In The Sober Truth, acclaimed addiction expert, Lance Dodes, takes on a myth that is as gargantuan as the industry it has spawned, the rehab industry--the myth that the myriad 12-Step rehab programs, from the common Alcoholics Anonymous, Narcotics Anonymous, and Gamblers Anonymous, to the paradisal rehab retreats of the wealthy and famous, are the best and most effective approach for curing addictions. These programs are uncritically presented to the public as the single hope for addicts, to the extent that they have since the 1980s been codified into the legal system and are a court-mandated staple of drug crime policy, draining upwards of $15 billion of federal funds every year. However, the fact is that these costly programs almost always fail. Dodes reviews the flawed science behind the impressive claims of recovery rates made by these programs to find a demonstrated success rate of less than 5-10%, about the same rate that we know people would over time find their way out of addictions on their own ("spontaneous remission," treated in Chapter Three).
While Dodes acknowledges that the social element of rehab programs can provide comfort to those who feel ostracized by their "disease," he notes many destructive aspects of the programs--including framing addiction as a "disease"--that actually work against an addict's recovery. For one thing, the inflated claims about program success result in the paradoxical charge that "[t]hose who do not recover are people who cannot or will not completely give themselves to this simple program" (quoted from Alcoholics Anonymous, 3rd edition, on Dodes, p. 3). The overblown confidence ethos blames the individual, rather than the program, for any failures to overcome addiction," thus laying the blame for their program failure on the very people their program has failed.
This is only one of a number of myths, catalogued in the 12 Steps, which are potentially dangerous and harmful to the person seeking to overcome their addiction. First, Step 1 requires an admission of powerlessness that grates heavily on many people, and one wonders at the wisdom of this self-effacement given the lack of any clinical merit or scientific evidence that this serves any recuperative benefit.
Secondly, many of the Steps betray the conceptual roots of AA in a religious organization. These roots are revealed in the general orientation evidenced in Step 1, where members are considered to be flawed and sinful, and in need of a conversion experience to cast off their sinfulness. Though AA denies any continuing religious affiliation, Bill Watson writes in the AA "Big Book": "Our real purpose is to fit ourselves to be of maximum service to God" (p. 77, quoted at Dodes, p. 4). Steps 2, 3, 4, 5, 6, and 7 strike out the path of religious conversion, from admission of moral defectiveness, embrace of powerlessness, to a cure in the form of divine purification. In Chapter Two, Dodes traces the history of the rise of AA and its blossoming into the myriad forms that we find it today.
Dodes is insistent that the 12 Step programs in all their many and varied forms compound the addict's sense of shame, anger and self-loathing by blaming their continuing addiction on a lack of will power or fortitude that, according to the logic of the program, stands in the way of their mastering their addiction. Dodes is clear: "The degradation woven into these steps . . . seems unwittingly designed to exacerbate, rather than relieve, the humiliating feelings so common in addiction" (p. 5). Anyone who has ever known an addict up close and personal knows all too well the self-flagellation through which addicts put themselves. Surely if self-debasing worked, there would be very few addicts to cure!
The entire approach is wrong and dangerous, argues Dodes, but with the huge profits made by the rehab industry--some charge over $90,000 per month--it is unlikely that we will soon see them closing their doors, deterred by a small thing like lack of success. Each program is heavily invested in the myth that 12 Step programs are the sole effective answer! Dodes meticulously works through the scientific data and offers a critical assessment of each study, highlighting the scientific flaw with which the "research" on 12 Step programs has laid its claim to phenomenal success rates. Then Dodes offers us a detailed glimpse into the very regimented daily life inside a rehab center, showing that this largely unregulated industry uses unstudied treatment methods, applied by largely unprofessionally trained staff, rarely tracks their patients after they "graduate," and release little to no data to back up their inflated success claims. It is important to understand that the very lucrative addiction treatment industry is based on a model of "cure" that has remained virtually unchanged since the 1930s, and the centers remain staffed almost exclusively by people with no knowledge whatsoever beyond the AA model.
Finally, Dodes gives us the benefit of his expertise in treating addiction by pointing out that drunkenness is not equivalent to addiction. Treating addicts effectively requires uncovering the underlying causes that lead to their addiction. "One of the principal sources of confusion," Dodes notes, "was that people mixed up physical addiction with the underlying nature of addiction" (p. 81). Physical addiction is a simple physiological phenomenon of tolerance that happens to anyone when whose body changes in reaction to drugs and alcohol by adapting to accommodate their presence. Physical addiction has nothing to do with the true nature of addiction, argues Dodes. Physical addictions can be removed by detoxification, but addiction remains intact for true addicts post-detox, driving them relentlessly back into their destructive habits until the underlying causes are treated.
What AA and its like do not seem to realize is that addicts are not sinful people who let the party get out of hand or are having too good a time to clean up their act; far from pleasure seeking, true addicts are driven by agonizing psychological factors to self-medicate the intolerable pain of feelings they cannot bear or manage--feelings of extreme overwhelm or powerlessness. True addiction is more akin to obsessive-compulsive disorder in that its primary characteristic is compulsion.
Humans regularly take up compulsive acts in reaction to being upset. These acts may be drinking alcohol or taking drugs, but they might also include shopping or promiscuous sex. Compulsions are displacements, Dodes explains. The Sober Truth records many case studies of patients who typify true addiction and we come to see that often the person begins to feel better as soon as they decide to practice the compulsive behavior, be it taking a pill or eating chocolate cake, because deciding helps them to take control of their lives again when they are feeling out of control. So practicing the addiction, utterly contrary to AA logic, is not about failure to control themselves; it is about taking control of their lives. The case study we are given is a woman who feels overwhelming helplessness at her husband's demanding practices toward her, and who reaches for a pill to feel better before she complies with his demands. Effective treatment helps her to identify what is really happening for her and why, so she can take control in less destructive ways.
This case study helps us to see a further fatal flaw in the 12 Step system: teaching people that they will always have their "disease" and thus to take "one day at a time" robs the individual of the opportunity to gaze across the landscape of their lives and develop the self-understanding that would allow them to identify the triggers that drive the addictive behavior so that they can substitute a different, less destructive, type of behavior that allows them to feel in control again, or better yet, to act in their own defense and remove themselves from the situations that cause their feelings of helplessness.
Addictions are so common in the high-pressure rat race of modern consumer societies that few readers will fail to meet their personal demons as they read this very valuable book: reflecting upon their own unhealthy practices or their uninformed maltreatment of family members and friends who struggle(d) with addiction and were labelled as "failures" because they couldn't overcome their addiction with the sure-cure 12 Step program. This book alerts us to a widespread and genuine tragedy issuing from the general misunderstanding of addiction that results from our uncritical trust in the widely publicized success rates of AA and other forms of the 12 Step rehab industry. This book is a must read for therapists and rehab industry workers as much as for family members and friends of addicts, who will be better informed of the need to seek actual experts in the field to help these struggling people, rather than blaming the victims who fail 12 Step programs.
© 2016 Wendy C. Hamblet
Wendy C. Hamblet, Ph.D. (Philosophy), Professor, North Carolina A&T State University.