Liese Recke, Cand. Psych.
Kråsiglund Kråsigvej 9
8700 Horsens,
Denmark
Liese@mail.dk

The development and application of the 12-steps model in Danish Drug Addiction Treatment.
Abstract: This paper presents a discussion on the attraction of the 12-step program based on the 12-step model's rapid expansion in the Danish drug treatment system. Taking popularity as a point of reference, it is proposed that it might be more productive to look at the 12-step model as an ideology about managing the late modern self, rather than a treatment approach to drug addiction. It is argued that the attraction and popularity of the 12-step ideology can be understood in the light of several cultural factors with emphasis on the growing trend in individualizing social problems and difficulties.

First, I will give an introduction to the diffusion of the 12-step model in the Danish Treatment System. Then I will raise the question: What is the cultural basis for the current rapid expansion of the 12-step movement in Denmark regarding treatment of drug addiction?
My first claim will be that addiction issues play a constantly growing part in the mainstream culture, and that it makes sense to the late modern individual to define a broad range of problems within addiction issues.
My second claim is that participation in the 12-step program serves at least two basic needs of the late modern individual: 1: The need for an identity constructed as a personal narrative and 2: The need for social relationships and intimacy. The latter is seen in the light of the therapeutic emancipation discourse, which has had a profound impact on the way we – in Scandinavia - define psychological health for the past 15 years.
I will terminate the discussion, assessing some of the impact from the 12-step program to other treatment approaches, and I will present the question: Could the apparent success of the 12-step program contribute new information about the treatment of drug abuse within a wider perspective?

The 12-step model in the Danish Treatment System

The 12-step model incorporated in the Danish Drug Treatment system is a relatively new approach. Until 1990, only a few sporadic institutions existed, based on social re-parenting, and at this point, the government had almost entirely ceased to finance them further. AA – Alcoholics Anonymous – had existed in Denmark since approximately 1975, and alcoholics had for some years been presented with the opportunity to be treated in private 12-step based institutions, if they paid for the treatment themselves.
Until 1990, the 12-step model was not in any way integrated in the professional discourse of treatment and hardly in mainstream culture. The introduction of Narcotics Anonymous was instigated by the influence of a single moral entrepreneur, who aggressively focused on and utilized the Danish media, and by the marketing of a private 12-step based treatment institution (“Egeborg”), coincidently owned by the same moral entrepreneur. Former clients from this institution established the first self-help groups using the NA-program. The 12-step based treatment industry in Denmark has rapidly accelerated since then, and I will demonstrate shortly the prevalence of the all-encompassing 12-step ideology in present-day treatment.

• In Denmark, the total number of severely addicted drug users is estimated 14.000. A great number of those who enter treatment are treated with methadone maintenance, and only about 1/5 of the drug addicts in treatment end up in specific drug-free treatment modalities, where they receive inpatient care for up to three years, and where they often are readmitted several times without reaching the goal of abstinence. Treatment in Denmark is financed via public funding, and between 80-90% of the drug users currently in drug free treatment, are institutionalised in private institutions, using Minnesota treatment, - without any further definition of this concept. The in-patient 12-step based treatment is time consuming and expensive.
  
• Regarding outpatient drug free treatment, two bigger projects are established within the last couple of years, based on 12-step ideology¹. Besides these, very few modalities are available.
  
• Lately, a new phenomenon has appeared in several Danish cities: drug-and alcohol free cafés managed and used by addicts in recovery, and recovering addicts residing in so-called halfway houses. The cafés and the houses provide a supportive environment for people who stopped using drugs. However, it is important to recognize that the conception of addicts being in recovery is presupposed by the 12-step ideology, where addicts continue being addicts – clean addicts - after quitting drugs. Other treatment approaches – not 12-step based, are aimed at an invisible integration by the former drug addict into “normal” society. In the perspective from other treatment approaches, finishing the drug abuse means that the addict is no longer considered an addict. Only addicts using the 12-step concept keep on defining themselves as addicts.
  
• In Denmark, we have two newly established training facilities for professional addiction counselors receiving large economic subsidies from the state. Both facilities are based on the traditions of the American addiction counsellor training, which again is based on the 12-step ideology. Besides these two facilities, no other possibilities for education in addiction counseling exist, except a few postgraduate courses for related professionals.
  
