The Heart of Addiction

How psychology drives addictive behavior.

A Poor Critique

Criticism needs to be based on fact.
Eugene Beresin, M.D.
This post is a response to What Science Tells Us About Treatment of Addiction by Eugene Beresin, M.D., M.A.

In a recent post, "What Science Tells Us About Treatment of Addiction," my new book, "The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry" is criticized in a manner that is both poorly researched and flatly incorrect. For starters, this post appears to be based on listening to a radio interview, rather than on carefully reading the book the interview was based on. This approach has colored the entire piece, informing not just its profound factual limitations, but its embarrassing ad hominem tone.

The authors of the post feel that if various authorities support AA, that should suffice to end discussion. The fact that these organizations have endorsed 12-step programs is, of course, meaningless if those organizations base their conclusions on the same poor science that we described in the book. The history of science is fraught with such “consensus by volume” pronouncements, despite the fact that many are later overturned by more careful inquiry. (Consider, for example, that we have been authoritatively told for decades that eating fat is the problem in obesity and cardiovascular disease, and are only now beginning to learn that this advice may have been disastrously off-base. A recent editorial in the British Medical Journal suggested that the entire nutrition field offer a public apology for the views they insisted were correct for so long.)

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Here are some further problems with the rest of this post. To enumerate them all would require more space than I have to offer.

1. The authors state that AA and 12-step treatments are "among the most effective ... treatments for facilitating addictive behavior change," and complain that we misinterpreted the Cochrane Collaboration report about this. This would be hard to do, given that we simply quoted the study itself. Here is what the Cochrane paper said: "No experimental studies unequivocally demonstrated the effectiveness of AA or TSF [Twelve Step Facilitation] approaches for reducing alcohol dependence or problems." Finding no evidence for the effectiveness of 12-step programs is difficult to reconcile with the authors' claim about how effective they are. The post also selects a single, early paper of the many papers we reviewed (the 1991 Walsh study) and objects to citing it as evidence for the problems within 12-step treatment. Yet we did not say, as the post states, that "AA is poor while inpatient treatment was good." An attentive reading of our book – which, again, the authors did not appear to have done – would show that we are highly critical of inpatient treatment when it is based on the 12-step approach. Here is a direct quotation from the Walsh paper itself:

"The hospital group fared best and that assigned to AA the least well ... Additional inpatient treatment was required significantly more often (P less than 0.0001) by the AA group ... The estimated costs of inpatient treatment for the AA ... groups averaged only 10 percent less than the costs for the hospital group because of their higher rates of additional treatment. ... Even for employed problem drinkers who are not abusing drugs and who have no serious medical problems, an initial referral to AA alone ... although less costly than inpatient care, involves more risk than compulsory inpatient treatment and should be accompanied by close monitoring for signs of incipient relapse."

There is nothing bizarre about concluding, as we did, that this paper raises serious questions about the routine practice of referring patients to AA.

The authors also refer to Project MATCH. They write, improbably, that this expensive study somehow supported 12-step treatment. Here is a direct quote from a published scientific review of Project MATCH, which is what we included in the book:

"Overall, a median of only 3% of the drinking outcome at follow-up could be attributed to treatment. However this effect appeared to be present at week one before most of the treatment had been delivered. The zero treatment dropout group showed great improvement, achieving a mean of 72 percent days abstinent at follow-up ... two-thirds to three-fourths of the improvement in the full treatment group was duplicated in the zero treatment group. . . . The results suggest that current psychosocial treatments for alcoholism are not particularly effective. Untreated alcoholics in clinical trials show significant improvement. Most of the improvement which is interpreted as treatment effect is not due to treatment. Part of the remainder appears to be due to selection effects."

To suggest that Project MATCH provided evidence for the effectiveness of 12-step treatment is simply wrong.

2. The authors point out that AA is free. There is actually some evidence that the decreased cost of AA has been offset by increased costs from the need for subsequent treatment. Even if this were not true, however, the book was not about cost, but about harm to the vast number of people told to attend AA who cannot make use of it.

3. Concerning whether 12-step treatment is better than doing nothing, the authors of this post, incredibly, write that we are suggesting that people "just stand back and wait." Of course, we did not say that. What we did say is that the spontaneous remission rate for alcoholism without any treatment is roughly the same as the AA success rate.

4. The authors charge that I allegedly "don't realize that for the past several years the addiction research field has moved beyond asking whether AA and 12-step treatment works." Aside from the insulting nature of their comment, it is a major problem that the industry has stopped examining the science behind 12-step programs. It is precisely this failure that made it necessary to write the book.

5. The authors of this post write that we say "genetics do not play a role in addictions." I did not say that in the radio interview, nor in the book. Here is the exact quote from The Sober Truth: "There is probably some genetic influence on addictions, but this shouldn’t be surprising. Many human conditions, like peptic ulcer disease or hypertension, have some genetic loading."

It is deeply disappointing to see such a poorly considered critique of our work. We invite scholarly discussion of The Sober Truth, but these arguments must pass a higher threshold if they are to inspire useful conversation.

 

Lance Dodes, M.D., is an assistant clinical professor of psychiatry at Harvard Medical School.

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