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AA and the Twelve Steps come in for another drubbing

Dr. Lance Dodes
Photo by Zachary Dodes/Beacon Press
Dr. Lance Dodes

Criticism of Alcoholics Anonymous and Twelve-Step programs is nothing new, but every now and then the widely accepted approach to addiction and recovery gets a fresh whack upside the head.

Re-entering the fray is Lance Dodes, M.D., with “The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry” (co-authored with his son, Zachary Dodes, and published by Beacon Press), a book that began generating heated online exchanges a good 48 hours before its official release Tuesday.

Dodes, a retired Harvard psychiatry professor and longtime addiction treatment specialist, is the author of two previous books, “The Heart of Addiction” and “Breaking Addiction” – preludes to this more full-throated challenge to conventional wisdom around addiction and addiction treatment.

“The Sober Truth” elucidates the many flaws and shortcomings in research studies that point to the efficacy of AA and Twelve Steps, including the absence of randomized, clinical trials; the overreliance on self-reporting, and the failure to adjust for “motivational confound” (while those who stay in the program tend to do well in the program, studies don’t account for the people who dropped out).

Dodes also dismisses findings of genetic and neurobiological links to addiction, and does not embrace the “disease” construct. “[N]obody in human history has ever walked into a bar because a gene told them to,” he writes. And the more equine therapy, Reiki massage and outdoor adventures offered at any given rehab center, the more his suspicions are aroused.

By his lights, addiction is a purely psychological disorder, one that is driven by a desire to overcome the feeling of helplessness by “replacing it with its opposite, empowerment.” Therefore, a treatment philosophy that begins with the idea of powerlessness might well work against those it intends to help, he argues. With his approach, “The problem becomes ordinary, no more or less manageable than any psychological problem and can be managed as such” – with psychotherapy.

Cyclical criticism

Marvin Seppala, M.D., chief medical officer of Hazelden Betty Ford Foundation, is unperturbed. “It’s just cyclic bashing that I’ve heard before – every five years or so,” he said.

Some of the criticism carries the suggestion that AA is a form of treatment, Seppala said. But it’s not treatment and doesn’t pretend to be, he said. “It is a mutual help program. People enter, they don’t pay anything, there are no professionals, and they help each other. And research has shown that it is successful in that regard.”

As for Hazelden, he said, “we provide treatment based on the best evidence of what works for addiction, and that includes different psychotherapies, it includes medication, and it includes facilitating people to attend AA in the long run – because addiction is a chronic illness, and disease management systems work for chronic illness.”

AA is not for everybody, Seppala said. People with social anxiety disorder, for example, or those who are agnostic or atheist. There are AA groups designed to accommodate the latter, he said. “They don’t pray, they don’t talk about a higher power, and they use other terminology that works for them. But they support each other, and they still use the steps in their own way.”

He’s baffled by anyone who would reject a neurobiological interpretation of addiction. “These drugs powerfully affect the reward center in ways that reprioritize drive states, so that people are willing to risk and lose their lives just to keep getting high,” he said. “It’s hard to even fathom that. When you’re dealing with people who are really at that stage, where it’s overwhelmingly altering their lives in that manner, it’s hard to say that it’s not a biological illness, that somehow it’s just a behavioral problem that people learn how to do and now somehow choose to do.

“How do you address such powerful drives? You have to [employ] something remarkably powerful as well.”

Anything but simple

For some seeking treatment, the prevailing therapies provoke a strong and complicated response.

Take John J., for example.

He’s a longtime Minnesota transplant who experienced the full range of the state’s treatment options over the course of 10 years. He openly expresses his antipathy toward AA culture (as he experienced it) and the Twelve Steps. Even as he criticizes, however, he admits that he contradicts himself.

Chief among his objections is that, contrary to the oft-repeated admonition to “Keep it simple, stupid,” the Twelve Steps are anything but simple, he said.

