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.
In the rooms of the 12-step programs, it has been said that, “Religion is for people who are afraid of hell, spirituality is for people who have been there.” In your book, why is no distinction made between spirituality and religion?
It goes back to the differences between AA groups. Although AA has always officially claimed that it is not religious and Bill Wilson went out of his way to make it less fundamentalist Christian than it was to begin with, which was part of his marketing genius, it is still true that there is still plenty of religion in AA rooms. I have heard from so many people all around the country who have been to AA who have told me this that I know it is a fact. You can certainly find AA groups that believe that addiction is not a religious issue and they may be more sensible. But there are plenty of fundamentalist, mostly Christian, groups out there saying the Lord’s Prayer at the end of every meeting. You probably remember from the book that 25 states have ruled that AA is a religious organization, so it isn’t just me.
To get to your point: Is there a difference between religion and spirituality? I don’t doubt that. But if I were investigating it, I would ask them to define what spirituality is.
On page 34 of your book you write that, “A treatment for alcoholism may be called successful if an individual no longer drinks in a way that is harmful to his or her life.” This is how you define the success you have had with your patients. Not continual abstinence, but a shift away from abuse and addiction. Yet, in your condemnation of the 12-step program’s success rate, you are referring to people obtaining continual sobriety from day one and continuing for 10 years, 20 years, unto forever. Why are the 12-step programs held to this very high standard as opposed to the standards by which you judge the results of your own work?
No, we didn’t say that. All of the studies that we looked at defined success their own way and none of them defined it as absolute abstinence. One of our critiques of some of these studies is that they didn’t define success at all. They said that these people are better, but we don’t know what that means. It’s a condemnation of the study if they don’t define what they’re talking about. In the Rehab chapter, we looked at a study that measured the success by a PDA or the percentage of days abstinent, and I think that is a much better way to look at it in terms of the success of any of these things. Complete abstinence is lovely if you can have it, but the important thing is to be better.
Isn’t the full title of the book The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry problematic because it promotes a concrete connection between rehabs and 12-step programs that does not really exist?
It exists in terms of rehabs basing their treatment models off of AA. It does not exist in the reverse. I agree that AA is not rehab and there is a definite difference between the two. But rehabs do advertise their programs as being 12-step programs. That’s why they are put together. We didn’t say that AA is rehab, but we did say that a majority of the rehabs are based on AA.
As much as possible in the book, we do not have opinions, but we do quote from the sources. The quote that leads off the chapter from Betty Ford herself about the 12 steps in relation is illustrative. These programs were started by people who are in 12 steps to be 12-step programs. Looked at from the rehab side, they lump themselves with AA even if AA wouldn’t lump itself with them. Let me put it that way.
[EDITOR'S NOTE: The quotation actually is not from Betty Ford, but it is taken from an internal page on the Betty Ford Center website that is in response to the question “Are There People Who Don't Make It In AA?” The quote is located in the comments section. It is a response by the Betty Ford Center to the question and reads in total as follows with the italicized portion quoted in The Sober Truth on page 58: “The Twelve Steps are a design for living. Many of the Steps are meant to be practiced every day so alcoholics can stay sober and achieve better lives. The great thing about the Steps is they can be incorporated in so many facets of our lives, and working the Steps day after day makes us even better at it, too. The other great thing about the Steps is that they work. If they didn’t work, then doing them over and over again would be insanity.”]
Wouldn’t the solution you offer to replace the 12-step programs - years of therapy - leave many people out in the cold? What would you recommend to homeless alcoholics and addicts who could never afford therapy on that level? AA and the other 12-step programs have consistently welcomed these people. Are you considering the possibility of pro bono work to help such people?
I think you are misstating the contents of the book. I have never said that people with addictions should be in psychoanalysis. I don’t believe that and I have never said that. What I am talking about is psychodynamic psychotherapy which is not psychoanalysis. It’s just based on similar ideas. It’s based on uncovering the roots of problems as opposed to just looking at the behavior.
But it still takes time?