• An increasing number of various treatment institutions, methadone clinics included, employ addicts in recovery for counseling purposes. Addicts in recovery are, as I pointed out before, always 12-step oriented.
  
• Moreover, what is most interesting is that more than 200 NA meetings convene each week, besides an uncertain number of related 12-step meetings, and an even bigger number of AA meetings. Many 12-step oriented treatment centers refer family members to co-dependency groups and groups for adult children of alcoholics, and it is not unusual for people to join different groups over the same period of time. The wide-ranging development from AA and the prime focus on alcoholism to a larger recovery-movement within the 12-step discourse (Rice, 1996), indicates, that the basic concern in 12-step ideology is about managing the self, more than managing a peculiar condition associated with the traditional definitions of disease (Valverde, 1999).
  

A logical explanation on the rapid expansion of the 12-step model in Denmark would be that the 12-step oriented treatment approach provides a better treatment outcome in the treatment of drug addiction than other kinds of treatment approaches. This assumption is not supported by evidence in the international scientific literature. In addition, a large study recently conducted in Denmark was unable to identify higher rates of positive outcome in 12-step oriented institutions, than those found in other treatment approaches (Pedersen, 1999).
However, definition of a treatment success in scientific studies is often defined as abstinence, reduction in consumption, and reduction in criminal activities and improvement in social adjustment. Other definitions and understandings of the term “success” could be applied. –Frequently, agendas for drug policy and drug treatment are created and managed through a series of “moral panics”. Someone – often a moral entrepreneur, is contributing to a moral and social outcry, resulting in the need for “someone’s got to do something about this - until now, neglected social problem”.
An important ingredient in a moral panic is the visibility and promotion of certain definitions of a given topic, which subsequently is categorized as a social problem. Danish media havehave been more than willing to promote personal stories of 12 step based recovery from popular TV hosts and politicians. Not to mention the dramatic and sensationalistic tales from ex-criminals and ex-prostitutes confessing in TV-shows and popular magazines, and it has been increasingly popular to pep up hearings and conferences about drug issues with personal tales using the 12-step agenda of disease and recovery.
The “success” of the 12-step approach is, in this view, not based on evidence from outcome studies, but rather on the emotional seduction arising from dramatic tales and subjective stories – and the taxpayer’s hope for a simple solution for a growing social problem.
A brief summary: The 12-step discourse is expanding rapidly in the Danish drug treatment system, and positive effects have been seen. What is especially optimistic is the great influence the 12-step model until now has had on the amount of money spent on research and development of projects in the Danish treatment system. Moreover, it has been visible for politicians and for the public, that it is in fact possible to treat drug-addicts. And to many drug addicts, the visibility of 12-step role models has been a source of hope and optimism. In spite of the apparently positive effect, I wish to challenge some basic beliefs about the function and use of the 12-step approach in the Danish treatment system. First, I will illustrate that the attraction and the popularity of this approach are build on the cultural actualisation of the main topic in the 12-step discourse, which I define as a strategy of managing the late modern self. Then, I will shortly outline some of the consequences for alternative treatment approaches.

The concept of addiction in mainstream culture

During the nineties, the concept of addiction is used to label a growing number of human sufferings and problem behaviors. In Denmark, the current trend seems to be Internet addiction, and before that, we have seen compulsive gambling being promoted by moral entrepreneurs, as a condition, demanding treatment. An increasing number of human behaviors appear to be labelled in terms of addictions, or less demonising: as bad habits. It is fascinating to observe that the same behaviors, earlier described as virtues, now potentially are being identified as problem behaviors understood in terms of addiction. Working hard - earlier a virtue and the road to success and happiness, is categorized as workaholism. Keeping your family together especially in hard times, used to be an appreciated skill. Now this is co-dependency.