“You just get engrossed in somebody else’s idea, somebody else’s outline,” he said. “You’re trying to do your homework, and you’re trying to get things done. But there are so many decisions to make, and it becomes a quagmire. … With every step, there are 20 other steps underneath. And you’ve got to take a left turn here, and a right turn there, and there’s an alley you’ve got to go down, and a garage door to open. And it’s just so labyrinthine. You can get lost.”

As well, he simply could not accept the “powerlessness” that is required in Step One. “The idea that you’re helpless and powerless is the beginning of the end,” he said. “You have to get in the driver’s seat. You have to take control. If you don’t, you’re dead.” Even his rabbi cannot accept the idea of “letting go of volition,” he said.

Serenity Prayer featured on the back of an Alcoholics Anonymous medallion
The Serenity Prayer featured on the back of an Alcoholics Anonymous medallion.

Grumpy old men’

The general climate inside AA meetings, which John J. said was true of the hundreds and hundreds of meetings he attended, did not help matters. “Everybody there is pissing and moaning about how their relatives (who are supporting them) are not being nice to them and not understanding, and how their boss is firing them because he didn’t understand their disease.”

His most pointed observations are reserved for the “grumpy old men” standard-bearers. “They’re the only ones who enjoy the meetings because they get to bark at the new people and try to boss them around. They’ve lost their authority on the home front and everywhere else. … and they’re just dry drunks, grouches. And they hate their lives – they hate every moment of their lives – until they get into their meetings, where they can exercise power, and tell you, ‘You’re going to die.’ ”

John J. would also prefer that his “ex-sponsor” not show up at his workplace to “remind the people around me how bad it used to be for me. I’ve moved on.”

All that said, John J. acknowledges that his recovery began at Hazelden Betty Ford Foundation, a treatment program firmly grounded in Twelve Step principles and practices. It was there, he said, that he recovered his physical strength, became enlightened about the physiological effects of addiction and grasped the absolute imperative to set aside his idea of uniqueness. Among his takeaways, in his words:

Whatever drug you’re taking lives in you: The more you subscribe to this substance … it’s physically implanted in your body. And unless you get it out of there, it’s not going to go away. That seems simple on the surface. But it took beating it into my head for me to really comprehend that you are what you eat. I should have learned that in the ’60s, but I didn’t get it because it wasn’t the right time for me to learn it. I had to wait for that lesson to come along. It’s the very first lesson I learned in there [at Hazelden].

You’re not what you think you are: When you are under the influence, including of some of the things that are prescribed by the treatment community, you’re not presenting the way you think you are. Your speech and tone of voice are what you believe to be reasoned. Your sister is looking at you sideways, and asking, “Who … are you?” But you don’t get it then, and you don’t understand afterwards until you make that change. Being in the moment with how you’re presenting is not an obvious thing. You’re delusional, hyper, often hysterical, overdramatic, grandiose – all those things don’t occur to you because, really, what you want is the next pill and the next drink and nothing else is on your list of priorities.

You have to have some humility: You think you’re special. You think you’re different. You think you’re unique. This is something that was impressed upon me as a child: I’m different, I’m special, and I’m one of God’s chosen because I’m an artist. Nobody understands me, and maybe they will after I die. And who cares? That has to go away. You have to have some humility. That aspect of recovery has to occur or you are going to die. … I’m not special. I’m flesh and blood. I’m just like everybody else here. I have something in common. There is something in common here. The only uniqueness you find in art and poetry and literature is the fact that maybe you can resonate because you are the same, not because you are special.

One step, not 12

John J. said his long awakening (which cost hundreds of thousands of dollars), continued after he left Hazelden and sought further treatment for mental-health issues at Cedar Ridge in Stillwater, a men’s residential center that he remembers as a “cold encampment … slim on creature comforts.” There he found a dog-eared copy of a self-help book promoting “health realization,” an approach to recovery that teaches how to allow positive self-image and “innate health” to emerge.

“The answer lies in acceptance, not in powerlessness,” he said of his epiphany. “It’s one step, not 12.”

These days, John J. avoids getting involved in other people’s recovery dramas (“it destroys relationships”), and he gives back by working with seniors.

“And that’s what gives me the most joy of anything,” he said. “I used to be very, very object-based with success. … [My new spouse] has taught me it’s more about who you are in the moment.”

