Irrationality of A.A.?
A critique of the recent Atlantic article.
Posted Mar 25, 2015
As an author and therapist, I make every effort to be open-minded when learning, speaking and writing about topics. If I did not have personal and professional experience with alcoholism and in treating alcoholics, then I may not have felt the need to respond to this article. I am also writing out of concern that individuals and loved ones of those who are questioning their alcoholism, know they are alcoholic and/or are seeking help may be misguided or confused about what evidence-based treatment options exist after reading her piece. Additionally, that they will needlessly be biased against Alcoholics Anonymous (A.A.)., when there are many ways to make mutual-help programs such as A.A. work in combination with other treatment modalities.
Glaser begins the article with the case example of “J.G, a lawyer” who has struggled with alcoholism and relapses. He “for years used alcohol to soothe his anxiety," stated that A.A. led him to “feel utterly defeated” but did not discuss how he had sought out appropriate treatment for his anxiety issues—which A.A. is not intended to treat. She then writes “The 12 Steps are so deeply ingrained in the United Stated that many people, including doctors and therapists, believe attending meetings, earning one’s sobriety chips, and never taking another sip of alcohol is the only way to get sober” and “The problem is that nothing about the 12-Step approach draws on modern science.”
This is untrue. Evidence-based treatment indicates that clients should also receive treatment for their underlying mental health issues simultaneously. (This is referred to as co-occurring disorders or dual diagnosis—note the work of McLean Hospital/Harvard psychiatrists Dr. Roger Weiss and Dr. Hilary Connery’s book “Integrated Group Therapy”) Individual/group therapy, medication management as needed, spirituality (as understood by that individual, even if atheist or agnostic), self-care (exercise, adequate sleep, etc.) and attending mutual help groups such as A.A., SMART Recovery (cognitive behavioral therapy and abstinence-based) or Women for Sobriety can all play a concurrent role. Yes, there are other options for mutual help groups other than A.A., but in my experience, many individuals have benefitted from attending both (Women for Sobriety encourages A.A. attendance). Additionally, The National Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA) National Registry of Evidence-Based Practices and Programs lists 12-Step Facilitation Therapy includes A.A.principles and strategies. Most recently, the April 6, 2015 New York Times article "Alcoholics Anonymous and the Challenge of Evidence-Based Medicine" discusses a 2014 research article from the journal of Alcoholism: Clinical and Experimental Research titled "Estimating the Efficacy of Alcoholics Anonymous without Self-Selection Bias: An Instrumental Variables Re-Analysis of Randomized Clinical Trials". The research study (yes- researchers found a way to study A.A.!) concluded that "increasing A.A. attendance leads to short- and long-term decreases in alcohol consumption that cannot be attributed to self-selection".
In addition, there has been a great deal of research which indicates that spirituality (a vital component of 12-Step Programs such as A.A.) has proven to be valuable in the healing process from addiction, mental and physical health issues. Columbia University’s National Center on Addiction and Substance Abuse (CASA) program’s report “So Help Me God: Substance Abuse, Religion and Spirituality” offers such research. Dr. Herbert Benson, founder of the Benson-Henry Institute for Mind/Body Medicine at Mass General Hospital in Boston, MA has written and researched the power of meditation and other spiritual practices such as the “faith factor” and “relaxation response” and their healing effects on medical/mental health issues including stress-related medical issues, chronic pain, infertility, cardiac disease and many more. He offers frequent courses through Harvard Medical School as well. Dr. Jon Kabot-Zin is the Executive Director for Center for Mindfulness at the UMASS Medical School in Worcester, MA and has been a leading researcher about the effectiveness of mindfulness meditation and mind/body healing. Again, the spirituality referred to in A.A. can include whatever “works” for an individual (nature, connection with people, the universe, religion, meditation, etc.) but also may include evidence-based practices.
Another reason that A.A. may be less effective for some is that their mental health or healthcare providers may not be effectively integrating A.A. into their treatment plan—which may also include discussion, questions and application of the program and how it correlates to other aspects of their care.
Glaser also described common misconceptions about hitting a “bottom” when she writes that “AA truisms have so infiltrated our culture that many people believe heavy drinkers cannot recovery before they ‘hit bottom.’ Researchers I’ve talked with say that’s akin to offering antidepressants only to those who have attempted suicide, or prescribing insulin only after a patient has lapsed into a diabetic coma.” The researchers she spoke with may be correct about those specific medical conditions, but there a various ways that individuals may experience a “bottom." For example, many individuals reach an emotional bottom without many tangible losses, some receive an intervention and the “bottom is raised” allowing them to receive help before a tragedy occurs and others receive help for addictions only after they have had major losses (i.e., divorce, unemployment, legal issues).