Yes, it takes time and I have no apology for that. When it comes to the first case I mention in the book, it only took him eight months to stop drinking through this therapy. I find these negative comments about the time incredible because people on average usually take 10 years to stop drinking. That’s just the statistics. People in AA would never claim that they get people cured in eight months. Eight months is not a long time for a lifetime condition. If we could get cancer cured in eight months, we would all be happy. I don’t think there’s anything wrong with taking time. It always takes time.
I have had people walk into my office and stop drinking right away, but the reasons for that have nothing to do with what’s in the book or very little. Sometimes people stop and there’s also a spontaneous remission rate. To say it takes time is not a criticism. AA would never claim that it cures everybody in the first eight months or the first meeting or at any particular time. That’s ridiculous.
As far as the cost, absolutely. This treatment is not widely available and people who have no resources should get what they can. It should be more widely available, but it’s not. I am not saying that AA shouldn’t exist. But there is a problem with referring everybody to it. It’s not only not helpful to most people, it’s actually harmful to some of those people because they are told or they feel like they are failures. This is because our whole culture believes that AA is the right way to go.
Take the example of the famous people, the celebrities that go in and out of rehab or in and out of AA and they return to drinking, they are always condemned. We always say, “What’s the matter with them? Why couldn’t they stick with the program? Why didn’t they do the 90 in 90? What’s the matter with them?” (NOTE—90 meetings in 90 days is often recommended to newcomers in the rooms of 12-step programs, but it is not a written facet of the AA program).
Nobody says: Maybe this is not a good treatment for them. Maybe it has nothing to do with their stamina or their willingness or their honesty. Maybe it’s just not right for them, and that’s the right thing to say. Because it isn’t right for most people. Once you get that fixed in your mind, we can go back to the point that you’re saying: We are there for everybody. Well, that’s wonderful, but everybody is not the right people to go to. It’s true that AA is available, but the fact that you are down and out or you are living in the slums or on the streets, doesn’t necessarily make you a better candidate for AA.
It’s fine and I’m glad AA is there for them, but to criticize what I’m suggesting because AA is available, doesn’t mean anything. You have something that’s available that will work for a very small percentage of those people just like it works for a very small percentage of everyone else who goes to AA. Does that make sense?
It would be much better if the free clinics and the low fee clinics that exist, not AA, but if all these places that are intended to be open to everybody offered better treatment, but they don’t. If you go into a free clinic and you say that you have an addiction, nine times out of ten you will be sent to the addiction part of it that is run by an AA person and his credentials may not be any good. He may be a recovering person and believe that is a credential, but it’s not. He may have some training, but the fact is that the best trained people - people with social work degrees, psychology degrees, medical degrees - tend not to work at those places because they pay badly. I’m not saying that’s the way the world should be, but it’s a fact.
The world would be a better place if we had more sophisticated, better trained people working in low fee clinics, and then we’d be able to reach out to those people too. I’m in favor of that. I’m not opposed to that. I just wish that we could do it. Incidentally, I ran a low or no-fee clinic for years when I lived in Boston. I ran the Center for Problem Gambling for compulsive gamblers. We charged as little as we possibly could. The hospital required us to charge something so we charged two or three dollars a session. We wanted to be a clinic for everybody and gamblers, of course, have no money because they gamble it all away. I am in favor of helping everybody, but I don’t believe that since psychotherapy is expensive is a reason to knock it, it just should be made more widely available.
In your analysis of the 4th step of the 12-step programs, you write that a searching and fearless moral inventory is problematic because it implies an overall failure of morality that shames an alcoholic through “self-flagellation” and “degradation.” From the way it has been explained to me by other experts, the 4th step is about listing resentments, trying to see one’s part in those resentments and thus by doing so, understanding the patterns of behavior behind those resentments. Why is there such a gap between these two perspectives?
Well, if it were the way you described it, I would have no problem with it. It reminds me of what you were describing before as theory and practice. The problem is that the theory behind the 4th step is wrong. The theory is clearly moralistic because Bill Wilson invented it. The word moral is not there by accident. If you read the Big Book, Bill Wilson makes it very clear by listing all the sins of alcoholics. Of course, it’s all nonsense. He had in mind that this was sinful and it needed to be morally repaired.