Comments (20)

  1. Submitted by Paul Brandon on 03/26/2014 - 10:00 am.

    Some very good points in here.

    Basically, AA-type step programs are not supported by bad science; they’re not supported by ANYthing that could be called science. I’m saying this as someone with a doctorate in Experimental Psychology and some background in behavioral pharmacology whose done animal research on ethanol consumption.
    And unlike Hazelton I am not a business with skin in the game (I’m a retired professor).

    AA is one of those ‘zombie ideas’:
    It keeps getting killed and it keeps coming back even though it’s no longer breathing.

    I agree that the medical model of ethanol abuse and addiction has not proved productive since no direct underlying causal pathology has yet beet identified.

    Dodes does overstate the case for genes, however. While there is no known genetic -cause- for alcohol addiction (no gene accounts for more than a few percent of the variance), there do appear to be some genetic predispositions which (coupled with other factors) make alcohol addiction more likely.

    • Submitted by Bill Schletzer on 03/26/2014 - 11:40 am.

      It keeps coming back….

      because it works. Simple. Your doctorate and animal research have taught you not one thing that can help others. The whole body of acceptable academic psychology goes against the language and concepts of AA but AA has helped millions and the all the PhDs are still befuddled. Speaking as the son of a PhD is psychology, I have seen your arguments before, but the argument goes, “that isn’t scientific so you must be deluded if helps you, but what I have is scientific, although it can’t help you.”

      And if you are of retirement age you must be very familiar with Freud, who was taught as fact well into the time your career would have started. Speaking of unsupported ideas, he’s got a few doozies.

      • Submitted by Paul Brandon on 03/26/2014 - 01:44 pm.

        Read the article

        Science is a way of proving that something works.
        You can assert all you want that AA works, but the evidence says otherwise.
        About 30% of addicts kick their addiction without any intervention whatsoever. To prove that a program is effective, it must show that it does better than this no-treatment base rate.
        The evidence does show that behaviorally based programs (based in part on principles derived from animal research) do work.

        And Freud is irrelevant to this discussion.
        His work was state of the art at the end of the 19th century (I’m not quite that old), but while psychodynamic theory derived from Freud’s work (not Freudian theory itself) is still taught in a few programs, it is far from the mainstream, and has been so for the past 50 years.

        • Submitted by Bill Schletzer on 03/27/2014 - 07:59 am.

          30%

          Could you please cite a source for that 30% number. That is new news to me. I’ve never heard a recovery number approaching that. Question: does it include people who become free of their addiction by dying?

          I brought up Freud only to show how unscientific much of academic psychology can be. His theories were taught as fact for years. Id? Superego? Show me “proof” of their existence. The only proof could be that they were used as therapy tools and if therapy helpe someone, that was used as “proof”. I have known hundreds and hundreds of people helped by AA. I have also met many people outside that program who have very distorted ideas of what it is about. I see some of them commenting here.

  2. Submitted by Bill Schletzer on 03/26/2014 - 10:46 am.

    Whatever…

    I read the longer piece on Salon about this book. He attacks “pseudo science” by people trying to help each other, often successfully, with his brand of pseudo science created by a guy trying to make a buck. The fact is that many approaches can work but the differenece is that the AA program holds to a basic tenet to have no opinion on the approaches of others, but his approach seems to be rooted in being contrary to AA. Also in reading these articles I see that he has misperceptions about what AA is. Of course those misperceptions are used to justify his approach. As for John J, glad he’s sober now but it sounds like he spent ten years going to meetings, failing to stay sober, and blaming everyone but himself.

    • Submitted by Jack Shuman on 03/27/2014 - 07:02 pm.

      Re: Whatever

      “…the AA program holds to a basic tenet to have no opinion on the approaches of others…”

      Since I first attended AA in the mid-seventies or so, AA insisted it was the only way. These days, after being confronted frequently and aggressively with the fact that it is in fact not the only way, most AA members will admit that “it’s not the only way.” I honestly never thought I’d see the day. But even though this claim is admitted, on either side of that admission you’re likely to hear the insistence that AA is the only way, or at the very least insinuations along those lines. It’s strange.

