Ask an Expert: As a Therapist, How Can I Challenge My Patient's 12-Step Beliefs?

By Dr. Richard Juman 08/04/15

Can therapy work when the therapist has a visceral reaction to the client's closely-held 12-step ideology? Our panel of experts weighs in.


Question: I am a licensed clinical social worker in private practice. I have several clients whose presenting problem is drug and/or alcohol abuse. I am comfortable working with these clients, and they are generally doing well with respect to recovery and in other areas. Here is my question: A couple of my clients are in 12-step programs and occasionally mention certain beliefs that I do not agree with and would certainly explore deeply were they not in AA or NA. One example that both of them have discussed is the prohibition against becoming romantically involved until one has a year of abstinence. I think that kind of rigid "rule" makes no sense and want to jump out of my chair when I hear it, but I am afraid that if I pursue the issue, the clients will feel that I don't understand them or their addiction and that our treatment alliance will be derailed. So I sit on my hands. What advice would you give me about how to handle these kinds of situations?

Answers from our panel of experts:

Debbie Rothschild: I hear in what you are saying that you refrain from exploring because you are afraid your bias will come through. I am guessing that you have trouble with “rules” like the one you mentioned because they are attempts to apply a uniform standard to individuals when in fact, people are so different. That said, it sounds like your feelings about these beliefs are clouding your therapeutic position. Why do you think you would explore the prohibition and not your client’s unique response and experience of it? Like with anything in therapy, if a client raises an issue, it is probably worth exploring why they are raising it and what it means to them. I would imagine you and your client would learn a lot through that exploration and what you would learn would have everything to do with that individual client and little to do with the prohibition itself. Many things can emerge. I would suggest you ask your client how they feel about the prohibition if they raise it and what it means to them. The best therapist is a curious therapist. Listen carefully and try to reflect back what you hear. The beauty of therapy is that it is a chance for people to learn about their own mind and thereby empower them to move things from automatic givens to choice.

Debra Rothschild, PhD, is a psychologist and psychoanalyst in New York City. Full bio.

Barry Lessin: I’m glad to see that your clients are doing well in their recovery. Your comfort level in working with clients with substance use disorder is important and I appreciate you reaching out for a consultation after recognizing that your strong reactions to these 12-step-related issues will affect the treatment alliance.

These issues are ones specific to a substance use disorder case, but we know that when issues arising from our therapy with clients in any setting begin to create negative feelings within us like this (what’s called "countertransference"), it’s important to take a step back and try to understand them better so they don’t become a threat to the treatment alliance.

In terms of the treatment alliance, our comfort level is not as important as our clients' comfort level. Clients will detect our discomfort in exploring these issues, which interferes with them building trust and feeling safe with us.

I check in with clients every few sessions to “see how we’re doing.” I review their progress according to their current treatment goals, discuss aspects in our treatment and our relationship that are working well and those that may need improvement.

This "check-in" is important for several reasons. It takes the "temperature" of our relationship and lets the client know you care about them and the outcome of their treatment. How clients answer these questions helps me get a more accurate reading of the nature of the therapeutic relationship from their perspective. Their responses act as a guide in making any necessary adjustments to our interactions, and contribute to refocusing treatment goals and possibly even my treatment approach.

Getting back to your negative reaction: It’s important to get a consultation from a trusted professional peer when you become aware of countertransference issues. The consultation can help you get insight into how your opinions about 12-step programs as helpful mutual aid programs are getting in the way of you being more present with your substance use disorder clients, ultimately helping you be more effective in your work with them.

Barry Lessin, M.Ed., CAADC, is a substance use disorder psychologist and public health advocate with a career spanning almost 40 years as a clinician, administrator, educator, and researcher. Full bio.

Carrie Wilkens:

What a great question. As therapists, we encounter lots of moments when we disagree with our clients or with advice they get from others. It is a crucial skill to be able to step back (as you are doing) and reflect on our feelings and impulses.

I wonder a few things. Why are you hesitant to explore your client’s feelings about the suggestions they hear while attending 12-step meetings? Would you have the same hesitation if they were talking about a suggestion given to them by a parent? A member of the clergy? An employer? We all, for the most part, have to navigate different groups whether they are family, a work group, a religious organization, or peers, and every group has its rules and norms. The 12-step community is just another group, and for those who relate, it can be a powerful source of community. The interesting thing is that many clients hear the “suggestions” of AA/NA as “rules,” when in fact they are just suggestions. They can choose to follow them or not.

