The Twelve Steps Explained
The Carlat Addiction Treatment Report, Volume 3, Number 8, November 2015
Daniel Carlat, MD
Step 1: The surrender
“We admitted we were powerless over alcohol—that our lives had become unmanageable.”
The first step may happen on the first day a patient gets into treatment, or it may be what brings the patient to treatment. But much of the time, this step requires help: Someone needs to ask the questions to make the patient understand that repeated attempts to cut down or stop drinking have not worked—that is the “powerless” piece. This is not the same as feeling powerless in general, it is very specific to alcohol. The patient has to understand and believe that there is a connection between his or her drinking and what has brought the patient to treatment, such as financial problems, job loss, family problems, arrest, feeling sick, and so on—that is the “unmanageable” piece. The sense of relief that comes with the admission of powerlessness and unmanageability in terms of alcohol is liberating for patients.
Step 2: The higher power
“Came to believe that a power greater than ourselves could restore us to sanity.”
Many patients who go to Acoholics Anonymous (AA) talk about a “spiritual awakening,” which often occurs very early in recovery. That awakening is often a result of Step 2. While going to AA meetings, patients become engaged in the process of recovery, sometimes for the first time. The act of going to the meeting, and of speaking in a supportive setting, gives the patient the feeling of taking the initiative. It also inspires a sense of hope, which can be experienced so intensely as to seem religious or spiritual.
Step 3: The decision
“Made a decision to turn our will and our lives over to the care of God as we understood Him.”
Again, this step is not necessarily about religion, but about being willing to trust the process of AA. The patient emerges with a stronger sense of self-efficacy.
Step 4: The self-assessment
“Made a searching and fearless moral inventory of ourselves.”
Psychiatrists can be very helpful in this step because it can lead to guilt, shame, and anger. In fact, the purpose is to acknowledge the sources of those feelings and then to improve problem areas by having patients understand them. This in turn reduces the likelihood of relapse, which these triggers, when unrecognized, can lead to. The therapeutic value of this step lies in the patient’s ability to have better insight.
Step 5: The sponsor (or psychiatrist)
“Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.”
The psychiatrist may not have the time it takes to go through this step with patients, and many patients end up just relying on their AA sponsor. But it’s not an easy task to be this listener. The goal is to reduce shame and guilt by talking to another person. The advantage of sharing these confessions with a sponsor, rather than with a therapist, is that the patients can see they are not the only ones with these problems, and can get a better and more balanced view of themselves. Therapeutically, this step has the result of reducing shame and guilt.
Step 6: Readiness to change
“Were entirely ready to have God remove all these defects of character.”
It can take days or weeks to get to this step, which is a recognition that what has been learned in the assessment phase needs to be dealt with, or relapse can follow. Whatever the problems are that contributed to the drinking, the patient admits that they need to be fixed.
Step 7: Humility
“Humbly asked Him to remove our shortcomings.”
Similar to and closely tied to Step 6, this humility means the patient accepts the need to stop whatever behaviors led to drinking and could lead to relapse.
Step 8: Taking responsibility
“Made a list of all persons we had harmed, and became willing to make amends to them all.”
Patients make a list of people whom they have harmed, and also list whether they feel harmed by those people. Forgiveness of perceived harms is required so that honest amends can be made in the next step. Together with step 9, this process helps the patient achieve peace of mind.
Step 9: Restitution and amends
“Made direct amends to such people whenever possible, except when to do so would injure them or others.”
When making amends would harm the other person, it should not be done—sometimes just contacting the other person would cause harm. But patients should make direct amends whenever possible; the process of doing so leaves them with peace of mind.
Step 10: Balance
“Continued to take personal inventory and when we were wrong promptly admitted it.”
This step shows that some of the work of AA members is far advanced from where many patients are in their lives. A form of self-regulation, it involves watching oneself on a daily basis and making sure any new problems that arise are corrected quickly.
Step 11: Connectedness
“Sought through prayer and meditation to improve our conscious contact with God, as we understood him, praying only for knowledge of his will for us and the power to carry it out.”
Like “God” in the other steps, “prayer” and “meditation” are vaguely defined, mainly according to the patient’s own faith or spiritual sense. The point is to have some regular method of keeping balanced emotionally. This step helps patients’ awareness of themselves and improves well-being.
Step 12: Helping others
“Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.”
This is a unique aspect of mutual support groups based on the Twelve Steps, in which part of continuing recovery for the patient—usually a former patient by this point—includes helping other alcoholics.
The Twelve Traditions: A how-to guide for AA meetings
AA’s Twelve Traditions are less well-known, but constitute a sort of manual for how meetings should operate. For example, one tradition involves eligibility—the only requirement for AA membership, which means attending meetings, is “a desire to stop drinking.” All AA groups must be self-supporting, can collect donations from members but nobody else, and must not own any property. Money, according to AA tradition, just distracts from the primary purpose—“helping alcoholics achieve sobriety.” Another tradition is that AA doesn’t take any positions on anything. Finally, AA members are supposed to be anonymous and not disclose their relationship to the media. This is not the same as people disclosing that they are in recovery.
Meetings usually last about an hour, start with a reading from the “Big Book” (the main AA text), and usually have a member talking about his or her experiences.
“Open” meetings are for anyone, including people who have no desire to stop drinking; “closed” meetings are only for AA members or potential members. Family, friends, students, professionals who are curious, and others can go to open meetings—and it’s recommended.
Source: The information for the therapeutic effects of the Twelve Steps comes from Twelve Step Facilitation in Non-Specialty Settings by John F. Kelly, Ph.D. and Barbara S. McCrady, Ph.D.
A Twelve Steps Mnemonic
by Daniel Carlat, MD
Since I can never seem to remember the Twelve Steps, I created this silly rhyming mnemonic for myself. I figured there might be some readers out there who would find this helpful. So here it is, take it or leave it!
1. One, one, alcohol’s no fun.
2. and 3. Two, three, a higher power than me.
4. Four, four, take an inventory like a store.
5. Five, five, by revealing I’ll survive.
6. and 7. Six, seven, ready to change and make life heaven.
8. Eight, eight, I’ll make a list and I won’t wait.
9. Nine, nine, I’ll make amends then I’ll feel fine.
10. Ten, ten, every day do it again.
11, 12: Eleven, twelve, say my prayers and try to help.
Editor and writer specializing in substance abuse issues
Ms. Knopf has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.