      When people make criticisms of AA, they’re generally told that they could cost a newcomer his/her life. Bad advice from a sponsor would more likely cost a newcomer his/her life. (Advice such as “You’re not really sober as long as you’re taking that antidepressant.”) To hear AA true believers tell it, once one enters AA, does the steps, gets a sponsor, reads the big book, she will not have to worry because her higher power will take care of things for her. This is magical thinking, it’s foolish, and at best it is simply not true.

      John J.’s awareness of things is impressive, much more so than a group of zombies sitting around a table reciting slogans. He’s thinking, which of course is something that AA discourages.

      90 meetings in 90 days is nothing more than a way to indoctrinate newcomers.

      These days there are different support groups to help someone with (drinking, drug, or other) problem. One should not have to be railroaded into a 1939 pseudo-evangelical program. Someone should be free to attend SOS, HAMS (Harm Reduction) network, SMART Recovery, or any other method they choose, including a network of family, friends or both. They should not have to owe anyone any explanations for their choice, nor endure any judgements from AA true believers.

      There are many of us who have no fondness for the AA program. Personal experience, rather than science, has been our foremost guide.

  3. Submitted by charles thompson on 03/26/2014 - 11:12 am.

    AA’s profile is cultlike. Hazeldon is one of the gurus.

  4. Submitted by Steve Boese on 03/26/2014 - 12:29 pm.

    12 Steps as social movement, not science

    For me, the key to the way the 12 Steps are deployed is treatment professionals promising their programs will adhere to them even though “they’re not for everybody”.

    Basic scientific understanding does not require that cancer patients must be loyal only to chemotherapy or radiology or be labeled non-compliant and in denial. Treatments are studied carefully to identify the tweaks that will improve outcomes. The stuff that doesn’t work, or causes more harm than good, is set aside. Techniques on the margins are offered only with carefully informed consent.

    The 12 Steps, by contrast, are not up for scientific review and modification. It’s laudable that they have done so well by so many. But when they fail, the guardians of the steps aren’t equipped to ask why failed and what can be done to prevent similar deaths.

    When my best friend died of alcoholism in his early 40s, he had a solid 15 years of professional treatment and working the steps under his belt. His problem had been remarkably consistent over time, weeks/months of abstinence followed by a 24-72 hour binge, then back to meetings for several weeks or months. It struck me that he had a distorted take on powerlessness, that once a binge began, there was nothing for him or anyone else to do except let it run as long as it pleased. His treatment pros didn’t want to do relapse management or talk harm reduction. They didn’t press him for the simplest accountability, like setting up a drop-safe for his car keys, so after 15 years of doing the same thing, getting the same result, he was still driving drunk in mid-binge to replenish his supply.

    In his last couple years, I was reading Dodes and others, getting a handle on alternatives to the 12 Steps and how harm reduction can be deployed on a path to long-term abstinence. When we discussed the idea of decreasing the severity of his binges or taking a more cognitive-behavioral approach, his response was that he’d be written off as sicker (in deeper denial) than he already was if he broached such topics to his treatment pros.

    The ideologies of a movement can be helpful to many, but they cannot be good health care.

  5. Submitted by Peter Connor on 03/26/2014 - 02:30 pm.

    The Sober Truth

    It doesn’t matter to me if someone thinks the rock he has in his back pocket keeps him/her sober.

    Hazelden and AA are tantamount to my being sober for 33 years.

    Unlike the professor, I will tell anyone my story. If it works, wonderful. If not, read the professor’s book.

    And that’s MY sober truth!

  6. Submitted by charles thompson on 03/26/2014 - 02:32 pm.

    furthur

    The positive point of view for AA is anecdotal. That is all to the good, but it is not science. Dr. Dodes is looking for the way forward.

