Addressing the Causes of Substance Abuse vs. Addiction

I saw Johann Hari interviewed on Real Time the other day, and what he essentially offered during the interview was a version of the essay published here, in which he argues that the real cause of addiction is the addict's environment, not the nature of the addictive substance itself:

This gives us an insight that goes much deeper than the need to understand addicts. Professor Peter Cohen argues that human beings have a deep need to bond and form connections. It's how we get our satisfaction. If we can't connect with each other, we will connect with anything we can find -- the whirr of a roulette wheel or the prick of a syringe. He says we should stop talking about 'addiction' altogether, and instead call it 'bonding.' A heroin addict has bonded with heroin because she couldn't bond as fully with anything else.

So the opposite of addiction is not sobriety. It is human connection.

Before I get into the obvious faults of Hari's theory, there is some merit to his position within the larger realm of substance abuse. Many people go through periods of their life in which they rely too heavily upon alcohol, or engage in the recreational use illicit substances or prescription medications, perhaps to the point that their lives seem to be coming apart at the seams, but are subsequently able to scale back or stop that behavior on their own. Their substance abuse may be largely situational, and when the situation changes so does the appeal of drugs or alcohol.

The problem that Hari's theory does not address is why certain individuals are not able to stop using drugs or alcohol without -- and sometimes even with -- significant intervention. Why, if it's the human connection that matters, some individuals will continue to use drugs even as their actions alienate every single person who is trying to connect with them or help them. Hari's theory might explain in part how dealing with addiction can seem like a game of whack-a-mole -- how the successful cessation of the use of one substance, such as alcohol, might be associated with the onset of the use of a different substance or a behavioral disorder. But his theory does not explain why addicts have different drugs of choice, or why rates of successful recovery can differ dramatically between substances.

Hari brings up behavioral addictions,

It was explained to me -- you can become addicted to gambling, and nobody thinks you inject a pack of cards into your veins. You can have all the addiction, and none of the chemical hooks. I went to a Gamblers' Anonymous meeting in Las Vegas (with the permission of everyone present, who knew I was there to observe) and they were as plainly addicted as the cocaine and heroin addicts I have known in my life. Yet there are no chemical hooks on a craps table.

Except, of course, there are. People do get a biochemical reward from gambling. Were that not the case, people would get nothing out of gambling -- there would be no thrill, just boredom associated with an overall loss of money -- and gambling would have no appeal. As it turns out, there is evidence "that the opioid systems in the brains of pathological gamblers may be different, affecting their control, motivation, emotion, and responses to pain and stress."

Problem gamblers appear to have an issue that is similar to that of some problem drinkers, "it seems that pathological gamblers just don't get the same feeling of euphoria as do healthy volunteers". As counter-intuitive as it may seem at first blush, a rapid response to intoxicants is an evolutionary defense against over-consumption. Broadly speaking, when you need to consume more of a substance to get the same thrill, you are at increased risk of addiction.

Hari engages in the dangerous practice of predicating his entire theory on a study of rats. Rats, he tells us, will deal with isolation and boredom by using drugs, but when given many exciting alternatives to drug use they largely choose life's other pleasures over drugs. While, yes, that does suggest that environment can affect rates of drug use, it tells us nothing about why two people who enjoy pretty much the same environment can have extremely different levels of interest in intoxication.

If you attend open AA meetings, those that welcome all members of the public, you will likely soon hear an addict describe his or her first experience with alcohol or drugs. You will very likely hear many speak of their extreme euphoria, their eagerness to repeat the experience, the steps they took to increase their access to their drug of choice and their frequency of use. While Hari would have us believe that in each case there was something -- some level of connection with others -- missing in their lives, and with some of those accounts suggesting such a lack of connection, Hari's argument nonetheless hits a stumbling block: Why do other people with similar or worse environments or levels of isolation try the same substance yet avoid a similar outcome? From another angle,

Time magazine reported using heroin was "as common as chewing gum" among U.S. soldiers [during the Vietnam War], and there is solid evidence to back this up: some 20 percent of U.S. soldiers had become addicted to heroin there, according to a study published in the Archives of General Psychiatry. Many people were understandably terrified; they believed a huge number of addicts were about to head home when the war ended.