Much of the focus of the article references the Moderation Management debate, but that ended abruptly on March 25, 2000 when the founder of that movement, Audrey Kishline, had a severe drinking relapse leading her to be arrested for a DUI after her vehicle hit and killed a father and his 12-year-old daughter. (She admitted to engaging in “non-moderate” binge episodes). Kishline herself concluded in her own words when interviewed by Dateline NBC:
Murphy: “Do you still believe a person can be a moderate controlled drinker?”
Kishline: “As long as they’re not truly an alcoholic.”
Murphy: “But what’s that line?
Kishline: “Nobody knows where it is.”
Kishline’s statement that an alcoholic cannot be a “moderate controlled drinker” is profound. There is a continuum of drinking issues that require different types of treatment, and I have written a blog post in the past defining each. The symptoms of alcoholism or “Alcohol Dependence” (as per DSM-IV TR diagnostic manual) or “Alcohol-Use Disorder” (as per DSM-V diagnostic manual) are more severe than a “problem drinker” or individual with “alcohol abuse” (DSM-IV TR diagnostic manual) or who has a “moderate versus severe Alcohol-Use Disorder” (DSM-V diagnostic manual).
Problem drinkers may decrease their heavy drinking patterns or “phase out” of a heavy drinking phase if given sufficient reason (i.e., negative consequences, graduating college, life milestone, believe drinking is excessive, etc.). In fact, Dr. Mark Willenbring, whom Glaser interviews and quotes, reported in a 2008 Wall Street Journal article that National Institute on Alcohol Abuse and Alcoholism research indicates 72% of individuals pass through a heavy drinking phase, most often between the ages of 18-24. While these individuals may mimic alcoholic drinking behaviors, the majority are able to self-correct to low-risk drinking patterns. However, this differs from an individual who is alcoholic—as they may have tried many ways to control their drinking or obsess about additional strategies to be able to “drink normally” in the future. It is the mental obsession to successfully become a “controlled” or “moderate” drinker, despite many failed attempts, that demonstrates an addictive thought process that can lead to the progressive cycle of addiction. The idea “if you have to control something, then it is out of control” is applicable in this case.
In the past, I have treated clients through the application of harm reduction/moderation techniques (only if determined to be clinically appropriate) because the individual is questioning his or her relationship to alcohol and believes that they may be able to adhere to low-risk drinking limits. My question to those who are most likely alcoholic but are preoccupied with keeping alcohol in their lives (with or without professional help) is “considering the negative consequences that you have experienced or could encounter (i.e., impact on others, risks, possible progression of a disease) if you did not have an addictive relationship with alcohol, then wouldn’t you choose to abstain—because the risks would not outweigh the benefits of drinking?” When alcoholics take a drink of alcohol, this sets off a physiological “craving” in their brain to drink more and they lack a “shut off” to control their intake—much like an individual who has a binge-eating disorder and cannot have “just one” of certain types of food. Alcoholics also have a mental obsession about when they can have another drink, the next time they will be able to drink or about the fact that they are not drinking.
Glaser explains that “in order to understand” the reason that the US standard of care for alcoholism is an abstinence-based model “you have to first understand the history," and then begins writing about “religious fervor and prohibition." But the reason the abstinence-based model is the standard of care for alcoholism is both scientific and practical. Alcoholics have a chronic, progressive and fatal disease. Additionally, if an alcoholic could safely, efficiently and consistently moderate their drinking, then they would not be considered addicted.
Glaser also focuses much of the article on a discussion about the drugs Natrexone and Baclofen (that debate has lost traction) as being the solution for alcoholism. She reports on addiction treatment in Finland at “Contral Clinics” and interviews co-founder Dr. John Sinclair, whose research with rats led him to conclude that abstinence from alcohol versus moderation for alcoholics is leading alcoholics to relapse due to the “alcohol-deprivation effect." Therefore, he states that he is advocating for moderate drinking for alcoholics. The most valid piece of that interview is his support of using Naltrexone/Vivitrol as part of a treatment plan for an alcoholic (in the US the expectation would likely be that the individual was abstaining from alcohol). However, Sinclair’s belief is that the drugs should be prescribed for alcoholics to “take an hour before” drinking to decrease their cravings to consume alcohol in a high-risk pattern. Glaser quotes an outdated JAMA 2006 research study indicating that “less than 1% of people treated for alcohol problems in the Unites States are prescribed naltrexone or any other drug shown to help control drinking." However, naltexone is frequently prescribed as an anti-craving medication in the US. Glaser comments about Hazelden and other 12-Step model treatment centers, writing: “The Minnesota Model: Alcoholics and addicts can help each other. That may be heartening, but it’s not science.”
