One of the seminal experiences in my early career was an exchange visit to South Carolina in 1991 during which I spent most of my time observing addiction treatment in both public and private settings. Compared with my training in Scotland in a unit for treating alcohol dependence, I had arrived in a totally different world. The most striking aspect of the difference was the predominance of a strict disease model of alcohol and drug dependence that was in full accord with the precepts of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). This had many strange consequences, including enforced 12-step treatment under chemical dependency laws that paralleled the mental health civil detention procedures. The presence of such 12-step treatment in the hospitals also made for an easy transition into the free and extensive follow-up of AA and NA groups in the community. Although this particular state may have been at one extreme on a spectrum, there is no doubt that 12-step fellowships predominate in the world of addiction therapy in the USA. There are some voices raised against this state of affairs: most notably Stanton Peele in books such as Diseasing of America. Reference Peele1
Given these differences, it begs the question as to how useful a book such as that by Schenker might be to professional audiences in parts of the world where the influence of 12-step programmes is less apparent. Undoubtedly, it will find a ready market in North America.
My feeling is that the book is of value, if one can make allowances for its apparent US-centredness. Whether we are aware of it or not, AA and NA are all around us in our communities, and at least one-third of patients in British clinics with an addiction issue will have tried such therapy. I will certainly make use of the chapter in this book that sympathetically outlines the 12 steps and 12 traditions with trainees after we have visited an AA meeting as part of their addictions experience. It is clear from his book that Schenker is not a zealot but a pragmatist and he has discovered the popularity and success of the 12-step approach to addiction as his own career developed, noting the contrast with less successful approaches that failed to put a clear spotlight on the core problem of the addictive behaviour itself. The failure of psychodynamic psychotherapy in this area is the most notable, given it was eventually shown in one study to fair worse than control psychotherapy.
The book acknowledges the paradoxes and contradictions within the 12-step programme and also faces up to the issue of spirituality which stems from the origins of the movement in an evangelical Christian group. It is a practical book. Although aware of the growing academic literature on the hard-to-study area of outcomes within an organisation that eschews publicity and self-promotion, it is primarily designed to educate the frontline mental health practitioner on a topic that most likely will have been overlooked in their training. In particular, it is an antidote to a potential clash of models if one is dealing with a patient who is particularly invested in a 12-step programme, where a naive therapist might apply an approach that leads to dissonance for the patient around the question of autonomy, given the crucial first step of admitting powerlessness over the addictive substance.
Overall, I would recommend this book as a useful addition to a local mental health library to be shelved alongside Heather and Robertson's Problem Drinking, Reference Heather and Robertson2 the first half of which will give a balancing view on the history of the 12-step approach and its consequences.
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