Dependency disorders were not so long ago associated exclusively with the use of a substance – alcohol or drugs -; this is no longer the case. The addiction concept occupies a central position in several discourses, serving as a clarification of a multitude of phenomenons, ranging from eating disorders, relationship problems, frequent use of Internet technology or sudden economic ruin. This is most obvious when we explore the discourse of the recovery movement, but it is also observed in professional psychology and psychiatry as well. “Compulsive gambling” is listed in the International Classification of Diseases. Admittedly - not as a dependency disorder, but the treatment provided is frequently based on the same assumptions as treatment of dependency disorders. The American Addictive Behaviors School provides an eminent example of this (Marlatt & Gordon 1985). Writers and clinicians representing this point of view, argue that the concept of habit and the occurrence of frequent relapse are basic elements in many different types of behaviors. And even though they do not characterize troublesome habits as diseases, they prescribe the same treatment procedures for smoking cigarettes, extensive gambling, cocaine addiction or eating disorders, - even for sexual misbehaviour.
Using the addiction concept –in its problematic aspect, as a disease – or in the normalizing aspect, as a habit – makes it possible for the individual to understand and describe his or her life problems in terms of addiction. Issues, earlier described as moral, social or even political phenomenons, become individualized, and the 12-step program prescribes the cure for multiple personal problems. The purpose is not to change the world or even the way other people behave, addiction is your own personal problem. Following the simple rules in the 12-step program, you will recover. (I should say that the same ambition is common in most forms of professional psychotherapy using whatever terms the specific school has coined for problems and solutions).

The philosopher and sociologist Zygmunt Bauman has written, that the hero of the modern culture could be viewed as a pilgrim. In addition, he has shown that it is impossible to maintain a life long pilgrimage in today’s turbulent world – in the late modern world, where sacred shrines are relocated and today’s values are in the process of inflating and devaluating tomorrow. Hence, the late modern hero is not a pilgrim; he should rather be compared to a tourist.
The tourist is characterized by disconnection from time and space, and consequently disconnected from history. Life is a never ending now – where there is no determination from past times, and where the future is unpredictable. What counts is mobility. The point of the tourist’s life is to be on the move …never arriving. Spontaneity rules the tourist’s life, and the tourist is always ready to choose a new purpose and a new destination.
In the late modern society, where traditions are replaced with habits, in order to guide and stabilize the tourist’s life, it becomes increasingly important to choose one’s habits carefully. There are good habits and there are bad habits. Evil habits are associated with perceptions of immobility. It is not the ecstasy, not the adventure, not the excitement, which are main issues of concern. The central point is whether a given phenomena or behavior can be understood or interpreted as a state of incarceration.
The most demonised aspect in the concept of habit is addiction. Addiction is one of the greatest dangers the tourist might encounter. Being addicted, means that the tourist is robbed of the illusion of having a free will, and being unable to spontaneously choose a new travelling schedule or even being able to move on.
In late modern culture, we are bearing witness to intense propagation for the free will. The ultimate positive status for the late modern hero – besides the demand for mobility, lies in providing the image of freedom of choice. The freedom to choose acts as a basic value in contemporary culture, and the phenomenon can be interpretated on several levels. In psychotherapy and in many so-called spritual development programs the goal is to provide the individual with an abundance of choices. Manifestation of the free choice based on free will is the ultimate position of status demonstrated by the late modern hero.
In maintaining the illusion of freedom of choice in daily life, the late modern hero has to avoid certain pitfalls; bad habits like dependency and addiction. Regarding the growing focus on mobility and the potential future demonising of any habit in late modern culture, the tourist must closely guard his or her behavior intensely, and thereby demonstrate high levels of self-reflectivity.
In the late modern world, with the risk of global destruction hanging like the sword of Damocles, the hero must at all times be in charge of his life project, busy manifesting freedom of choice and personal autonomy. Only the hero himself is to blame for unhappiness and life’s frustrations, and the illusion of freedom of choice serves as a basic tool in the overall coping strategy: You can always choose otherwise at this very moment. On these premises, addictive behavior represents a major threat to the creation of the late modern lifestyle. The concept of addiction seems to expand into an endless continuum of all sorts of behaviors, followed by the same endless row of coping strategies. And for every addiction, there is a 12-step program. Fig. 1 serves as an illustrative example of the potential expansion of addiction issues.

Fig. 1
The Addiction Tree, found on the Internet, serves as an illustration of the multitude of problems to be addressed within the addiction agenda.
http://www.relaxx.co.uk/page63.html

Attending 12-step meetings and working the steps keeps your attention and your reflective skills in good shape, and you are conclusingly able to recognize and identify possible signs of relapse. Working continuously with the 12-steps, optimises your reflective skills, and updates your present knowledge about yourself. Participation in the 12-step program promises, in this sense, a kind of inoculation effect, and the disease of addiction is, not surprisingly, often compared to diabetes. Attend to your treatment – your meetings– or your insulin – and nothing can go wrong.
The 12-step concept presents an offer difficult to resist. A possibility of acquiring coping strategies aimed at one of the most feared psychological problems in the late modern culture: Addictions and dependencies.
Yet, another strategy presented in the 12-step groups is aimed at the late modern hero’s need for a contemporary identity.

