AA Critic Lights Another Fire (includes new section)
Dr. Lance Dodes co-authored the latest book arguing why AA is not effective treatment for alcoholics. Lots of people are angry.
By co-writing The Sober Truth with his son Zachary, Dr. Lance Dodes has ignited a familiar brushfire in the recovery community. His anti-AA book is making more of an impression than the usual attacks. His book takes a slash and burn approach to dealing with 12-step programs. Dodes talked to The Fix about how he came to his convictions and the options that he thinks exist for treating alcoholism.
Anti-AA sentiment regularly comes up in the news. Why do you think this is the case? And how is your work different?
When we talk about why AA has been so fabulously successful in being accepted by the general public, it’s the same answer as to why all of the other books seem to fade away. The people who are pro-AA and getting something out of it - the people who are devoted to it in a quasi-religious sort of way - have a huge influence. Many of them are successful in other ways and they have risen to positions of prominence. This has always been the case as we reviewed in the book. From the incredibly positive and completely inaccurate review of AA written by Jack Alexander in the 1940s [the article was originally published in the Saturday Evening Post] that helped to promote the idea that AA was the best treatment for alcoholism
On the other hand, it’s also true that there’s a kind of silent majority, although I hate to use that phrase. Most people with addictions do not belong to 12-step programs, and many of those people have tried them and failed. But those people don’t talk about it and this is what we call the sampling bias in the book. We hear from the people who do well and we don’t hear from the people who don’t do well. If you go to the recovery section of a bookstore, you’ll see book after book about how AA saved my life, but you won’t see any books about how AA didn’t save my life. People don’t write those books and no one reads them.
The basic answer is that AA is sort of self-sustaining. It’s now added a bunch of people who should know better because they are scientists and researchers and now they have done studies to try to prove AA’s effectiveness. That’s why we wrote the book; to see if those studies are valid and it turns out that they’re not. They are riddled with errors and the science that supposedly is supporting AA is no good. The bottom line is that AA does have a five to ten percent success rate and that’s fine. We need AA and it should be there for those five to ten percent. The problem is that because of the power structure, we prescribe AA for everybody and that’s just a mistake.
The answer to your second question if my book will make a difference is I don’t know.
Do you see a distinction between theory and practice when it comes to the 12-step programs in general and AA in particular? Is the theory behind the 12 steps as expressed in the Big Book the same as the practice of the program in the rooms? Shouldn’t the two things be distinguished?
Okay, that’s a good question, and we tried to address that in the book as well. Since AA is intentionally unregulated, anyone can start an AA group. AA groups are very different from each other. Any one AA group may be composed of thoughtful, mature people who are simply there to help each other stay sober. You go to other groups and they have a power structure within them in which there are fundamentalist people who will berate you if you are not doing well and who insist you buy into the religious aspect of AA - which is very powerful in many groups that are much less thoughtful and much less flexible. If you look at the practice of it, it’s all over the map and that is actually one of our main issues with AA. Namely, there are groups which are much better than others. As a result, the overall practice of AA is not so great because there are places where people have had a terrible experience and we know this from first-hand testimony.
As far as the theory goes, I don’t think the theory has any merit whatsoever actually. If you look at the 12 steps themselves, if that’s the theory behind it, it’s based on an idea that this deeply religious stockbroker Bill Wilson came up with based on the Oxford Group which was, of course, a very fundamentalist Christian organization [The Oxford Group was a Christian organization founded by American Christian missionary Dr. Frank Buchman in 1928]. There is no reason to think that a spiritual approach to addiction makes any sense at all. Nothing against spirituality, but it is the same as saying you should use a spiritual approach if you have a compulsion to keep the things on your desk parallel to each other or a compulsion to clean the house.
There is just no role for it. Bill Wilson just dreamed it up and even though a lot of people can find some use of it, it is still one of the main things that limits AA from being truly useful. We put a suggestion to AA in the book that to make it more popular, they should take out some of this religious stuff because it has no bearing on the problem. Bill Wilson originally said that addiction is a failure by a person to be closer to God and he later changed this for marketing reasons into a failure to be closer to a higher power. If the idea is that we are sinners and we need to be closer to God to be free of our addictions, I think that’s utter nonsense.
Can you clarify your position on the genetic background of alcoholism? Although your book refutes the disease model of alcoholism, you seem to agree with the idea of a genetic predisposition. For example, you mention how alcoholism plagued the family line of Bill Wilson. Is there a genetic predisposition towards alcoholism, and what does such a genetic predisposition imply?
I have no personal opinion about it at all, and I tried to avoid putting any opinions whatsoever in the book. There is, however, a lot of scientific literature about it and the literature suggests that there is some evidence for some genetic loading or some genetic influence in some people with alcoholism. But those studies also are quite inconsistent.