I think one of the most profound things we can do as therapists is help our clients have healthy relationships with their chosen support systems. If a client expresses ambivalence about following a group suggestion or norm, it is a great opportunity to walk through the costs and benefits of all sides of the equation. Let’s stick with the suggestion you reference: delaying the start of romantic relationships for the first year of sobriety. Making significant changes in how one uses substances can be fraught with intense emotional reactions, insecurity, and difficulty managing personal boundaries. Starting a new relationship in the middle of all that change can be messy to say the least. The cost of listening to that suggestion however, might be missed opportunities and loneliness. I think with an open mind you can respectfully complete a cost/benefit analysis of following a “suggestion” like this one and doing so can be a great way to better understand your client. The process can also shed light on the skills they may need to learn in order to better navigate the “group” that they belong to in a healthy and balanced way.

Carrie Wilkens, PhD, is the co-founder and Clinical Director of the Center for Motivation and Change in NYC, a private practice of psychologists who specialize in the treatment of substance use/compulsive behavior disorders and trauma using a variety of evidence-based treatments. Full bio.

Jeannie Little: What a good question, and what restraint you show in not acting on your countertransference! Absolutes—recommendations or prohibitions—tend to evoke resistance or rebellion, including in the therapist. There is a real risk that, without permission to explore a prospective relationship, your clients might just do it, then have to manage the consequences of betraying their program. It is also possible that you are being induced to promote rebellion by exploring rather than supporting the “rule.”

Your real challenge is not whether to question or support the rule, but whether you can maintain therapeutic neutrality when you disagree with clients or feel that something in their life is harmful.

The good news is—you can explore anything if you work in the hypothetical. Working in the hypothetical allows a client to explore their wishes, manage their impulses, and work through pros and cons without there being any suggestion that they should or should not take action.

I would ask three questions:

  1. Would you like for me to help you think about the importance of this rule to your recovery right now?
  2. If you were to break the rule, what would be the benefits and risks of a relationship right now?
  3. If you were to break the rule, what consequences might it have in your program?

You accomplish several things with these questions: 1) your clients can explore the rule, and you can learn what your clients want from you in order to avoid overstepping; 2) they can do a cost/benefit analysis; and 3) they might discover that there is validity to the rule for them, and thus feel comfortable honoring it. If they were to choose to proceed with a relationship, they would be prepared to manage the risks and enjoy the benefits, and you would have fulfilled your responsibility as a therapist.

Jeannie Little, LCSW, CGP is the co-founder and Executive Director of the Harm Reduction Therapy Center in San Francisco. Full bio.

John Kelly: I think a client-centered approach would help ameliorate the therapist’s own sense of frustration here and also help the patient foster their own sense of agency and confidence. Asking the patient what their own thoughts are about the pros and cons of seeking and forming a new romantic relationship and the pros and cons of not engaging in a new romantic relationship early in the recovery process will help them explore thoroughly the relative benefits of each course of action and arrive at their own conclusion. Another way to inquire about this is to ask why the patient thinks this might be a recommendation of people who are in long-term recovery from addiction. If they asked for my opinion or advice on the matter, given that addiction recovery is a life and death issue, and the power of new romantic endeavors to be all-consuming, especially early in the relationship, I would probably recommend not to begin a new romantic involvement early in recovery and devote attention instead on building the skills and resources that have been shown empirically to predict the chances of long-term remission.

Dr. John F. Kelly is the Elizabeth R. Spallin Associate Professor of Psychiatry in Addiction Medicine at Harvard Medical School—the first endowed addiction Professorship at Harvard. Full bio.


Please make note of The Fix Comment Policy


Please read our comment policy. - The Fix

Dr. Richard Juman is a licensed clinical psychologist who has worked in the field of addiction for over 25 years. He has treated hundreds of patients as a clinician and also provided supervision, program development and administration in a variety of settings including acute care hospitals, long term care facilities and outpatient chemical dependency centers. Find him on LinkedIn and Twitter.