Identity: Creation of personal narratives

In late modern society, self and identity is no longer given as a birthright. Identity is something one must work for. Some writers have argued that one of the ways a late modern individual can attain identity, is through the development and elaboration of the personal narrative. As anyone can observe on the Internet, people here present themselves through storytelling. Storytelling is the gateway to make personal contact and establish relationships. Without a personal narrative, - and it better be in detail and entertaining - you are lost in cyberspace regarding the creation of personal relationships. Managing the personal narrative is an important task for the late modern hero – the tourist, to whom presenting the Kodak-pictures and the adventurous stories seems more important than enjoying the journey itself.
The basic structure of the 12- steps groups is centered on the personal narratives of the participants. The members take turns telling their personal life stories, and the narratives are created on the basis of mutual acceptance of points of escalation, emphasis on certain values, the causal correlation between addiction, unhappiness and destruction among other 12- step based concepts.
It is possible to view the 12-step meeting as a reflecting teamwork, where the personal narratives are constructed and elaborated with the help of alternative narratives apparently describing the same phenomenons (Nevels, 1997). Joining a 12-step group will provide the grouper rich opportunity to develop a very thorough and detailed personal story, which appears to be a necessity for the hero in the late modern culture.
From this point of view, participation in the 12-steps groups can be seen as exercises in creating and promoting a thorough and well-elaborated version of the personal narrative concerning the past, the present and the future. The personal narrative is created and developed inside a certain frame, in this case - the 12-steps together with the obligatory 12-step literature. In elaborating and repeating the personal narrative, the late modern hero is able to establish a valid identity, familiar and well known to other 12-step groupers. An identity, which could be lifelong – at least for the moment.

Bonding and relationships

The glorification in the late modern culture of the free will and the growing demonization of bad habits – addictions, could also be seen through the influence of the architects of emancipation psychotherapy, who developed the psychotherapeutic version of emancipation based on the theories from the post war philosophers of the Frankfurt School of Sociology. It is not surprising that the theories of personal development and psychotherapy are considered with growing importance, taken into account that the individual is receiving more and more responsibility for managing social and existential problems. American psychotherapists and writers like Abraham Maslow and Carl Rogers have had a profound effect on contemporary western societies in the way, we define the healthy individual. The emancipation psychotherapists argued for the self’s autonomy from culture on the premises of ”the total collapse of all values outside the individual” (Maslow, 1968) and because ”societal and cultural repressions mass-produce a profoundly diminished self” (Rogers, 1961). Within the classic dichotomy between determinism and free will, the discourse of emancipation took the stand of the individual’s right to self-expression and self-fulfilment procured at the expense of social institutions, traditional bonds and social commitments.
In a world where traditions and institutions are conceived repressive and limiting, and the primary virtues are considered personal mobility and freedom of choice, an important task for the free agent –the tourist – is to establish and maintain intimate and close relationships to other people The question is: how can the tourist bond and create relationships with other human beings while being loyal to the discourse of emancipation?
An ever expanding self-help literature focuses on the means and methods in the art of maintaining romantic relationships based on the concept of confluent love and pure relationships, which is instant love and relationships based on mutual negotiations including the acceptance of multiple alternate choices – relationships with no strings attached, only for now (Giddens, 1992). Lesser emphasis has been given on the skills of creating and maintaining friendship and other social relationships, which are becoming increasingly important skills in a country like Denmark, where many people are living singlely, facing the risk of alienation and loneliness because they find themselves isolated in their single homes. The risk of loneliness and social exclusion is even greater for the drug addict – or the recently detoxed former addict-, who per se is marginalized and expelled from normal society.
Through the promise of a voluntary participation including total anonymity, the 12-step groups offer a unique opportunity to bond and make personal commitments - just for the moment- without being disloyal to the emancipation discourse. With the increasing number of groups concerned with various problem-parameters, it is also possible for a growing number of people to find a 12-step group especially designed for their specific choice of disease or habit. People in a 12-step fellowship are united in their individuality. No promises, no lasting commitments are made, and you are able to come and go as you please. And yet, many participants would say that a 12-step meeting generates extremely high levels of intimacy.