The one study we cited specifically in the book was the twin study. If you take two people who have exactly the same genes and one of them has alcoholism, the statistical likelihood is that the other doesn’t. It would be hard to say it’s a genetic illness if that’s the case. Of course, you can have some genetic influence on almost anything. And that is true. The analogy I’ve seen from geneticists - I didn’t make this up - is that the inheritance for alcoholism is probably similar to peptic ulcer disease or essential hypertension which is ordinary high blood pressure.
So could there be a genetic factor? There could, but you have to understand one more thing. When people study this, their studies are flawed by the fact that they are looking at a behavior, namely drinking. But if you look at a behavior, you are not looking at the right thing because genes don’t control complex behavior. They may control something else, but if you look only at this specific behavior, you are leaving out people who are compulsive in other ways. What happens if you add those people in? What happens if you have people who instead of compulsively drinking are compulsively cleaning their house. Same problem, but they don’t get included in the data.
I would say that I don’t deny there is a genetic influence because there is for almost anything. But I don’t think the studies are good because they [don't include] everybody who has this kind of trait - if you want to call it that, but I would rather call it a symptom. I don’t think the statistics are very good for that and you can’t rely on them. Now if you said to me, “If there were a genetic factor, how would I explain it?” I can’t explain it because obviously no gene ever told anyone to walk into a bar. It would be very complicated and nobody actually has a valid explanation for it even though they like to tap these faulty statistics.
In your book you conclude that addiction is a psychological challenge, not a disease, and that the challenge of addiction can be overcome through a therapeutic process that engenders self-knowledge. It is well-known that such therapeutic strategies of treating addiction have not worked in the past. Why would the results be different this time around?
Okay, that is the one place in the book where you could say that you might criticize the wording of it. What I should have said is that everything I say about that works for some people. It was unintentional to suggest that that is the way to treat everybody. However, I will stand my ground about the idea behind it: To call addiction or alcoholism a disease, doesn’t help understand it, and I have always felt it interferes with understanding it. When you add the label in there, it tells you nothing and kind of confuses matters. Second of all, I don’t think it’s accurate because we know that people can switch from addictively or compulsively using alcohol to addictively or compulsively gambling or addictively or compulsively having sex or shopping. We know that because that really happens in the real world.
So what’s the disease? If the disease is that you have compulsions that shift from one thing to another, I don’t need to call that a disease because I already know what that is. It’s called a compulsion and it’s been well-studied for over a hundred years. It does have a psychological basis. Your point that it’s been studied and it doesn’t work well is true. But I’m not sure it has been well-studied. People have been studying and using cognitive behavioral therapy, but the kind of treatment I’m talking about hasn’t existed. It really hasn’t been studied and I wish somebody would study it.
When I wrote my first book, The Heart of Addiction, I described a way of thinking about addiction and, in my second book, Breaking Addiction, I described a way of treating it that nobody was doing. I do believe it’s accurate to say that that approach has not been studied. I think what has been studied is old-fashioned treatment which I agree with you is not effective. I don’t think you can walk up to somebody and say to them, “Okay, let’s start talking about your mother” and hope to treat the addiction. That’s not good treatment for addiction. You may get to your mother eventually, but that’s not going to deal with the issue. What I came up with was a way of dealing with the issue and dealing with the underlying factors behind it. No one has tested that.
[A brief description of Dr. Dodes treatment therapy can be found at the end of this interview.]
I want to say one more thing to further muddy the waters. The harm reduction movement is quite important because to consider that you are not doing better if your addiction is improving is wrong, and that’s part of my criticism of AA. If you relapse, you go down to zero in terms of the number of days sober and you have to start all over and that just makes no sense - to criticize people for not being absolutely abstinent. When you do a kind of introspective therapy which is designed to root out the cause of it, naturally there are going to be up and downs in the behavior and the behavior may last for a while. If you’re only looking at complete abstinence, then you’re going to say that it’s an ineffective treatment. Like with all psychodynamic therapy, the longer you follow it, the more effective it is because instead of looking at the superficial system, you are looking at the changes in the human being.
To recap, I think that the way it was worded in the book overstated the case. Of course, this isn’t the treatment for everybody and it isn’t the treatment for the 10 percent who are doing well in AA. I stand behind the idea because I think it is an effective psychotherapeutic approach.
You refer to Carl Jung as “the eminent psychoanalyst” in the book so you clearly must respect him. Why do you disagree with Carl Jung’s belief that a spiritual solution is necessary for an alcoholic or an addict?
I don’t have any particular respect for Carl Jung, and I believe your reading of that is not what we intended. He was an eminent psychoanalyst at the time - eminent meaning well-known - not because he was such a great analyst because he was not. His backing of AA is one more example of why I don’t respect him or his work. He recommended religion as a way to be cured of alcoholism, and it’s a position I do not respect and it’s one of the reasons he’s not well-respected today in my field.