But in fact some 95 percent of the addicted soldiers -- according to the same study -- simply stopped. Very few had rehab. They shifted from a terrifying cage back to a pleasant one, so didn't want the drug any more.

The thing is, every single veteran had a new, much more pleasant post-war "cage" -- so why did 5% remain heroin-addicted? Similarly,

If you get run over today and you break your hip, you will probably be given diamorphine, the medical name for heroin. In the hospital around you, there will be plenty of people also given heroin for long periods, for pain relief. The heroin you will get from the doctor will have a much higher purity and potency than the heroin being used by street-addicts, who have to buy from criminals who adulterate it. So if the old theory of addiction is right -- it's the drugs that cause it; they make your body need them -- then it's obvious what should happen. Loads of people should leave the hospital and try to score smack on the streets to meet their habit.

But here's the strange thing: It virtually never happens.

If by that Hari means that most people who are administered powerful opiates during hospitalization don't subsequently become heroin addicts, he's correct. But if he means to suggest that large numbers of addicts don't have their addictions start with their taking properly prescribed pain medications, he's wrong. Most patients will come out of surgery, deal with their inadequate post-hospitalization pain control, recover, and go on with their normal lives. Some will suffer a bit more during their recovery but again go on with their normal lives. Some will actively drug-seek, displaying behaviors consistent with substance abuse and addiction.

If Hari's theory were accurate, we should be able to easily define who is likely to become addicted and who is not. We could simply perform a survey of that person's life, their connections, their stressors and the like, and that should give us an excellent idea of who is likely to have a substance abuse problem and who is not. The problem is, you cannot predict substance abuse or addiction in that manner. You may find overall trends and risk factors, such as a family history of substance abuse, a childhood pain condition that was not properly managed, a history of being the victim of child abuse, and the like. Yes, some predictors do suggest a behavioral component to addiction -- which is what you would expect from something that is in large part a behavioral health problem. But other predictors are not behavioral. Why should it be a risk factor to you if relatives who you have never met, or who were never in a position to model addictive behavior to you, had substance abuse problems?

It's important to recall, also, that not everybody has the same reaction to the same substance. Alcohol triggers different physiological reactions in different people. Some people have little ability to metabolize alcohol, and within their communities rates of alcoholism are very high. Some people flush upon consumption of alcohol. Some become nauseous. Some quickly become tipsy, even with modest alcohol consumption. Others can consume large quantities of alcohol without displaying strong signs of intoxication. Similar things can be said of opiates -- if your reaction to opiates includes feeling itchy all over your body, feeling nauseous, experiencing severe constipation, or feeling confused and anxious, the odds are much lower that you're going to want to repeat the experience than if your principal memory is of euphoria.

These differences in reaction are biochemical, not behavioral. It reasonably follows that some of the differences in why people become addicted to drugs or alcohol, why people prefer one substance over another, and why some people have much greater difficulty establishing and maintaining sobriety, are biochemical. Yes, you may need to address psychological and environmental issues in order to help the addict achieve a stable recovery, but simply changing the addict's environment will not cure the addiction.

Hari suggests that the history of nicotine patches supports his theory,

Everyone agrees cigarette smoking is one of the most addictive processes around. The chemical hooks in tobacco come from a drug inside it called nicotine. So when nicotine patches were developed in the early 1990s, there was a huge surge of optimism -- cigarette smokers could get all of their chemical hooks, without the other filthy (and deadly) effects of cigarette smoking. They would be freed.

But the Office of the Surgeon General has found that just 17.7 percent of cigarette smokers are able to stop using nicotine patches. That's not nothing. If the chemicals drive 17.7 percent of addiction, as this shows, that's still millions of lives ruined globally. But what it reveals again is that the story we have been taught about The Cause of Addiction lying with chemical hooks is, in fact, real, but only a minor part of a much bigger picture.

