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"Do 12 Steps Cause Suicide?" / Response From A Harm Reduction Advocate

Posted on November 7, 2014 at 5:08 PM Comments comments (900)

The question of whether 12 step programs "cure" or "cause" anything is a misrepresentation of 12 step doctrine, and, thus, misleading.

12 step doctrine says addiction is a chronic disease that cannot be cured; rather, it is a disease that can be "arrested" so that the disease goes into a full remission, optimally for the rest of one's life.

So to clarify, 12 step programs neither claim to "cause" or "cure" anything.

The research on suicide and other co-occurring mental health issues of a significant number of substance abusers is true, without question. But there are no studies on rates of suicide by 12 steppers to build this argument upon.

Robin Williams' suicide may not have been prevented by his 12 step work, but I don't know that this proves AA caused him harm. There are too many unknown variables to prove his 12 step work encouraged him to end his life. The variables disclosed about Robin included his just having been diagnosed with Parkinson's disease and bipolar disorder.  Other variables we know nothing about include the suicide history within his family or origin, the stability of his home life, work life, and PTSD going back to childhood and more.  An autopsy confirmed that there were no addictive substance in Robin's body following his death.  And had Robin had a drink or cocaine, who is to say he would not have taken his life anyway.  

Although I advocate for harm reduction, I believe Robin Williams' death was sensationalized and exploited to argue that AA was to blame. This, to me, is irresponsible and hurts the evidence-based movement that is the foundation harm reduction.

But what, exactly, is harm reduction? During the past 20 years I've been in practice, I have found that all addiction treatments are, in fact, some form of harm reduction. We've yet to find an infallible treatment for addictions and substance use disorders. However, the change in the DSM terminology is very significant. It differentiates diagnoses of substance abuse and chemical dependency from it's evolved diagnosis of substance use disorder - mild, moderate or severe. 

Those with severe diagnoses (co-morbidity involving diabetes, liver damage, severe psychiatric conditions, dementia, legal, etc) would certainly be appropriate candidates for abstinence over moderation. But as I see it, at the end of the day, from moderation to abstinence it's all harm reduction.

For any patient who repeatedly relapses and is referred to the "higher level of care," this, too, is a form of harm reduction. We've learned how poor the success rates are at inpatient facilities that practice abstinence-only 12-step model approaches. Without guarantees, this too is a harm reduction approach.

In this regard, I believe the term "harm reduction" is obsolete. It is a "given" in any treatment to practice some form of harm reduction. The professional who believes relapse prevention techniques and behavior modification are not a form of harm reduction is terribly misinformed.

But I will state for the record, I believe more substance users will be attracted to treatment facilities that are not abstinence-only, where clients' lives will be saved by being medically monitored by trained professionals. Once stabilized, every patient--regardless of their clinical needs, has the right to have reasonable access and education regarding current evidence-based treatment. Ultimately, it is the patient's right to be empowered to make choices regarding his or her own health and treatment.

Unfortunately, the polarization of professionals who see harm reduction and abstinence as opposing treatment models often do not empower clients with education of all current treatment and self help options accessible for substance use disorders.

This is a serious bias in our field that dis-empowers patients ("knowledge is power"),  with potential to cause more harm to those substance users at risk out there.

Response to "12 Steps Are Anti-Medication and Anti-Psychiatry"

I've heard  some 12 Step members at some meetings discourage the use of any medications for psychiatric disorders. But which ones do and which ones do not is another variable that must be considered before lumping ALL 12 step meetings together.

Furthermore, NA, another 12 step program, does not advise its members to discontinue any medications.  

So, I find many generalizations and misinformation in the argument that these programs cause suicides (show me the data--I love research!). 

There is no uniformity in 12 step meetings town to town, city to city, state to state, country to country (planet to planet).  No two AA meetings are exactly alike or conducted the exact same way. Sponsors vary is how they coach, train or work with sponsees and without uniformity, the variables between meetings and protocols are too great to reach an evidence-based conclusion that "12 step programs cause suicide."

Besides location (NY meetings are run differently from Alabama meetings) other variables include gender, political ideals--there are always politics, even at 12 step meetings, age, sexual orientation, socio-economic backgrounds of members, etc.   Furthermore, OA (Overeaters Anonymous), DA (Debtors Anonymous), SA (Sex Anonymous), SCA (Sexual Compulsives Anonymous) and SLA (Sex and Love Anonymous) are also 12-step programs that work with both moderation and abstinence.  Again, there is no uniformity within the scope of the 12 steps. It is simply impossible to draw conclusions about all 12 step programs the same way.

Thus, with so many different variables, how can one conclude anything about 12 step meetings as a whole? Too many assumptions are based on opinion or anecdotes without evidence to back them up.

In Response to 12 step programs "playing doctor or psychiatrist"

Regarding physicians and medication, the 3rd Edition of the AA Big Book reads:

 "God has abundantly supplied this world with fine doctors, psychologists, and practitioners of various kinds. Do not hesitate to take your health problems to such persons. Most of them give freely of themselves, that their fellows may enjoy sound minds and bodies. Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward." (AA Big Book, 3rd Edition p.133.)

I know of no where in the Big Book to support any 12 step member who tries to "play doctor." 


I am neither defending nor attacking AA, but I am being objective.  And many claims are made with bias instead of research, which is the foundation of evidence-based movement for harm reduction and abstinence treatment models.