there’s a better way to treat addiction

DR. LANCE DODES AND ZACHARY DODES

The pseudo-science of Alcoholics Anonymous: There's a better way to treat addiction

Note:  the above picture does express a truth about AA…

Excerpted from:  The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry

 

Alcoholics Anonymous is a part of our nation’s fabric. In the seventy-six years since AA was created, 12-step programs have expanded to include over three hundred different organizations, focusing on such diverse issues as smoking, shoplifting, social phobia, debt, recovery from incest, even vulgarity. All told, more than five million people recite the Serenity Prayer at meetings across the United States every year.

Twelve-step programs hold a privileged place in our culture as well. The legions of “anonymous” members who comprise these groups are helped in their proselytizing mission by TV shows such as “Intervention” (now canceled), which preaches the gospel of recovery. “Going to rehab” is likewise a common refrain in music and film, where it is almost always uncritically presented as the one true hope for beating addiction. AA and rehab have even been codified into our legal system: court-mandated attendance, which began in the late 1980s, is today a staple of drug-crime policy. Every year, our state and federal governments spend over $15 billion on substance-abuse treatment for addicts, the vast majority of which are based on 12-step programs. There is only one problem: these programs almost always fail.

Peer-reviewed studies peg the success rate of AA somewhere between 5 and 10 percent. That is, about one of every fifteen people who enter these programs is able to become and stay sober. In 2006, one of the most prestigious scientific research organizations in the world, the Cochrane Collaboration, conducted a review of the many studies conducted between 1966 and 2005 and reached a stunning conclusion: “No experimental studies unequivocally demonstrated the effectiveness of AA” in treating alcoholism….

The AA monopoly

AA began as a nonprofessional attempt to grapple with the alcoholism of its founders. It arose and took its famous twelve steps directly from the Oxford Group, a fundamentalist religious organization founded in the early twentieth century. It came to life on the day that its founder, Bill Wilson, witnessed a “bright flash of light” in a hospital room.

Although the fledgling organization lacked any scientific backing, research, or clinical experience to support its method, AA spread like wildfire….And science looked away.

AA has managed to survive, in part, because members who become and remain sober speak and write about it regularly. This is no accident: AA’s twelfth step expressly tells members to proselytize for the organization: “Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.” Adherence to this step has created a classic sampling error: because most of us hear only from the people who succeeded in the program, it is natural to conclude that they represent the whole. In reality, these members speak for an exceptionally small percentage of addicts….

In other words, the program doesn’t fail; you fail.

Imagine if similar claims were made in defense of an ineffective antibiotic. Imagine dismissing millions of people who did not respond to a new form of chemotherapy as “constitutionally incapable” of properly receiving the drug. Of course, no researchers would make such claims in scientific circles—if they did, they would risk losing their standing. In professional medicine, if a treatment doesn’t work, it’s the treatment that must be scrutinized, not the patient. Not so for Alcoholics Anonymous.

Walking the twelve steps

More than anything, AA offers a comforting veneer of actionable change: it is something you can do. Twelve steps sounds like science; it feels like rigor; it has the syntax of a roadmap. Yet when we examine these twelve steps more closely, we find dubious ideas and even some potentially harmful myths.

Step 1: “We admitted we were powerless over alcohol, that our lives had become unmanageable.”

This step sounds appealing to some and grates heavily on others. The notion of declaring powerlessness is intended to evoke a sense of surrender that might give way to spiritual rebirth. Compelling as this is as a narrative device, it lacks any clinical merit or scientific backing.

Step 2: “Came to believe that a Power greater than ourselves could restore us to sanity.”

Many scholars have written about the close bond between AA and religion. This is perhaps inevitable: AA was founded as a religious organization whose design and practices hewed closely to its spiritual forerunner, the Oxford Group, whose members believed strongly in the purging of sinfulness through conversion experiences. As Bill Wilson wrote in the Big Book: “To some people we need not, and probably should not, emphasize the spiritual feature on our first approach. We might prejudice them. At the moment we are trying to put our lives in order. But this is not an end in itself. Our real purpose is to fit ourselves to be of maximum service to God.”

Religion can have a salutary effect on people in crisis, of course, and its strong emphasis on community bonds is often indispensable. But do these comforting feelings address the causes of addiction or lead to permanent recovery in any meaningful way? As we will see, the evidence is scant.

Step 3: “Made a decision to turn our will and our lives over to the care of God as we understood God.”

For an organization that has expressly denied religious standing and publicly claims a secular—even scientific—approach, it is curious that AA retains these explicit references to a spiritual power whose care might help light the way toward recovery. Even for addicts who opt to interpret this step secularly, the problem persists: why can’t this ultimate power lie within the addict?

