Debunking the bad science behind 12-step programs and the rehab industry
Book Review by Tom Horvath, PhD., ABPP
Text: 160 pages; Preface: 1 page; Notes: 9 pages
The subtitle of this book guaranteed that it would be unpopular with many in the 12-step and rehab communities. However, titles are often a compromise between publisher and author. The publisher wants to sell books. The authors do also, but do not want to diminish the credibility of the work. A controversial title may be acceptable to authors if it can be nuanced in the work itself. This writing team is a psychiatrist and addiction expert father, and his son, a free-lance writer with a BA from Yale and an MFA from USC. What exactly do they say about 12-step groups and the rehab industry?
Chapter 3 is entitled “Does AA work?” The closing paragraph (pg. 57) begins “All that said, there is no question that AA is useful for some people.” The previous 25+ pages have been devoted to carefully preparing the reader to understand that (pg 56):
“AA works well for the people who are most invested in it. But this correlation becomes considerably less impressive when it is placed in the context of all the people who try but fail to benefit from 12-step recovery. An objective calculation puts AA’s success rate at 5 to 8 percent. Controlled, randomized studies, on the other hand, have revealed an even more discouraging picture: No such study to date has been able to prove AA is effective at all. The issue of spontaneous remission further erodes AA’s reputation…A higher percentage of people get better without any treatment than with AA, suggesting that some of AA’s success rate may simply be nature taking its course.”
Their summary of the literature about AA is consistent with my understanding of it, yet they are willing to acknowledge, as I am, that “AA is useful for some people.” They reinforce that point later (pg. 122): “It is clear that a small number of people get well in AA because of AA [emphasis in the original].” However, the authors suggest that the US needs to consider the human costs associated with decades of promoting AA almost exclusively, while demeaning other approaches and shaming those (the majority) who do not succeed in AA. These costs have been considerable.
Back to that subtitle. The science that we have is actually fine, as long as we realize that there are no studies that confirm AA’s effectiveness. The problem is not bad science, but misinterpretation of data. Many start with conclusions (AA must work), then look for data to match. Science goes in the other direction, questions (does AA work?) and data, then conclusions.
What about the rehab industry? The authors appear to have some sympathy for non-professionals associated with AA who may misinterpret scientific data. That sympathy falls away when dealing with the rehab industry, which ought to know better.
In Chapter 4 (The business of rehab and the broken promise of “AA-plus”) some of the worst aspects of the industry are highlighted: The increase in opulent settings vs. providing meaningful treatment, the increase in questionable holistic services vs. providing meaningful treatment, the emphasis on groups vs. providing meaningful individual treatment, the use of barely trained counselors vs. experienced providers (who can provide meaningful treatment), and an almost exclusive focus on getting all clients to AA or other 12-step meetings vs. providing meaningful treatment.
Which brings them to explaining what meaningful treatment might consist of. Dr. Dodes’ first book, The Heart of Addiction, addresses meaningful treatment in detail. In the current book the authors summarize meaningful addiction treatment by saying that “addiction can be understood, managed and ended through learning about oneself.” Several case examples show how various individuals use addiction as a mechanism to solve feelings of overwhelming helplessness, and how learning a more direct response can resolve addiction and improve their lives. “Like the TB sanitaria of the late 19th century, 12-step treatments are trying their best to solve a problem whose fundamental essence they do not understand (pg. 95).”
Some clients need intensive psychotherapy for addiction, but most do not. Dr. Dodes’ second book, Breaking Addiction: A 7-Step Handbook for Ending Any Addiction, may suffice for many individuals seeking a guided approach to learning about how addiction actually works in them.
For some individuals a mutual help group alone is sufficient. AA remains the preferred mutual help group in the US, in part because of its availability, but it is not the only option. Within about a decade, at its present rate of growth, SMART Recovery will be comparably available to AA in the US. If any mutual group does more harm than good it needs to be avoided. That message is in need of wide dissemination in the US.
Back to that subtitle. The situation is the same for rehab as it is for AA. The science we have is fine, but much data has been misinterpreted (and perhaps misrepresented). There is very little data to support the effectiveness of rehab. As someone who owns and operates rehabs (which include some holistic services), I do view them as an important component of a treatment continuum. It is important, however, not to mislead anyone about “success rates” or dramatic cures in a short period of time. At best, for most, rehab is the start of a much longer recovery process.
The authors describe (pg. 79) a “better rehab,” which would include flexible length of stay, intensive individual psychotherapy with experienced, well-trained therapists, groups that help participants learn about themselves rather than groups with a set “educational” agenda, and no lectures about drugs or how to use 12-step groups (although these groups should be made available outside the rehab for those who can make good use of them). I’m pleased to say that Practical Recovery follows these principles (and makes available SMART Recovery as well, which is the group more frequently chosen by our residents).
Because I have focused on selected aspects of this work, I am copying below the chapter titles, and the 11 myths presented in Chapter 8:
1) The problem
2) The rise of AA
3) Does AA work?
4) The business of rehab and the broken promise of “AA-plus”
5) So, what does work to treat addiction?
6) What the addicts say
7) Why does AA work when it does?
8) The myths of AA
9) The failure of addiction research and designing the perfect study
The myths in Chapter 8:
1) You have to “hit bottom” before you can get well
2) You must “surrender” your will to get well
3) Counting your days of abstinence is a useful thing to do
4) People with addiction are all the same: “Drunks”
5) “One day at a time”
6) “Stick with the winners”
7) “90 meetings in 90 days”
8) People with addictions have character defects
9) Only an addict can treat an addict
10) “The definition of insanity is doing the same thing over and over and expecting a different result”
11) “Denial ain’t just a river in Egypt”
Lance Dodes has over three decades experience treating addiction. He is a retired assistant clinical professor of psychiatry at Harvard Medical School. His work deserves the consideration of any serious student of addiction treatment.