Hari makes three fundamental mistakes in his comparison. First, he presupposes that the use of a nicotine patch is evidence that a smoker wants to quit. In fact, many smokers who attempt to quit are doing so not because they want to do so, but because they are under social pressure to stop smoking. Some people are afraid to quit smoking, for example because they fear weight gain. Second, he presupposes that establishing a baseline level of nicotine will remove any biochemical incentive for a smoker to smoke. The steady baseline certainly can help control cravings, but it is not going to provide the spike of nicotine exposure to which a smoker is accustomed. Hari is apparently referring to Treating Tobacco Use and Dependence, U.S. Department of Health and Human Services, June 2000, summarized here on page 491. Yes, Third, the abstinence rate for the study was premised upon six months of abstinence, so we're not merely talking about how well smokers abstained during their twelve weeks on nicotine patches, but during a period of months after they stopped using the patch. It's interesting to see that a nicotine nasal spray resulted in a 30.5% abstention rate over the same period, as did buprenorphine -- a medication that does not imitate nicotine, but instead blocks opiate receptors. If biochemistry weren't a big part of the story, the results should have been the same no matter whether the smoker received a placebo, a particular administration of nicotine, or buprenorphine.

Fundamentally, as with any addiction, no treatment program or assistive medication is going to work over the long-run unless the addict wants to stop using his drug of choice. Medications and treatment can provide a window of opportunity during which the addict can establish a period of abstinence and have an opportunity to consider a future both with and without his substance of choice, but unless the addict is sufficiently motivated to stop the addict will relapse. For that matter, many addicts who truly want to stop will still have problems with relapse, whether due to a momentary lapse in judgment, the strength of their cravings, or a combination of factors.

At the end of the day, yes, it makes sense for a recovering addict to improve his environment -- to address facors, internal and external, that contribute to addiction and could contribute to relapse. To ignore the biochemical side of addiction, the predispositions that some people have to the use and abuse of certain chemical substances, and the difficulty that addicts of all backgrounds experience when trying to establish and maintain sobriety, by suggesting... is it that this could all be fixed with warm feelings, love songs and group hugs... is to turn a blind eye to the leading factors in addiction.

Loving an addict is really hard. When I looked at the addicts I love, it was always tempting to follow the tough love advice doled out by reality shows like Intervention -- tell the addict to shape up, or cut them off. Their message is that an addict who won't stop should be shunned. It's the logic of the drug war, imported into our private lives. But in fact, I learned, that will only deepen their addiction -- and you may lose them altogether. I came home determined to tie the addicts in my life closer to me than ever -- to let them know I love them unconditionally, whether they stop, or whether they can't.

I'm not one to point to a show like Interventions and argue that it's a model for addiction treatment. The purpose of an intervention is to inspire an unwilling drug addicted person to go into residential treatment. Contrary to what Hari suggests, the message is not (or at least should not be) that "an addict who won't stop should be shunned" but is instead that the family has the right to draw boundaries and to state that, if the addict chooses to continue down the road to ruin, they will have to limit their role in the addict's life in order to protect themselves and their own mental health. Sometimes it takes a dose of that sort of reality to get the addict to go into treatment. Sure, others will reject the attempted intervention, but it's facile to suggest that it is a failed intervention that causes addicts to "deepen their addiction" -- addiction is a progressive disease and thus, absent some limiting factor, gets worse over time. Many addicts describe the fear of loss of family, the embarrassment of an arrest or jail sentence, and the like as the very thing that inspired them to finally work toward recovery.

What Hari describes as his ultimate take-away, "to let [the addicts in my life] know I love them unconditionally, whether they stop, or whether they can't", is a basic teaching of programs like Alanon, under the name of "detachment with love". Hari may not like some of the implications of that approach, the idea of telling an addict who calls you hysterically in the middle of the night that he was picked up by the police and needs to be bailed out, that he'll have to wait until morning -- or that he'll have to face the natural consequence of his decisions and find a way to bail himself out -- but allowing an addict to face those natural consequences is not an indication that you don't love them. It's a means of protecting yourself, of avoiding the anger and resentment that get in the way of love, and of allowing them to experience the negative consequences that they bring upon themselves such that they might decide that it's finally time to give sobriety a honest chance -- whether through inpatient treatment, an intensive outpatient program (IOP), counseling, peer support, and with or without assistive medication. When the addict reaches the point of wanting to recover, you can start implementing the structure and changes that Hari correctly associates with improving the chances of long-term sobriety. But no, when you're dealing with populations of addicts, you cannot simply work to improve their emotional environment and expect it to be a miracle cure.

