This article aims to help psychoanalytically oriented clinicians address and manage the needs of patients in Alcoholics Anonymous and other 12-step programs, who represent an understudied population in our field. Drawing upon clinical experiences, it focuses on four challenges that arise for psychoanalytic clinicians, including conflicts between psychoanalytic considerations and the disease model, transference/countertransference dynamics that may emerge when a patient addresses a major problem of living in a separate context that is inaccessible to the analyst; considerations impacting the appropriate stance and level of neutrality clinicians might adopt in regards to AA participation; and factors that may prevent useful exploration of the spiritual components of AA. For each challenge, implications are discussed and considerations are offered for addressing these dynamics in treatment.