Why we need an alternative to the AA
Stanton Peele challenges the received wisdom of the 12-step approach.
I recently received this email from a UK addictions worker:
‘Stanton, I was in a public health meeting today (well I was until I walked out). The government focus is currently all about facilitating 12-step engagement. I tried to make some kind of stand, and the only progress made was to get an acknowledgement that where people are persuaded to reduce mental health meds, life may be put at risk, and they wanted cases of this to be reported. I pointed out that 12-step fellowships do not work like this or have a reporting structure to facilitate this, but was brushed aside. Anyway, I don’t have an ability to work through research or writing on the matter, so I wondered if you have produced a clear (not too long) summary of the potential harms of the 12-step approach with some handy and convincing figures that I can use as part of my rearguard action. I dare say you are busy, but anything would help. Thanks, A.’
Here is my response for people in situations like A.
Many Europeans are aware that we in the United States, home of American exceptionalism, tend to go it on our own, and expect the rest of the world to follow. Understandably, in recent years, Europe has become wary of following us blindly in our overseas adventures (like the invasion of Iraq), the consequences of which haven’t been good, or certainly what we claimed they would be. Instead, many European nations prefer to develop their own policies steeped in their own national traditions and values. Good for you!
But the exception to this self-assertion lately has been in the area of alcoholism and addiction. After decades of not rushing down the American route (which is 75 years old) of Alcoholics Anonymous, the 12 steps, and perpetual abstinence as the best – the only – approach to use in the treatment of alcoholism and addiction, a number of European countries have been moving steadily in the 12-step direction (including, as in the quoted mail above, the UK). They are often pushed in this direction by the US rehab industry (called the Minnesota Model), which has a roving group of consultants/lobbyists. This shift is unwise and contrary to Europe’s and addicts’ best interests.
That the UK and other countries are coming gung-ho now is particularly puzzling for these reasons:
1. The US has often been criticised for its decades-long delay in implementing clean needle programmes, which led to a second wave of HIV infections among IV drug users in the US (primarily minorities) – a public health disaster avoided in the UK, Australia, and virtually all other Western European and Commonwealth nations. Even today, as every public health body in the US and the rest of the world strongly endorses provision of clean syringes, the US Congress has rescinded government support for this policy, based on America’s abstinence fixation.
2. No one in the United States answers the question, ‘How are we doing in fighting alcoholism and addiction?’ with a wholehearted endorsement of the success of our approach. Instead, there is great soul-searching about every new drug and substance use scare that comes down the road – including, recently, off-label overuse of prescription painkillers and ADHD medications such as Adderall, increased drinking by young women, use of illegal drugs like methamphetamines and heroin, and so on.
3. No one here has great confidence in our treatment modalities. Indeed, AA and 12-step rehab’s greatest innovation has been to redefine failures – up to and including death, as in the cases of Philip Seymour Hoffman and Cory Monteith – as proof of its underlying ‘cunning, baffling and powerful disease’ sales pitch. Yet people simultaneously endorse the strange, religious-based self-flagellation rituals of AA as being a medically efficacious treatment! What’s really ‘cunning, baffling and powerful’ is AA’s hold on the American psyche.
4. Recently, through the work of Lance and Zachary Dodes’ The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, and my and Ilse Thompson’s Recover! Stop Thinking Like an Addict and Reclaim Your Life with The PERFECT Program, Americans have been presented with some powerful voices rejecting the efficacy of our most popular addiction treatment. Although our books are, in themselves, unlikely to reverse America’s ardour for AA and its steps, nonetheless the simple simultaneous appearance of these books, their wide circulation, and their coverage in the media suggest that change is in the air.
As an answer to A’s note, let me present the five primary reasons AA and the 12 steps should not be supported among best practices here in the US as well as in Europe. In a quick overview, the 12 steps’ powerlessness model distorts our understanding of why people become addicted, downplays the great potential for self-recovery, limits the use of effective treatments, and syphons resources away from pragmatic strategies that help alcoholics and addicts. At a more basic level, it diminishes people’s sense of their ability to manage themselves and their worlds, and results in wasteful and often destructive public policies that treat alcoholics/addicts as helpless victims.
1. AA causes us to deny the realities of recovery. The fastest growing body of addiction research shows that most alcoholics and addicts outgrow addiction without treatment. In 2002, the National Institute on Alcohol Abuse and Alcoholism studied 43,000 randomly sampled Americans’ lifetime history of alcohol and drug abuse. Called the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), it concluded: ‘20 years after the onset of alcohol dependence, three-fourths of individuals are in full recovery; more than half of those who have fully recovered drink at low-risk levels without symptoms of alcohol dependence.’ Only a quarter had treatment of any sort, and only half of those (13 per cent) actually attended AA or rehab.
NESARC found the same to hold for drug addicts. Gene Heyman has analysed these results and those of three other national surveys of drug addictions: ‘Each found that most of those ever addicted to illicit drugs were ex-addicts by about age 30. Moreover, most of those who quit did so without professional help. Follow-up analyses reveal that the high remission rates were not temporary, due to missing addicts or a function of other methodological pitfalls.’
Several longitudinal studies – those following people in the general population – have tracked people who developed alcoholism or drug addiction for years, even decades, and found that ‘people mature out of addictions at all ages’, and that ‘relapse does not appear to be as ubiquitous as one might expect based on estimates from clinic samples.’ All these findings lead to ‘the view that alcoholism, at least in most cases, represents a changeable habit rather than a brain disease.’
2. AA exaggerates and oversells its success. Dodes cites research indicating that AA works for 5 to 8 per cent of those who participate in the group. But that figure must be compared against the numbers who recover on their own – indeed, several studies comparing alcoholics randomly assigned to AA or left to their own devices found the latter did better on average! And 12-step rehab results are hardly better. According to the Cochrane Collaboration, the prestigious group of scientists that compiles evidence on the effectiveness of various treatments, in the case of the 12 steps: ‘No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems.’
3. AA and 12-step treatment drive out other, often more effective, treatments. Like carp infesting a lake drive out other species, AA and 12-step treatment rule out other, often more effective, approaches. A British group, the Effectiveness Bank, compiles data on such treatments, including motivational interviewing, skills training, social network therapy, community reinforcement approach (CRA) and community reinforcement and family therapy (CRAFT), solution-focused therapy, narrative therapy, purpose-driven therapy – hardly any of which are known, not only to the public, but by treatment providers in the US. They have been thrown overboard due to the myth of 12-step effectiveness and the 12 steps’ own imperialistic, take-no-prisoner view of the alcoholism treatment world.
4. AA attacks self-efficacy. What enables people to overcome alcoholism and addiction, particularly considering that most people outgrow it with age and maturity? The single factor most often found in effective treatments is that individuals become more confident of their own strength, sometimes called ‘self-efficacy’ or, more popularly, ‘self-empowerment’. AA’s central message is of the individual’s powerlessness that we all know to be the first step. Then, there is step 3: ‘Made a decision to turn our will and our lives over to the care of God as we understood God.’ Sound like a sound therapy principle to you? And are you aware of these steps? 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 do not encourage self-confidence and acceptance of the self – they are not so subtle ways of attacking people’s sense of themselves, just like some therapists and group leaders tell people, ‘You have had a deep trauma in your life which is saddening and weakening you; what is it?’ Everyone has a response to an intrusive question like that, and that answer leads one to a debilitating, self-loathing, or at least a self-pitying, place – not one likely to lead to constructive life changes.