Don't Trust Addiction Treatment Claims About Success Rates or Not Being a 12-Step Program

When you're trying to find a drug or alcohol treatment center for somebody you care about, you'll likely find yourself at a disadvantage. First, the person who needs treatment may attempt to impose conditions on the treatment center you choose and, even when they sound reasonable, some of those objections may be more about "How do I stay out of treatment or find something more akin to a spa than a treatment center" than about trying to find a good fit. Second, when you call treatment centers for information about their programs, you are trusting somebody at the other end of the phone to tell you the truth. Sometimes that happens, but often it does not - you may in fact be talking to somebody who works in more of a sales capacity than an intake capacity. Also, sometimes they'll share information in good faith but the experience will turn out to be quite different. If at all possible, visit a facility and get a sense of its program and stability before writing a check. Please note, even if the center is suggested to you by a facility that has a strong reputation, you should not trust the recommendation - you need to investigate any recommended facility and, if at all possible, visit the facility and see it for yourself.

One claim that many addiction programs make, that they really shouldn't, is a claim of how many people who complete their program remain sober. First, even if accurate (and it won't be) the statistic is going to be highly misleading - if you focus on treating teenagers who smoke marijuana, you're going to have a much higher "success" rate than if you're treating IV drug users. The same is true if you're counseling people who are concerned that they might be using too much alcohol or using too many drugs, coming to you as self-referrals, as opposed to people coming out of a multi-day medical detox who are not even slightly interested in being sober. Second, the definition of sobriety used by the program may be designed to give a misleading picture of the client's sobriety - focused on the "right now". Third, as responses to patient surveys are voluntary many clients who have relapsed either won't be located or won't respond. Fourth, the questions almost never extend to subsequent treatment - the quack program doesn't care if you had four relapses, completed three IOP's and spent 90 days in Hazelden between your graduation and the present, if you're sober they'll count you as a success. Fifth, the definition of what it means to complete a program can render the statistic meaningless.

One program I saw touted an 80% success rate at five years for patients who completed its program, and while it was a good program what they didn't tell you unless you asked was that they defined their program as being five years in duration, with completion meaning that through those five years you attended weekly meetings (free, or should I say, included in the price of the program) at their facility. If you stopped attending, you didn't complete the program. If you lived in another part of the state or country and thus couldn't attend those meetings, you weren't included in the statistic.

But the claim that makes immediately skeptical of a program is when it presents as a front and center part of its marketing, "We're not a 12-step program". Let me be clear: I am not wedded to the twelve step model. Twelve step program have an interesting history, emerging out of a religious self-improvement program and being transformed into a somewhat secular model for addiction support and recovery. A lot of people have difficulty with the notion of turning their will and life over to a higher power, or with making prayer and meditation part of their daily lives, even if you can do both in a largely secular manner. But as one addiction counselor, who himself had struggled with his fit with the twelve-step model, explained to me, "I tell my clients who have difficulty with the steps that if I had something better, I would send them to it instead, but I don't." Part of that is the fact that AA groups are everywhere, while non-12-step support groups remain relatively obscure. Part of AA's success results from primacy but, whether or not its critics choose to admit it, its success depends on people voting with their feet - the addicts in long-term recovery who go back to AA year after year do so because it works for them.

Through experience, 12-step programs implemented some measures that correspond to certain aspects of addiction and recovery. For example, in active addiction the addict's impulse control diminishes - desire and action become unchecked by rational thought. Twelve step programs attempt to interpose an outside reality check on the addict - if you are craving drugs or alcohol, go to a meeting or call your sponsor. As a period of sobriety expands, the internal mechanism between impulse and action can start to rebuild itself. Similarly, the concept of "90 in 90" - doing ninety meetings in your first ninety days of recovery - is reasonably consistent with the amount of time it takes for the addict's impulse control to start to approach normal levels. The social aspect of the group can be reinforcing - you're dealing with people who have been through what you have, or worse, and they want you to succeed in your recovery. They'll also welcome you back if you relapse. The group's sayings and slogans can give you something to think about, even if you reject the larger program.

