"Stuck" Treatment in Addiction

We've been stuck for a long time.

Posted Feb 24, 2013

Recently, someone told me he thought that when people relapsed to their addiction after many years, it was a different phenomenon from people who relapse quickly. He had decided that different factors might be at work when it comes to relapsing after long-term sobriety – perhaps some social reason, or inability to stand success, or forgetting the consequences of returning to addictive behavior. He felt the need to come up with these hypotheses because he had found an inexplicable problem: The folks who relapsed after a long time had been successfully abstinent through their involvement in 12-step programs. That they should relapse after so much time seemed strange to him; it did not square with his understanding of addiction. Therefore he reasoned that, since these people had truly “gotten” the 12-step method, he would need to think of a new explanation for their relapses. His idea reminded me of a basic fact in science.

Whenever we humans don’t know the cause or nature of a phenomenon, we instinctually generate many possibilities to explain it. Multiple hypotheses are themselves a good and healthy thing, of course: More ideas mean more things that we can test against experience or experiment. The downside to the many-hypotheses state of knowledge, though, is that before answers are actually understood, people often become attached to their views, whether they are correct or not. For thousands of years, many fervently believed that the earth was the center of the universe. That was a reasonable hypothesis if one didn’t understand the motion of the celestial bodies. But even when presented with overwhelming evidence to the contrary, the people of the 17th century clung to their outdated beliefs. Galileo was imprisoned in his house for the rest of his life for daring to dispute that ancient earth-centric idea. Today many millions of people are still waging already settled debates about issues like evolution.

Hostility to new ideas arises in addiction as well. Treatments for addiction that have arisen from old ideas have become especially “stuck” because of the investment by those who have benefitted from them. When a person is helped, it is understandable that he or she will feel their own experience “proves” the rightness of the approach. New ideas are especially hard for the therapists and counselors who provide treatment according to an old model. If all they know is that old formula, they may well fight to the (professional) death to defend it, since their jobs and professional identities are at stake.

This is what has happened with much of the addiction treatment industry today. Despite the now enormous body of evidence that 12-step programs are effective for only a very small minority of those who attend them, its defenders are commonly unswayed. This “stuck” system is cemented in place by the large financial interests of 12-step based addiction rehabilitation centers, who need to have people believe that their programs are sound in order to justify their often enormous expense.

One of the common byproducts of clinging to an outdated idea is the need to invent ever more elaborate “work-arounds” to account for new information and contradictory evidence. The model grows more and more complex, and the arguments more byzantine, as adherents struggle to incorporate the total tonnage of countermanding evidence. This man's ideas about relapse to addiction are a good example.

If one understands the psychological nature of addiction, there is no need to hypothesize new and distinct factors depending on when the relapse occurs. It is characteristic of every psychological symptom that it may occur at any point in a person’s life. Symptoms don’t die off with age (though their form may change); their reappearance depends on whether the factors which produce them are present. A woman who is meek in every circumstance, and drinks to reverse the sense of utter helplessness this creates, may marry a man who treats her well despite her need to capitulate. Her symptom may disappear. But whether it is six months or six years later, if she finds herself back in that old helpless position, she will be at high risk of drinking again. The psychology behind addiction doesn’t change when the drinking stops.

The best treatment for her would be psychotherapy to help her understand the connection between her meekness and her drinking, to see the ways she has unconsciously recreated her helplessness in her life, and ultimately to work out the roots of her need to be submissive. With this work done, she would have the best chance to avoid relapses forever. 12 Step programs work for a small number of people for reasons that are more complex than they perhaps even know, but such programs are not designed to do any of this work.

Unfortunately, at the present moment, referring everyone with an addiction to 12-step treatments has become routine in our culture. If this is going to change, then both those who have benefitted from the 12-step approach and those who rely on it to treat people will have to let go of some of their old and cherished beliefs.