Step 4: “Made a searching and fearless moral inventory of ourselves.”

The notion that people with addictions suffer from a failure of morality to be indexed and removed is fundamental to Alcoholics Anonymous. Yet addiction is not a moral defect, and to suggest that does a great disservice to people suffering with this disorder.

Step 5: “Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.”

Step 6: “Were entirely ready to have God remove all these defects of character.”

Step 7: “Humbly asked God to remove our shortcomings.”

These steps rehash the problems of their predecessors: the religiosity, the admission of moral defectiveness, the embrace of powerlessness, and the search for a cure through divine purification. The degradation woven through these steps also seems unwittingly designed to exacerbate, rather than relieve, the humiliating feelings so common in addiction.

If moral self-flagellation could cure addiction, we could be sure there would be precious few addicts.

Step 8: “Made a list of all persons we had harmed and became willing to make amends to them all.”

Step 9: “Made direct amends to such people wherever possible, except when to do so would injure them or others.”

There is nothing inherently wrong with apologizing to those who have been harmed, directly or indirectly, by the consequences of addiction. The problem is the echo once more of the fundamentalist religious principle: that the path to recovery is to cleanse oneself of sin.

Yes, apologies can be powerful things, and there’s no question that reconciling with people can be a liberating and uplifting experience. But grounding this advice within a framework of treatment alters its timbre, transforming an elective act into one of penance.

Step 10: “Continued to take personal inventory, and when we were wrong promptly admitted it.”

People suffering with addictions as a rule tend to be well aware of the many “wrongs” they have committed. Awareness of this fact doesn’t help the problem.

Step 11: “Sought through prayer and meditation to improve our conscious contact with God as we understood God, praying only for knowledge of God’s will for us and the power to carry that out.”

If AA were simply presented as a religious movement dedicated to trying to comfort addicts through faith and prayer, the program would not be so problematic. What is troubling is how resolutely—and some might say disingenuously—AA has taken pains to dissociate itself from the faith-based methodology it encourages.

Step 12: “Having had a spiritual awakening as the result of these steps, we tried to carry this message to other addicts and to practice these principles in all our affairs.”

AA’s emphasis on proselytizing, a basic tool through which recognized religions and certain fringe religious groups spread their message, is an essential part of its worldwide success, and it’s a big reason that it has been nearly impossible to have an open national dialogue about other, potentially better ways to treat addiction.

(HERE THE AUTHOR GIVES one CASE EXAMPLE TO PROVE THAT HIS APPROACH IS SUPERIOR…NO DOUBLE BLIND STUDY…and the patient is in therapy with him for YEARS)

Rehab owns a special place in the American imagination. Our nation invented the “Cadillac” rehab, manifested in such widely celebrated brand names as Hazelden, Sierra Tucson, and the Betty Ford Center. Ask the average American about any of these institutions and you will likely hear a response tinged with reverence…Where they deviate from traditional AA dogma is actually….alarming: many top rehab programs include extra features such as horseback riding, Reiki massage, and “adventure therapy” to help their clients exorcise the demons of addiction….there is no evidence that these additional “treatments” serve any purpose other than to provide momentary comfort to their clientele—and cover for the programs’ astronomical fees, which can exceed $90,000 a month.

….Repeat stays in rehab are very common, and readmission is almost always granted without any special consideration or review. On second and subsequent stays, the same program is offered, including lectures previously attended.

Any serious treatment center would study its own outcomes to modify and improve its approach. But rehabs generally don’t do this. For example, only one of the three best-known facilities has ever published outcome studies (Hazelden); neither Betty Ford nor Sierra Tucson has checked to see if their treatment is producing any results for at least the past decade. Hazelden’s follow-up studies looked at just the first year following discharge and showed disappointing results, as we will see later.

Efforts by journalists to solicit data from rehabs have also been met with resistance, making an independent audit of their results almost impossible and leading to the inevitable conclusion that the rest of the programs either don’t study their own outcomes or refuse to publish what they find.

Excerpted from “The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry” by Lance Dodes, M.D., and Zachary Dodes. Copyright 2014. Excerpted with permission by Beacon Press.

here is the WAY:

Whether you’re struggling with carb cravings or worried about a loved one who’s battling alcoholism, this podcast could be the most important 39 minutes of your entire year. Seriously! So put your listening ears on…

Today, Escape from Caloriegate welcomes Dr. Lance Dodes, a Training and Supervising Analyst with the Boston Psychoanalytic Society and Institute and assistant clinical professor of psychiatry at Harvard Medical School. Dr. Dodes is also the former Director of the substance abuse treatment unit of Harvard’s McLean Hospital.