  7. Submitted by Richard O on 03/26/2014 - 05:24 pm.

    AA

    I’ve been to AA meetings for the last 20 years and I’ve never experienced anything like John J. I suggest that he find another meeting. There are literally dozens going on in the Twin Cities every evening. AA works for a lot of people but obviously not everyone. The challenge for recovery is to find a therapist or program that meets your needs. I know, easy to say – hard to do.

  8. Submitted by Dennis Tester on 03/26/2014 - 06:52 pm.

    I’d be curious to know

    whether Dr. Dodes has himself ever overcome an addiction. His stated belief that addiction is a purely psychological disorder and not a physical one smacks of a lack of personal experience with his alleged expertise.

    I’ve never battled alcohol but I did kick a 30-year nicotine habit. Beating it was as much physical as it was psychological.

    • Submitted by Paul Brandon on 03/27/2014 - 09:27 am.

      Remember

      that he’s talking about -alcohol-, not substance addiction in general.
      Nicotine is a lot more -addictive- than alcohol; although alcohol is widely abused.
      The difference between abuse and addiction is that when you’re addicted to a substance you’re physically dependent on it and go through physical withdrawal symptoms (I’m sure that you’re familiar with them from nicotine withdrawal) when you quit.
      In the case of alcohol, you’re actually addicted when you go through delirium tremens (‘the DT’s’) when you quit. This is serious and life threatening, and needs medical support. It is also relatively rare; most alcohol abusers are not physically addicted.

      So for most cases of alcohol abuse Dodes is correct that it’s not primarily a physical problem. This is not true for other types of abuse which are really addiction.

  9. Submitted by Curtis Griesel on 03/27/2014 - 08:46 am.

    must everything be science?

    Must everything be reduced to science? If my marriage works, and my family works, are they not valid unless I have scientific proof?

    • Submitted by Jake Gysland on 03/27/2014 - 11:45 am.

      Logic measures validity, not science, and it a measure of whether a series of premises support a conclusion.

      Consequently, validity is not a property the workings of your marriage or your family possess.

      Unless you meant legal validity, but science has little to do with that, either.

      If you’re going to hate on science using arbitrary examples, at least make the effort to pick some that make sense.

    • Submitted by Jack Shuman on 03/28/2014 - 08:33 pm.

      Science

      The marriage comparison might be a good one. But what if the court orders your marriage and it doesn’t work? And what if your new spouse insists that it didn’t work because you didn’t do it right, and all those in attendance at the wedding agree? And what if they keep telling you that despite you putting forth your best efforts? And what if you know that your spouse is a liar and is misrepresenting herself? What then?

  10. Submitted by richard bonde on 03/27/2014 - 01:23 pm.

    AA is free and effective for many people. Many people do not have insurance that covers treatment centers.

  11. Submitted by larry maras on 03/28/2014 - 05:14 am.

    Powerlessness et al

    A lot of people get hung up on the word powerless in the first step. If they were to read it carefully, they would note that the first step says “we WERE powerless” not “we ARE.”

    That means we are responsible for our own recovery.

    So let’s bury that old protest, shall we?

    AA saved my life. I tried many other ways to stay sober; they didn’t work for me. Maybe they will work for you.

    Lots of gnashing of teeth over is it a disease, is it not a disease…who cares? Absolute knowledge one way or the other won’t keep one person sober. Being a genius won’t keep you sober. Being right won’t keep you sober. Try AA. “Take what you need and leave the rest.”

    As for AA not working for agnostics or atheists….hogwash. I’ve known both to become sober in AA.

    Regarding science….many studies show that one of the most successful tools for recovery from many afflictions is a self-help group. More so than therapy or treatment.

    The Twin Cities has an amazing AA community. If it’s a cult, it’s my kind of cult.

    Peace

  12. Submitted by james brummel on 04/30/2014 - 09:13 am.

    Spontaneus Remission numbers

    Couldn’t let Paul Brandons inaccurate remission numbers remain unchecked. The sources his cites are for all forms of substance abuse, not addiction and the “30%” is actually 26% “using broad definition of remission”, 18% using narrow definition.
    That is for all forms of substance abuse, not addiction. Someone as learned in the sciences as Brandon should be able to discern the difference.

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