Effective Addiction Treatment and 12 Step Programs

David Brooks recently offered a third-hand perspective on AA, a synopsis of an article from Wired followed by his own musings. The column and article are interesting. I don't agree with all of the arguments presented, but as I'm also interpreting the organization from the outside I'm in a poor position to argue the finer points.

I personally was skeptical of 12 step programs for addiction, with their low statistical "success rate" and their reputation for compulsory religiosity, despite having any number of clients sentenced to attend 12 step meetings as part of their probation. (I didn't have any who wanted me to challenge that portion of their sentences, although there have been a handful of cases around the country where people have successfully challenged being compelled to attend 12 step meetings on First Amendment grounds.) And then one day I found myself in court standing next to a client who, after a year of unsupervised probation, thanked the judge for sending him to biweekly 12 step meetings. He described how he had overcome his denial of his alcoholism, achieved sobriety, and dramatically improved his life and relationships. No, it's not for everybody, but when it works it works.

12 step meetings should not be confused with "group therapy", or for that matter any kind of therapy. They're support groups. People can achieve sobriety without formal therapy, and certainly a lot of addiction therapy is structured around 12-step programs, but therapy is often a necessary adjunct. Bill W., after founding AA, continued to consult mental health professionals for the rest of his adult life. Surely he benefited from the program he created, but he recognized that he needed additional professional support.

As I've learned more about 12 step programs, I've come to appreciate Bill W.'s effort to move the program outside of the auspices of a specific religion, and to open the program to people of all faiths (including those who, by conventional religious standards, are nonbelievers). You don't have to accept a specific God or join a formal religion. Instead you are asked to turn your will and your life over to the care of God as you understand Him. Yes, the standard phrasing is evocative of Christianity and yes, I'm aware that some 12 step groups emphasize Christianity, but you can complete that step with your higher power as what the Founding Fathers called "nature's God", or with your concept of a higher power being the collective wisdom of the group - in a sense, it's about recognizing your (small) place in the Cosmos, gaining some perspective and humility, and recognizing both that there's a lot in life you can't control but you can benefit from being optimistic that things will work out.

Leaving aside for the moment the finer points of 12 step programs and how they work, I do have to take issue with Brooks' position on social science:

The first implication of Koerner’s essay is that we should get used to the idea that we will fail most of the time. Alcoholics Anonymous has stood the test of time. There are millions of people who fervently believed that its 12-step process saved their lives. Yet the majority, even a vast majority, of the people who enroll in the program do not succeed in it. People are idiosyncratic. There is no single program that successfully transforms most people most of the time.

The first thing to remember about 12 step programs for addiction is that they have stood the test of time because nobody has yet developed anything better. I know a drug counselor who has spent a quarter century attending 12 step programs, and who counsels his clients who are uncomfortable with 12 steps programs, and in particular their emphasis on a higher power, he would send them to a better support group if it existed but until one comes along they will benefit from attending 12 step meetings, getting a sponsor, working the steps, and giving it their best shot.

The cliché from the perspective of a therapist or sponsor is that, "When you're not ready for recovery, I can't tell you anything that's right. When you're ready, I can't tell you anything that's wrong". An overheard conversation between a pedestrian, handing some change to a panhandler, "I'm on my way to a meeting. I'll save a chair for you." The response by somebody who by any objective measure was at rock bottom, "I'd go to the meeting but they don't serve beer." A joke, but a telling one.

The reason 12 step programs, and addiction treatment in general, fail most of the time is that most addicts don't want to stop using their drug of choice, and the statistics are no doubt worsened by the number of people who are compelled to attend by a criminal or drug court. This is really hard for somebody like me to grasp - in my mind, if you go through detox, establish some sobriety, and get a perspective on sober life, why would you want to go back? To look at it a different way, have you ever left a half-empty glass of beer on a table because you've had enough? Ask an alcoholic what they think when they see your half-empty glass, abandoned, and they'll likely tell you "What a waste." An alcoholic once told me that she stumbled across a half-empty alcoholic beverage somebody had abandoned and, despite a considerable period of sobriety, immediately had two thoughts before her rational mind regained control: "I could drink that," and "It's not enough." When Koerner writes, "AA is known for doing a better job of retaining drinkers who’ve hit rock bottom than those who still have a ways to fall", I suspect that's true, because that's the point when you are failed by the irrational thought patterns that have previously sustained your addiction.

Brooks both overgeneralizes from twelve step programs - arguing that because, statistically speaking, 12 step programs have a low "success rate", "we should get used to the idea that we will fail most of the time" - and overemphasizes the need for a single "magic bullet" cure for any given foible of humanity - that there should be a "single program that successfully transforms most people most of the time". As 12 step programs are not therapy, and many addicts need therapy, it should not be regarded as a stand-alone solution to addiction. It's a tool.

If the only tool you have is a hammer, perhaps everything does look like a nail, but twelve step programs are not the only tool used in addiction therapy. If I were to draw a medical analogy, imagine a patient with cancer who takes half a dozen medications, has several surgeries, undergoes radiation therapy... you could argue that as none of those treatments of itself would be adequate, they're all failures. But the point is, sometimes you need a multi-faceted approach to a medical or psychological problem before you're going to improve the patient's condition. An alcoholic may need therapy, a prescription for Antabuse, ReVia or Campral, a restructured home and social life, and ongoing participation in a support group in order to achieve and maintain sobriety. Difficult problems often require multifaceted solutions.

Brooks also argues,

The second implication is that we should get over the notion that we will someday crack the behavior code — that we will someday find a scientific method that will allow us to predict behavior and design reliable social programs.

In a sense it's true that we're unlikely to ever "crack the behavior code" such that we can identify a magic bullet cure for any and every behavioral condition. But Brooks is just plain wrong to suggest that we cannot analyze programs and treatments to determine which have higher success rates, or to help determine which populations of patients are more likely to benefit from a specific modality or mixture of modalities of treatment. You can also determine what treatments offer little to no benefit. Bill W. was given "the Belladonna Cure", described in Koerner's article, a "treatment" that nobody in the present era would regard as effective, appropriate or ethical. Were Brooks correct, nobody would have been able to figure out that it wasn't effective.