 

 

 

 

 

Here are some highlights from the episode from caloriegate:

  • The way most people think about addiction is wrong: they think it’s a physical problem; a spiritual or moral weakness; or a neurological problem
  • None of these things = true
  • Dr. Dodes has been talking to people with addictions for decades, and he’s learned from them and tested his hypotheses
  • He’s come up with a new way of understanding addiction
  • A case history to illustrate this new paradigm
  • Man stuck waiting for his wife became frustrated – spotted a bar and went in
  • When did you start to feel better? “When I was standing on that corner and I decided to get a drink”
  • Illustrative of what he’s heard from many people over the years – wasn’t the drink itself when he felt better. Something happened when he made the decision.
  • His problem was that he was helpless, trapped. When people feel overwhelmingly helpless, it precipitates addictive behavior. Once he decided to drink, he wasn’t helpless any more.
  • Addictive acts are ways of undoing or reversing overwhelming helplessness.
  • Addiction is not a “thing in itself” — it’s a symptom. It’s an “unlucky solution” to the problem of helplessness.
  • Triggers of helplessness are very personal and not conscious
  • “F*ck it: I’m going to have a drink.” What does the “f*ck it” mean? It’s a fury at being helpless.
  • Analogy to a cave-in. 300 tons of rock trap you in a cave, you’re going to freak out. That’s a normal reaction.
  • The people who get depressed and inert when helpless don’t do well — rage at helplessness is innate and healthy.
  • It’s that power that makes addiction so powerful.
  • This rage has certain properties which give addiction its properties.
  • At the moment of the addictive feeling, nothing else matters. If you break your wrist trying to get out of a cave-in, you’re not being self-destructive — you’re just not paying attention to the consequences.
  • Instead of taking a direct action to deal with helplessness, he took an indirect action.
  • All addictive acts are displacements. Helps to explain curious clinical features of addiction – e.g. that you can change focus of an addiction.
  • Drinking alcohol is most common displacement, but people can switch to other drugs or even to gambling, shopping or eating.
  • There is no difference between addictions and compulsions — this should change the way we think about treatment
  • We know how to treat compulsions! Figure out why they occur, when they occur, etc.
  • Addictions can be treated by a psychologically sophisticated therapy. Conversely, 12 step models don’t work well.
  • Giant modern myth about addiction – that it’s a chronic brain disease. Comes out of National Institute of Drug Abuse.
  • Physical addiction is VERY different from addiction. Very clear and simple phenomenon.
  • If you take enough of a drug in high enough dose, you become tolerant. To get same effect, you need to increase dose.
  • Pull the drug away, you go into withdrawal — in opposite direction of the drug.
  • Not important because anybody can become physically addicted.
  • Treat easily – by detoxifying them.
  • You can’t turn someone into an alcoholic by physically addicting them
  • Vietnam veterans study – dramatic example. In 1960s, heroin epidemic in our country. After detoxing, huge recidivism rate.
  • Soldiers in Vietnam also got addicted to heroin (high quality stuff).
  • When soldiers got back, they detoxed, and over 90% never used heroin again — the opposite of what happened with the stateside addicts.
  • The difference was in their psychology. Soldiers used it because of stress of war. When they got home, they didn’t need it and so didn’t use it.
  • What’s the retort? There is no response from the conventional thinkers. It’s unchallengeable.
  • Millions of people stopped smoking in the 1980s, once the Surgeon General’s anti-smoking campaign started up. Similar to what happened with the vets.
  • Scientists addicted rats to heroin and conditioned them, a la Pavlov’s dogs, with cues.
  • Rats releasing dopamine – the gas of the pleasure pathway. We see response from cue. Brain will create more dopamine – upregulate. The CW: “Now we know why people can’t stop taking drugs. Their brains have been chronically changed.”
  • Why this is wrong: if that was true, the Vietnam study wouldn’t have turned out like that, since the vets’ brains would have changed.
  • Also: people aren’t like that at all! People wait hours to drive to the casino. They’re not hyped up on dopamine.
  • Chronic brain disease idea is a mistake — even though rats and humans are similar, rats operate a simple system, so paradigm doesn’t really apply.
  • Also, doesn’t explain non-drug compulsions — no dopamine released when you arrange things parallel on your desk.
  • 5% success rate of AA because it’s approaching the problem without understanding it.
  • The idea that there’s a simple neurological basis of addiction misses a key point — assumes that if we only knew enough about the human brain, we could dispense with psychology.
  • That idea is false because of complexity theory – at increasing levels of complexity, new phenomena occur which are not present at the level of the simpler elements.
  • No matter how much we study water molecules, we cannot predict what happens when we get trillions of them together.
  • Likewise we cannot predict psychology from biology.
  • How these theories apply to food and carbohydrate addiction
  • Carb/food addiction has parallels with cigarette addiction
  • Conventional treatment centers are dependent on the standard addiction paradigm to be true.
  • You’re running into the headwind of what everyone believes or wants to believe, so it can be hard to get a fair hearing.
  • Could changing our paradigm about addiction save our society billions of dollars and save lives?

