virtual meeting; a quick internet search is all you need. You can help overcome inertia with a simple statement like, “The best meeting is one you can get to.” 

Returning to Alex, you now have an idea of how to respond to his concerns. You say: “You don’t have to believe in God or talk if you’re not ready. Just try one meeting. Let’s look one up together.” He pauses—then nods.

Carlat Verdict: Twelve-step programs are free and widely available, and evidence supports their ability to enhance recovery outcomes when patients are meaningfully engaged. By understanding how they work, addressing common concerns, and framing referrals in a collaborative way, you can increase the likelihood that your patients will engage and potentially benefit from them.