It's important to recall, however, that although treatment and therapy can incorporate aspects of the twelve-step model, twelve step programs are not therapy. They're structured peer support, coupled with a structured self-improvement program. Twelve step programs are an adjunct to treatment and, while some people achieve and maintain sobriety without any treatment or participation in 12-step or non-12-step support program, many people need the longer-term peer support and accountability. If you find a program that works for you, be it a 12-step program or one of the lesser-known non-12-step alternatives, it makes sense to take full advantage of the program. There's no reason you can't try more than one program, even at the same time, to see what works.

One of the reasons that long-term participants in 12-step programs can be dismissive of the argument, "I tried a twelve-step program and it didn't work for me," or "The twelve steps are nonsense", or "I don't see why I need to completely abstain from alcohol or substance use to be sober," is that they made those same arguments in their own early recovery. Sometimes they made those arguments for a period of years before they finally did what AA demands, surrendering themselves to the program, and that's when it worked. Again, I'm not arguing that 12-step programs can or will work for everybody, and if you're around addicts long enough you'll see unfortunate cases where a person who had achieved many years of recovery ends up relapsing despite seemingly doing everything right, but there is something to the argument that if you surrender to the program it can work for you.

The primary purpose of a marketing hook, "We're not a 12-step program", is to reach people who either are alienated by the very concept of the 12 steps, or people who find them difficult or intimidating. Were the argument intended to reach people interested in science-based recovery, it would put science front and center rather than a rejection of the twelve steps. To the extent that a recovery program can identify addicts who will or will not benefit from a particular treatment modality and channel them into programs and support groups that are likely to work for them, I'm all for it. But, as much as they may protest otherwise, when they flatly reject the 12-step model in toto they are rejecting approaches to treatment that have been documented to work for many people. If you're going to claim to offer science-based treatment of addiction the science should be front and center, not the rejection of a particular approach to treatment.

L.A. Weekly published an in-depth article about a treatment center that claims to reject the 12-step model,

I tell [a person who completed the program] that despite [the proprietor] Prentiss’ denouncements of 12-step programs, I saw residents’ schedules on the wall that indicated optional A.A. meetings.

“When I was there, we did six or seven [A.A.] meetings a week. Two or three in-house and the rest out,” he says. “And they were mandatory. When Chris wrote his book [The Alcoholism and Addiction Cure],that ended. That’s when he decided A.A. was the villain, because he decided he could make a fortune if he just claimed he had found the cure for alcoholism.”

The business executive continues in an upbeat, almost appreciative tone: “Chris has a brilliant scheme that they have cooked up there. He has the perfect sales pitch.” His voice suddenly drops. “I know. I fell into it. It’s a beautiful sales pitch when someone is at the end of their rope.”

When I tell Stuart I couldn’t find any of the success stories Prentiss brags about, he tells me, “People come in there, they fail and nobody can call him on it. He’s got clients with confidentiality agreements to hide behind.”

How did anybody at all get sober, I ask? The answer, says Stuart, is the ironic one: A.A. I remind Stuart just how adamant Prentiss was with me in mocking A.A.

“Chris was having trouble filling the beds, and the minute he changed the message, they filled to the brim. He created a cash machine,” Stuart [a person who spent $250,000 on the program] says. “After my stay in ’05, I was invited back as someone early in recovery, and I started talking of all the people I had been there with who had relapsed. And my message was, this is a great place, it’s just not gonna teach you anything about staying sober when you leave.”...

[Dr. Jason Giles, former medical director of the center] repeatedly hedges when asked to talk about Prentiss, but finally says, “The interesting part, I think, is how people are vulnerable to charlatans. I think these rehabs are modern-day quackery.”

Then he lowers his voice to a whisper and adds, “I’ve been in contact with a lot of my former patients from when I was there and the data, the data do not come anywhere near what he is quoting as his [84.4 percent] success rate.”

