Two articles about addiction and its treatment published lately have been widely shared in social media, and they bother me. There’s no question that the authors of both are well-meaning, but each purports to have a clear “answer” to the disaster of addiction. Though unintended, each distorts the big picture in a way that may confuse the people who need help most.
Albert Einstein said, “Everything should be made as simple as possible, but not simpler.” In Johann Hari’s recent article, The Likely Cause of Addiction Has Been Discovered, and It Is Not What You Think, he argues that the cause of addiction is no more than the lack of a strong, loving community. It follows that the cure for addiction then must be…a strong, loving community! For Mr. Hari to present this as a breakthrough, he must be unaware that Alcoholics Anonymous, its sister 12 Step tradition support groups, and a number of non-12 Step support organizations are *all* based on creating a welcoming, loving community for the “newcomer” seeking a life in recovery. Long story/short: it’s not news.
And what happens for the person who finds a better community and still struggles with addiction? Is he a failure? No, because Mr. Hari’s analysis leaves out two critical components of addiction: the very real, physical, brain disease – damage caused by too much drugs and alcohol in the blood – and the co-occurring psychological disorders that, in 70% of cases, drive the obsessive behavior we call addiction. If you’re interested, I think my January 2014 blog post (ironically, similarly titled), What is Addiction? Not what you think, offers a better explanation.
While Mr. Hari’s article promotes a simplistic concept which he extrapolated from a study of caged rats, Gabrielle Glaser’s article in The Atlantic Monthly, provocatively titled The Irrationality of Alcoholics Anonymous, goes to the other extreme.
To Ms. Glaser’s credit, her research is deep, she deplores the kind of one-dimensional thinking promoted by Mr. Hari’s article, and she makes a strong argument in support of individualized, evidence-based treatment. But in her zeal for a new generation of pharmacological interventions and a harm reduction (modified use vs. abstinence) approach, she goes too far: declaring war on Alcoholics Anonymous is not the solution to the problem.
The individualized, evidence-based treatment Ms. Glaser promotes is the basis of all Joint Commission-accredited addiction treatment programs. Lionrock Recovery is one of only two Joint Commission-accredited online programs, along with well-known treatment centers like Betty Ford, Hazelden, The Meadows, and Foundations Recovery Network. “Support group orientation” is an important aspect of the “best practices” program on which our accreditation is based. This means that we actively encourage our clients to seek a support group, including AA among others, that makes sense for them.
Addiction treatment and support group meetings are often confused by people outside of the recovery world, and for good reasons which I’ll cover another time. In reality, they have very different dynamics, and they play complementary roles in fostering recovery. The American Society of Addiction Medicine (ASAM), the primary authority on both medically-assisted and evidence-based treatment in our field, codifies this view in its addiction treatment best practices. Despite this, Ms. Glaser asserts that the 12 Step support groups like AA aren’t effective enough to be included in the mix of therapies used for treating addiction.
More than 2 million people participate in 12 Step support groups in support of their recoveries. By this metric alone, Ms. Glaser’s assertion that they offer no value is at odds with her argument for individualized treatment. Further, it gives rise to a practical problem for us in the treatment field: how do we meet the ASAM best practices requirement for promoting support group participation? AA is the oldest, most prominent of the support group organizations. It’s effectively free, and meetings are available around the world, often around the clock. There are alternative support groups for people who prefer a less spiritual focus, but AA is the easiest path because of its critical mass.
Unfortunately, despite some strong research and logical arguments for improving treatment, Ms. Glaser is throwing the baby out with the bath. If her articles discourage people who would benefit from AA from participating, is that a net gain? If her articles offend and turn off people who participate in AA, who might otherwise benefit from medically-assisted treatment, is that progress?
One example from Ms. Glaser’s article really illustrates the point for me. She tells the story of a 38 year-old Finnish doctor who decided to take the drug naltrexone “for the rest of his life” so that he can drink socially, “two, maybe three times a month”. She continues, “By American standards, these episodes count as binges, since he sometimes downs more than five drinks in one sitting. But that’s a steep decline…” Meanwhile, The Centers for Disease Control identifies many health risks associated with this level of drinking, including cardiovascular, liver, and neurological disease, and a host of other problems which you can find here.
Here’s what I’m taking away from her article: in pursuit of a little social activity, it’s okay to take on a lifetime pharmaceutical habit that reduces the potential harm of drinking to only really unhealthy from immediately disastrous, but participating in a semi-religious organization that promotes abstinence, and creates a strong community associated with it, is a terrible idea because it doesn’t work for everyone. Despite my slight over-simplification for effect, quite honestly, her logic evades me here.
That there are many paths to recovery is a homily in our field. Some people will only need a better community, as Mr. Hari argues. For some, the 12 Step tradition will be the wrong way to go. But for others, it will be the key to their recovery. Evidence-based therapy is a great advance, but doesn’t solve the whole problem. Some people will do well by adding the new generation of medically-assisted treatment. For others though, it will just put off the inevitable reckoning that, for them, being completely substance-free will be best. In sum, that’s what we mean when we say “individualized treatment”: there are many paths to recovery.
Addiction is a complicated and lethal problem affecting far too many people. Whether we’re talking about old school AA or cutting-edge addiction pharmacology, absolutist solutions in any direction don’t leave enough room for a client-focused approach to recovery.