It is important to note that there is a large amount of research generated by Hazelden at their Butler Center for Research. A New York Times article includes a relevant interview with Dr. Marvin Seppala, Medical Director at Halzeden. While these drugs may not be prescribed frequently to “control” drinking, according to Seppala, “27% of patients leave on some form of anti-craving medication” that he believes are most important to prescribe in the first 12-18 months of sobriety. However, a valid concern noted by Dr. Harry Haroutunian, physician director at the Betty Ford Center in Rancho Mirage, CA is “When you medicalize the disease and pay a lot of attention to the biology, it’s easy to get a patient to say, ‘Well, my cravings are gone, there’s nothing else I have to do’ … we try to use the principles of the 12-Step program as a source of strength during times of craving, to deal with the inevitable stressors. We want patients firmly involved with that.”
The most troubling section of this article is when Glaser (who claims to be a low-risk drinker and not alcoholic) asks her doctor to prescribe naltrexone to her and is denied because “I don’t have a drinking problem." She then orders the drug without a prescription off the internet to take before drinking as an “experiment” to see if she would drink less. She states that “I had never found wine so uninteresting. Was this a placebo effect?”
My friend who had forwarded me this article and in the past has attended residential addiction treatment, has relapsed, had attended A.A., has addressed dual diagnosis issues and now engages in a recovery program that he defines as “fellowship, spirituality and vigilance in recovery” responded to this part of the article stating eloquently that “The non-alcoholic trying naltrexone and reporting diminished cravings is meaningless … tantamount to a healthy patient taking a new medication to decrease Fibromyalgia pain and reporting pain relief when they never had pain to begin with."
Glaser writes that “as the rehab industry began expanding in the 1970s, its profit motives dovetailed nicely with AA’s view that counseling could be delivered by people who had themselves struggled with addiction, rather than by highly trained (and highly paid) doctors and mental-health (no hyphen needed) professionals. No other area of medicine or counseling makes such allowances.” However, the A.A. Preamble states “There are no dues or fees for A.A. membership; we are self-supporting through our own contributions. A.A. is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy; neither endorses nor opposes any causes. Our primary purpose is to stay sober and to help other alcoholics to achieve sobriety." A.A. members are not “counselors for each other", do not profit from treatment centers that may decide to integrate a 12-Step philosophy into their treatment and does not have an opinion about who should be providing counseling/therapy services for members or alcoholics in general.
I do agree with Glaser that far too many individuals die from alcoholism each year and do not receive appropriate treatment. She poses the question: “Could the Affordable Care Act’s expansion of coverage prompt us to rethink how we treat alcohol-use disorder?” There are also innovative and less traditional forms of addiction care that are growing in popularity, effectiveness and are not all covered by insurance (but maybe in the future they will be) and were not mentioned in her article (aside from having alcoholics try to find ways to drink moderately). I explore some of these in a past post about non-traditional forms of addiction treatment—they include case management, sober coaching, interventions, therapists with integrated dual diagnosis treatment approaches, collaborative outpatient treatment teams, evidence-based dual diagnosis care, trying different mutual-help groups (A.A., SMART Recovery, Women for Sobriety), lifestyle changes, self-care…
It is easy to get stuck in the details of this debate and to miss the “big picture” that was stated so clearly when I received feedback from another friend and addiction professional. He wrote:
"For over 15 years, I have been exposed to addiction on several levels; as a police officer, a mental health/addition counselor, and for the past 8+ years working directly with addicts/alcoholics in my current role as a Director of the Teen Challenge Men’s Program in Brockton, MA. Most importantly, I have personally recovered from a severe opiate addiction that almost took my life. Addiction is an all-consuming disorder that will eventually interrupt and cause damage in each area of the life of an individual. Addiction not only causes chaos in human physiology, but also warps our emotional, spiritual, relational and mental well-being. A significant part of recovery most certainly involves a strong group dynamic. It also involves the surrender of the individual to the addiction and a willingness to let others step in and help. Higher rates of depression may well be present in addicts/ alcoholics, but the author seems to give little thought to what may be the primary cause of this…While not perfect, A.A. has proven itself to have many of the fundamentals right. The suggested alternative seems to represent everything that is wrong with western medicine; treating the symptom and not the root cause. Telling the individual to pull themselves up by the bootstraps, take a pill or two and then perhaps one day they can drink again is a reckless alternative. A.A. has become a fellowship of millions of individuals who commit to be a part of each other’s lives, repair past damage, focus on sobriety and enjoy one day at a time. This seems to me a way to live that is far from irrational."
He so precisely captures that successful recovery from an addiction does not simply involve a surface level solution—it encompasses healing on a much deeper level internally and interpersonally.
In conclusion, I ask that readers remain open-minded about valid forms of addiction treatment that are evidence-based, safe and comprehensive. There are so many well-informed writers, addiction professionals, treatment options and it is a matter of identifying and connecting with them in order to achieve full recovery from addiction and mental health issues.
For more information about addiction treatment resources, please visit www.highfunctioningalcoholic.com.