 a brief youtube interview

The author’s website

Here is a critique:

In Defense Of 12 Steps: What Science Really Tells Us About Addiction

The chips AA members receive to mark sobriety. (Randy Heinitz/Flickr)

Last week, Radio Boston featured an interview with Dr. Lance Dodes, author of “The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry.” Here, two Harvard Medical School professors of psychiatry respond, arguing that Dr. Dodes misrepresents the evidence and that 12-step programs have among the strongest scientific underpinnings of any addiction treatment.

By John F. Kelly and Gene Beresin
Guest Contributors

In a recent WBUR interview, Dr. Lance Dodes discussed his new book, which attempts to “debunk” the science related to the effectiveness of 12-step mutual-help programs, such as Alcoholics Anonymous, as well as 12-step professional treatment. He claims that these approaches are almost completely ineffective and even harmful in treating substance use disorders.

What he claims has very serious implications because hundreds of Americans are dying every day as a result of addiction. If the science really does demonstrate that the millions of people who attend AA and similar 12-step organizations each week are really deluding themselves as to any benefit they may be getting, then this surely should be stated loud and clear.

In fact, however, rather than support Dr. Dodes’ position, the science actually supports the exact opposite: AA and 12-step treatments are some of the most effective and cost-effective treatment approaches for addiction.

In his book, Dr. Dodes commits the same misguided offenses he condemns. His critique of the science behind treatment of addiction is deeply flawed, and ironically, his own psychoanalytic model of an approach to solve the “problem of addiction” has no independent scientific proof of effectiveness, particularly in comparison to other methods of treatment.

Below, we address some of the specific pronouncements he made on Radio Boston and in his book in order to convey what well-conducted science actually tells us about how to treat addiction.

What he says: 12-Step programs do not work, are not backed by science, and are probably harmful.

The evidence is overwhelming that AA, and treatments that facilitate patients’ engagement with groups like AA, are among the most effective and best studied treatments for helping change addictive behavior.

This conclusion is consistent with the views of prominent organizations such as the National Institute of Health (NIH), the Substance Abuse and Mental Health Services Administration (SAMHSA), the American Psychiatric Association (APA), and the Department of Veterans Affairs Health Care System (VAHCS), all of whom recommend patients’ participate in AA or similar groups to aid recovery.

Dr. Dodes begins his criticism of AA and related treatment by citing a 1991 study published in the prestigious New England Journal of Medicine. This paper studied the treatment of a large number of individuals with alcohol problems. Dr. Dodes notes in his book that compulsory inpatient treatment had a better outcome than AA alone. But what he fails to mention is that the inpatient unit is a 12-step-based program with AA meetings during treatment, and requirements to attend AA meetings three times a week after discharge in the year following treatment.

Importantly, too, when you compare the alcohol outcomes (average number of daily drinks, number of drinks per month, number of binges, and serious symptoms of alcohol use), AA alone was just as good as the AA-based inpatient treatment. Yet Dr. Dodes uses this study to argue that AA is poor while inpatient treatment is good — a bizarrely distorted, misleading and incorrect interpretation of the study’s findings.

Dr. Dodes then cites a review article from another prestigious entity, the Cochrane Collaboration, to condemn AA and 12-step treatment. The Cochrane group is considered by health professionals to be the “gold standard” of good scientific procedure in its series of reviews. The article reviewed 8 studies from 1991-2004, comparing AA and 12-step treatment to other approaches, such as cognitive-behavioral relapse prevention therapies.

He concludes from this important paper that AA and 12-step treatment were ineffective. However, the study actually concluded that AA and 12-step treatment were shown to be as effective as anything else to which they were compared.

Perhaps not surprisingly, given his apparent agenda, Dr. Dodes doesn’t acknowledge the more recent randomized controlled trials of addiction treatment (that is, studies in which individuals with addictions were randomly assigned to different treatment approaches, comparing outcomes. See herehere, and here. Such studies are considered the most reliable sort of research.) These studies show that 12-step treatment improves outcomes by up to 20% for as long as two years post-treatment via its ability to engage patients, and also tends to produce much higher rates of continuous abstinence than other forms of treatment.