Consequences for social policy, drug policy and other treatment approaches

Despite the positive effects in the life of the late modern hero, the overall expansion of the 12-step model has a more problematic impact on other factors regarding social and drug policy.
Defining drug problems as poor individualistic management of the self, takes the focus away from community responsibility, and from the importance of conducting an adequate social policy regarding poverty, unemployment, and other negative social factors and their causal correlation to drug addiction and drug related misbehaviour. It is also a problem when alcohol and drugs are considered not dangerous to ordinary people, who do not have the disease of alcoholism or addiction. Taking this point of view, there is no need for controlled distribution of legal substances.
A growing emphasis on personal responsibility and the prevailing use of non-profit self-help groups could be a powerful political argument for less expenditure and for minimizing efforts into organized prevention and treatment based on scientific outcome studies. One of the consequences in Denmark has already been an expanding market for private grey-zone treatment-approaches, where addicts treat addicts with almost no supervision, and nonexistent control from the Danish authorities.
Staff-attitudes and beliefs are of great importance to treatment outcome (Caplehorn et al., 1998). Many treatment centers and methadone clinics employ “addicts in recovery”, and the basic concepts from the 12-step culture mixes into other discourses, such as medical treatment and harm-reduction approaches. Growing agreement of abstinence and sobriety as the ultimate goal of treatment, implicates that harm-reduction, controlled use or medical treatment are considered as “second best”, or even more radical: as a continuation or even a prolonging of the disease. Another common 12-step belief is that the drug addict must reach his or her bottom, before a genuine motivation to change occurs. The sooner the bottom is reached, the better are the possibilities for obtaining sobriety. There is therefore no need to ease up on the persistent “war on drugs”. Prison and poverty in this picture are strong motivational factors, and medical treatment should be regarded also as an unpleasant experience.
The glorification in the media of personal tales of recovery, and the visibility of “clean addicts” in drug- and alcohol free cafes and meeting places makes it difficult for professionals and policy-makers to argue for alternate approaches to treatment. As I have mentioned earlier: drug addicts from other treatment programs, do not find it attractive to hold on to the addict-identity after termination of treatment, and they will remain invisible in the eyes of the public, leaving the impression that they don’t exist.
Politicians and administrators frequently emphasize the importance of developing many different approaches in the treatment of drug addiction. In spite of the many positive effects, the overall diffusion of the 12-step program in the Danish treatment system makes it increasing difficult for other approaches to develop.

References

Bauman, Zygmunt: “Postmodernity and its Discontents”. Polity Press 1997
Caplehorn JRM, Lumley TS, Irwig L: Staff attitudes and retention of patients in methadone maintenance programs. Drug and Alcohol Dependence. 1998; Vol 52:57-61
Dahl, Helle et al.: ”Udvikling af et nærbehandlingsmiljø” Center for Rusmiddelforskning,1999
Giddens, Anthony: ”Transformation of intimacy” Stanford Univ Press, 1992
Marlattm Alan & Gordon, Judith R. (ed,): “Relapse prevention”. Guilford 1985
Maslow, Abraham: “Toward a Psychology of Being”. Princeton NJ 1968
Nevels B: A.A., constructivism, and reflecting teams. Subst.Use.Misuse. 1997; 32:2185-2191
Pedersen, Mads Uffe: “Stofmisbrugere før under og efter døgnbehandling”, Center for Rusmiddelforskning, 2000
Rice, JS: ”A disease of one´s own”, New Brunswick, New Jersey, Transaction Publishers, 1996
Rogers, Carl: “On becoming a person: A Therapist’s View of Psychotherapy”. Boston: Houghton Mifflin, 1961
Valverde, Mariana: ”Diseases of the Will. Alcohol and the Dilemmas of Freedom”, Cambridge University Press, 1999

¹ The “Frederica- model” and “Vejviseren”. “Vejviseren” is a drug free outpatient approach based on a relapse prevention program. As almost all relapse prevention programs in Denmark, “Vejviseren” is based on the CENAPS model, which is an American approach based on the 12 step program