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 hit TV shows such as "Intervention," which preaches the gospel of recovery. “Going to rehab” is likewise a common refrain in music and fi lm, 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.
[Source: Beacon Press; Copyright 2014, All Rights Reserved]
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. This group reached the same conclusion about professional AA-oriented treatment (12-step facilitation therapy, or TSF), which is the core of virtually every alcoholism-rehabilitation program in the country.
Many people greet this finding with open hostility. After all, walk down any street in any city and you are likely to run into a dozen people who swear by AA—either from personal experience or because they know someone whose life was saved by the program. Even people who have no experience with AA may still have heard that it works or protest that 5 to 10 percent is a significant number when we’re talking about millions of people. So AA isn’t perfect, runs this thread of reasoning. Have you got anything better?
There are good answers to these objections, and they will take up a considerable portion of this book. For now, I will simply say that there are indeed better treatments for addiction—but the issues with AA’s approach run far deeper than its statistical success rate. While it’s praiseworthy that some do well in AA, the problem is that our society has followed AA’s lead in presuming that 12-step treatment is good for the other 90 percent of people with addictions.
Any substantive conversation about treatment in this country must reckon with the toll levied when a culture encourages one approach to the exclusion of all others, especially when that culture limits the treatment options for suffering people, ignores advances in understanding addiction, and excludes and even shames the great majority of people who fail in the sanctioned approach.
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 through a country desperate for hope at the end of Prohibition and in the midst of the Great Depression. It soon became immaterial whether AA worked well or worked at all: it had claimed its place as the last best hope for beating the mighty specter of addiction. It had become the indispensable treatment, the sine qua non of addiction recovery in the United States. 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, as we will see.
Beyond these individual proselytizing efforts, AA makes inflated claims about itself. Its foundational document, "Alcoholics Anonymous" (commonly referred to as the “Big Book” and a perennial best seller), spells out a confident ethos regularly endorsed by AA members:
Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average. There are those, too, who suffer from grave emotional and mental disorders, but many of them do recover if they have the capacity to be honest.
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. I’ll examine this more closely in the chapters ahead.
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.
THE CONSEQUENCES OF BAD TREATMENT
I have been treating people suffering with addictions in public and private hospitals, in clinics, and in my private practice for more than thirty years. In that time, I have met and listened to a very large number of people who have “failed” at AA and some who continue to swear by it, despite repeated recidivism.
Dominic’s case is just one example (I have changed the names and nonessential details in the passage below and whenever I discuss patients in this book). Dominic began drinking heavily as a junior at a good college. Weekly binges soon turned to daily abuse, with predictable results: his grades plummeted; his attendance vanished. By the time he arrived home for winter break, Dominic’s family was deeply concerned about his deterioration. They advised him to seek counseling at the university health center.
Advisors there recommended that Dominic begin attending AA, which he did. He became fond of his sponsor and felt included for the first time in years—no small feat for a suffering young man. But he also found himself increasingly resentful of the “tally system” that
AA uses to measure sobriety: every time he “slipped” and had a drink, he “went back to zero.” All the chips he’d earned—the tokens given by AA for milestone periods of sobriety—became meaningless. This system compounded his sense of shame and anger, leading him to wonder why he lacked the willpower or fortitude to master the incredible force of his alcoholism.
By spring, Dominic had dropped out of college. His parents turned to the family doctor for advice. She told him to double down on AA—to attend ninety meetings in ninety days, which is a common AA prescription.
It worked. Although many of the faces at the meetings kept changing and Dominic constantly felt the urge to drink, he found a few “oldtimers” who believed wholly in the program and who encouraged him to dismiss the great majority of people who fell through the cracks. They just weren’t ready to stop, he was reassured. Dominic soon learned to distract himself from thinking about alcohol and to call his sponsor when the urge arose.
Four months into the program, Dominic became frustrated during a call with his bank. He bought a fifth of vodka and drank so much that he fell down the stairs, suffering three cracked vertebrae. A series of increasingly expensive stints in rehab followed throughout his twenties, with poor results. During this time, he was hospitalized twice and lost every job he held. A brief marriage ended in a bad divorce, and Dominic was deeply depressed by the time someone in his life recommended that he try something other than a 12-step program. Maybe talk therapy was worth a try.
When Dominic entered my office, he had accepted as empirical truth that he was a deeply flawed individual: amoral, narcissistic, and unable to turn himself over to a Higher Power. How else to explain the swath of destruction he had cut through his own life and the lives of those who loved him? His time in AA had also taught him that his deeper psychological life was immaterial to mastering his addiction. He had a disease; the solution was in the Twelve Steps. When he was ready to quit, he would.
It took eight months of psychotherapy before Dominic stopped drinking for good. Although he remained in therapy for several years after that, the key that unlocked his addiction was nothing more complex or ethereal than an understanding of what his addiction really was and how it really worked.
Dominic had felt enormously pressured all of his life, consumed by a suffocating need to excel in every activity. He was driven by a hunger to be “good enough”—accomplished enough, successful enough—to please his demanding father and blameful mother. Whenever he felt he was not performing up to his potential, his old sense of being trapped by implacable demands arose, and with it came a deep sense of shame and an equal fury at the awful helplessness he felt about this burden. Those were the moments he had to have a drink.
Eventually he came to realize that this odd coping mechanism made a certain kind of sense. By making a decision to drink, he was empowering himself—he no longer felt helpless. Once he understood the connection between his lifelong feelings and his urges to drink, he was able to view them with some perspective for the first time. He found that he was able to predict when his drive to drink would return, since it always tended to surface right after that old, unbearable pressure to perform. He developed enough awareness into what was beneath these urges that he could take a step back and deal with those issues more directly and appropriately. Over time, he was also able to work out the underlying narrative forces that had led him to feel so helpless throughout his life. He had, in other words, supplanted the notion of a Higher Power with something far more personally empowering: sophisticated self-awareness.
THE REHAB FICTION
Dominic’s history follows the same contours as thousands of others. But one part of his story warrants special attention: the series of failed attempts at rehabilitation. Dominic’s family lost close to $200,000— their total retirement savings—on this string of ineffectual programs.
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—these are the standard-bearers, our front line against addiction. The fact that they are all extraordinarily expensive is almost beside the point: these rehabs are fighting the good fight, and they deserve every penny we’ve got.
Unfortunately, nearly all these programs use an adaptation of the same AA approach that has been shown repeatedly to be highly ineffective. Where they deviate from traditional AA dogma is actually more 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. Some renowned programs even have “equine therapists” available to treat addiction—a fairly novel credential in this context, to put it kindly. Sadly, 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.
Why do we tolerate this industry? One reason may sound familiar: in rehab, one feels that one is doing something, taking on a life-changing intervention whose exorbitant expense ironically reinforces the impression that epochal changes must be just around the corner. It is marketed as the sort of cleansing experience that can herald the dawn of a new era. How many of us have not indulged this fantasy at one time or another— the daydream that if we could just put our lives “on pause” for a while and retreat somewhere pastoral and lovely, we could finally make sense of all our problems?
Alas, the effect is temporary at best. Many patients begin using again soon after they emerge from rehab, often suffering repeated relapses. The discouragement that follows these failures can magnify the desperation that originally brought them to help’s door.
What’s especially shocking is how the rehab industry responds to these individuals: they simply repeat their failed treatments, sometimes dozens of times. 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.