Finally, in the largest randomized controlled study of treatment for alcohol use disorder ever undertaken (Project MATCH), which he does mention, he fails to state that compared to the cognitive-behavioral and motivational-enhancement treatments included in that study, the 12-step treatment had more than double the number of patients who were continuously abstinent at one year after treatment and about one third more at three years after treatment.

What he does not mention: cost or access to care

Dr. Dodes fails to mention cost. Unlike psychoanalysis and other treatments, AA is free, and can be accessed almost anywhere at any time in the United States and many other countries (notably at high-risk relapse times when professionals are not available like weekends, holidays, and evenings.)

In fact, studies published in prestigious peer-reviewed scientific journals have found that 12-step treatments that facilitate engagement with AA post-discharge can not only produce about one third higher continuous abstinence rates, but also 64% lower health care costs compared to cognitive-behavioral treatments.

With the current pressure to configure a leaner and more cost-effective health care system, it is these kinds of double bonus effects that we are looking for.

What he says: 12-step programs are no better than doing nothing.

In addition, Dr. Dodes then goes on to try and make the case that 12-step treatment for substance use disorder is no better than doing nothing; he’s apparently implying that if we actually just stood back and waited, people with substance use disorders would overcome addiction at the same rate as our current best efforts. Presumably, his own approach to addiction treatment would work best? Unfortunately, his own method, promoted on the air and in his book, has not a single scientific study to demonstrate its effectiveness.

What he says: 12-step programs are no more than “religious” efforts that reinforce powerlessness and helplessness

Dr. Dodes’ book and comments are so far off the track of scientific research that he doesn’t realize that for the past several years, the addiction research field has moved beyond asking whether AA and 12-step treatment works, to investigating how and why they work. We have now discovered that the reason why 12-step based interventions so often do better than others is that they engage people with groups like AA, which increase people’s ability to cope with the demands of recovery, and foster critically important social network changes within the communities in which they live every day.

For some, AA also has been shown to work by increasing spirituality, which helps people reframe and take a different viewpoint on stress, such that instead of being seen as a negative it becomes viewed as the fertilizer that fuels personal growth.

Dr. Dodes complains that AA’s focus on admitting powerlessness over one’s addiction is a step in seeking a “higher power” and he interprets this literally as seeking God. For some, this is true and helpful. For others, particularly those for whom spirituality is not appealing, it is seeking help from the AA fellowship (for some “GOD” can stand for “Group Of Drunks, or ‘Good Orderly Direction’), and acknowledging that you cannot solve the problem alone; you need what Carl Jung called “the protective wall of human community.” Strength comes from assuming personal accountability and responsibility to a group, your AA sponsor and, most importantly, to yourself. This process empowers individuals to make the changes needed for recovery.

What he says: Genetics does not play a role in addictions. They are not diseases.

In a blog on the Dodes webpage, there is an assertion that genetics has no role in addictions. This assertion once again contradicts scientific evidence. Research demonstrates that about half of the risk for addiction is conferred by genetics. But the environment is critical too. Like many diseases, the condition is caused by a personal biological vulnerability coupled with environmental exposure and experiences.

In summary, while claiming to “debunk the bad science behind 12-step programs” Dr. Dodes instead reveals a selective and superficial review of the research, at times misinterpreting the studies that he uses to support his own assertions. From a clinician who professes to care about individuals suffering from addiction, Dr. Dodes’ conclusions are not only incorrect, they may have grave consequences.

For the families who have a loved one struggling with addiction, life is beyond tragic. Nights are sleepless while many wait for the proverbial shoe to drop. Will someone be killed by your son, daughter or spouse getting behind the wheel? Will you get the often-awaited call in the middle of the night that your child was found dead in her apartment? We know these stories. We hear them on the news daily.

What can we do to prevent the scourge of addiction? And what can we do when it appears in a family member? Surely we all want a magic bullet. But we also want care that is based on sound scientific research and evidence-based treatments. There are no cures. But there is hope for recovery, sobriety, and, while AA and 12-step treatments are not cure-alls themselves, research demonstrates that they are some of the most effective and cost-effective approaches to addressing chronic diseases of addiction in our society.

John F. Kelly, PhD., is the Elizabeth R. Spallin Associate Professor of Psychiatry in Addiction Medicine at Harvard Medical School, and the President of the American Psychological Association, Society of Addiction Psychology. He is also the Director of the Recovery Research Institute at Massachusetts General Hospital.

Gene Beresin, MD, MA, is Professor of Psychiatry at Harvard Medical School and Executive Director of The Clay Center for Young Health Minds at Massachusetts General Hospital.

 

 

 

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