This came to mind when I saw an invitation to submit questions to the medical director of an addiction treatment center on the New York Times website. The center utilizes the 12-step model, so predicably the critics of the twelve-step approach appeared to denounce it. One in particular was pushing an "education program" as an alternative to treatment, sharing this link.

Outside independent professional research firms have certified a long-term success rate of at least 62% for the St. Jude’s Program. This compares to a success rate in the range of 0-20% for conventional programs.

Let's take a look at an example of that "research".

Clearwater consulted with BRI regarding the specific information needed for fielding. Baldwin [the parent company for the education program] and Clearwater mutually agreed to have Clearwater use Microsoft Access to randomly choose names from a list provided to Clearwater by BRI. After the names were selected, Clearwater accessed BRI’s in ‐ house database containing contact information for each participant in the Jude Thaddeus Program to gather specific information that was copied manully into a spreadsheet. The contact information was loaded into our CATI system and the interviewers began to contact designated individuals and complete interviews.

It catches my attention that no claim is made that BRI provided a complete list of people who have completed the program.

Out of a total of 956 records called, 232 resulted in completed interviews with both parties, giving an overall response rate of 26.17%. Clearwater interviewers “chased” members of the sample who were not reachable at the household or telephone number provided by BRI when someone we contacted could provide us with an updated telephone number.

The low response rate should catch anybody's attention, especially given this note:

Many Guests to whom we were never able to speak with were actually back in rehabilitation again. That information was tracked in the attempt messages, but may be something that should be tracked more quantitatively using a specific disposition or answer choice.

First, it's a misnomer to say "again", given that the program being investigated is an educational program, not a therapeutic program. Second, why exclude from the claimed success rate the percentage of people who could not be surveyed because they were in treatment?

Also, the survey appeared designed to maximize the number of respondents who could claim to be sober,

Have you been sober, not using any illicit drugs or alcohol, for at least the last 30 days?

Self-reporting is a relatively poor method of evaluating sobriety. Some of the people contacted had provided a "corroborator" who was independently asked if the alumnus was sober. When reached, the corroborators indicated a lower level of sobriety than the alumni. Yet the program's official website presents a conspicuous pie graph labeled "62.5% sober for the past 23 years", a claim that they know to be at best highly misleading. As I interpret the graph they are deliberately implying that 62.5% of people who complete their program are verifiably sober after completion, when they know that's anything but the truth.

Going back to the website linked from the New York Times, the statistical argument gets worse,

This compares to a success rate in the range of 0-20% for conventional programs. Data published by Alcoholics Anonymous (A.A.) indicates that its 12 step method has a success rate of no more than 5%. Research also finds that no treatment at all has a success rate of about 30%. This suggests that traditional 12 step programs are less effective than doing nothing.

The "success rate in the range of 0-20% for conventional programs" statistic seems to have been fabricated. No source or context is provided.

In terms of the claim that AA "has a success rate of no more than 5%", if you hear that from any person or entity claiming to be an expert in either addiction treatment or 12-step programs, my suggestion is to run away. The figure being described is a one-year retention rate - how many people who start AA within a particular 12-month period continue to attend meetings. In a survey of people who are attending AA, "35 percent were sober for more than five years; 34 percent were sober from between one and five years; and 31 percent were sober for less than one year. The average time sobriety of members is more than five years." As I indicated earlier, the people who keep going back to AA (and who do the work necessary to pay for meeting space, set up the space, provide coffee, make literature available, etc.) do so because it works for them. If you have to fabricate a 95% failure rate in order to promote your program, the reflection is on your program and not on AA.

According to somebody who reports having twice completed the St. Jude program,

For me, the greatest injustice of all is St. Jude/BRI's CONSTANT slandering of A.A. No, not because I support A.A. (it's a religious cult, with rigid dogma and rituals and little to zero efficacy), but because....well....the St. Jude Thaddeus program IS A.A. I know, weird right? Basically, the St. Jude program is identical to the 12-steps, and its crux (and a "guests" likelihood of success) rests on willingness to "serve others". In A.A. that means make coffee, give away cigs, and **** vulnerable women. At St. Jude it means do dishes, hide candy under your roommate's pillow, and **** vulnerable women. Essentially, instructors act as sponsors who aid in a "guest's" acceptance, surrender (formal surrender prayer said with a sponsor, shit, I mean instructor) a detailing of misdeeds and character flaws, a drafting of an ammends list, and on and on. The only difference? St. Jude insists meetings are unnecessary, it's all about choice, and that after completing the "workbook" you're cured for life!! I just can't believe how much effort they put into distancing themselves from A.A. whilst simultaneously being A.A.

So again we have a program that bashes AA but reportedly adopts or utilizes many of its precepts. The alumnus recognizes the marketing aspect, "St. Jude needs A.A. to exist so they can sell their services based around NOT being A.A.". It's also surprising how some of the most vocally anti-AA treatment centers and programs seem to be owned or operated by people who have no credentials in either behavioral health or addiction treatment.

Somebody who makes a statement along the lines of, "Conventional treatment and 12-step methods of recovery don't work", is being no more true to the facts than somebody who claims "Conventional treatment and 12-step methods of recovery always work". No treatment works for all addicts all of the time, and some treatments that won't work for an addict at one state of addiction or recovery may well be effective when they've reached a different stage in their recovery (or lack thereof).

The Early 1960's as a Victorian Era

David Brooks offers a mostly interesting book review on habits and being a "good person", but I question the manner in which he romanticizes 19th Century values. I've touched on this before in relation to his praise of the early 1960's as a pinnacle of American values, somehow divorced both from what came before and what came after.

In the 19th century, there was a hydraulic model of how to be a good person. There are all these torrents of passion flowing through you. Your job, as captain of your soul, is to erect dams to keep these passions in check. Your job is to just say no to sloth, lust, greed, drug use and the other sins.

Sermons could really help. They could help you identify sin. Preachers could exhort you to exercise the willpower you need to ward off temptation.

These days that model is out of fashion.

Having spent much of my childhood in a town that was once a temperance community, I heard jokes that dated back to that era:

The temperance minister, preaching to his flock, thundered, "There are more than a hundred taverns and bars in this community and I haven't been to one of them!"

A voice from the back of the crowd asked, "Which one is that?"

The notion that the Victorian era was one of great manners and controlled behavior is nice, but if Brooks remains concerned that the wealthy and the working masses don't share the same values and interests, let's just say that modern society has nothing on the Victorians. Brooks also confuses a strong sense of public appearance among the wealthier Victorians with some of the behavior that went on behind closed doors. Brooks is simply correct when he suggests that Victorians had more willpower, although he would be correct to say instead that the boundaries of propriety have shifted such that behaviors that the Victorians kept secret are part of our open culture. It's also fair to say that certain behaviors that were tolerated or accepted in the Victorian era would not be acceptable today, particularly in relation to domestic violence and sexual impropriety, and that those changes have benefited our society and most notably the women in our society. As they say, the good old days weren't always good.

As the Victorians understood (and the folks at Alcoholics Anonymous understand), if you want to change your life, don’t just look for a clever trigger. Commit to some larger global belief.

I think Brooks also misunderstands 12-step programs. While those programs are about changing habits over the long-term, they provide a very important structure over the short-term. And in that regard, they are more like the mundane examples of habit-changing that Brooks previously mentioned,

You can change your own personal habits. If you leave running shorts on the floor at night, that’ll be a cue to go run in the morning. Don’t try to ignore your afternoon snack craving. Every time you feel the cue for a snack, insert another routine. Take a walk.

If you crave your substance of choice, call your sponsor. If you crave your substance of choice, find a meeting. If you crave your substance of choice, reach out to other members of the program.... Unless by "larger global belief" Brooks means "sobriety", I don't see that AA is (or that the Victorians are) as special and unique as Brooks implies. (Yes, a certain percentage of 12-step members become the de facto leaders of the group or the larger 12-step community, but most 12-step members do not demonstrate that type of commitment. The third step belief in a higher power, "God as you understand him," is quite a departure from the religiosity Brooks associations with the eras he is most inclined to romanticize.)

Did You Miss The Word "Anonymous"

I realize that the words "ethics" and "paparazzi" have very little in common with each other, but for goodness sake - don't stalk people at 12-step meetings, even if they're celebrities.

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.