Now you’re saying that there are people who have a much more enlightened view of it. And I agree. This is why we try to make suggestions in the book. AA could improve itself if it took out all of the moral qualities of it. They could take the word itself out if they wanted. If it just said a fearless inventory of yourself, well, that’s like psychotherapy itself. It is a fearless inventory of yourself and it does explore your role in things. If that’s what it means, I’m totally in favor of it.
You refer to the process of making amends in the 12 steps as cleansing oneself of sin by apologizing, thus leading to more shame and degradation for the alcoholic or addict. As I understand it, the amends process is not focused on apologizing, but about changing behaviors by asking a person wronged what can be done to heal a wound caused by a past action. I have heard it described as a process by which addicts and alcoholics clean up their side of the street by taking contrary action and amending past behaviors. Why is that process positioned as such a negative in The Sober Truth?
Same answer. The way you said it is fine. But that’s just not the way it is in the theory and practice in some cases. It’s the theory and I’m using your words because I kind of like them, it’s the theory that’s the problem. If you read that step, it says, “When we are wrong, we promptly admitted it.”
(EDITOR'S NOTE: Dodes is mistaking the 10th step for the 8th and 9th steps. In the Big Book of AA, these three steps read as follows: 8. Made a list of all persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 10. Continued to take personal inventory and when we were wrong promptly admitted it. Step 8 & 9 are about the amends process while Step 10 is the process of doing inventories on a regular basis and making an amend if the inventory reveals an issue that needs to be amended.)
If I were writing the 12 steps, I would never say it that way because it’s not a question of right and wrong; it’s not a moral issue. The way you said it is good. I have no objection whatsoever to that. It’s an important part of any psychotherapy to recognize the way that you have messed things up and caused troubles in your life and you correct them. You learn about yourself so you can make your life go better in the future. I have no objection to that whatsoever.
You emphasize the element of proselytization in your analysis of the 12th step. People in the 12-step programs could call this a misrepresentation. Doesn’t proselytizing outside of the rooms actually violate the 11th tradition that states, Our public relations policy is based on attraction rather than promotion? When discussing proselytization in The Sober Truth, why is there such a minimal discussion of anonymity as a spiritual principle of the 12-step programs?
As far as the tradition goes, the tradition is broken all the time. AA members, not AA itself, proselytize all the time, including in response to this book: AA worked for me, AA is wonderful, why do you criticize AA? and those kind of comments. My brother went to AA and got sober and then they act on it and send people to AA. That’s proselytizing, isn’t it? If you had a church and you send out missionaries, that’s proselytizing. If you are in a position to refer people to your group and you say this is the way to go, that’s proselytizing.
When a doctor prescribes a pill, he has no stake in that pill or that’s the way it should work. A doctor shouldn’t prescribe something because the company sent him a gift or he has some financial stake in that company. It should be prescribed because you believe based on all your experience, knowledge and training that it’s the best thing to do for that person. But AA doesn’t work that way. It may be based on experience, but there’s no knowledge and there’s no training. People say it works for me and it can work for everybody so you should go. People talk about AA all the time. Individual members espouse how wonderful it is so I think it’s fair to say it’s proselytizing.
As for anonymity, I don’t think it has anything to do with anonymity. For example, I don't know who this new Drug Czar is or what kind of person he is, but if somebody asked him about AA, I would think that he would recommend it. Everyone on the state boards seem to be AA members, so if you ask them what should be the policy toward treating addiction, they'll say AA. You don't have to violate your anonymity to proselytize. AA members don’t have to break their anonymity in order to recommend AA and tell people that AA is wonderful. And I don’t know what is so spiritual about anonymity in the first place.
Since you are against the disease model, do you agree with the late night television message expressed by Pax Prentiss, the owner of the Malibu rehab Passages in which a therapeutic cure for addiction and alcoholism is claimed? I know you don’t like the rehab model, but isn’t Passages the rehab that represents a model closest to your own beliefs?
We actually mention Passages in the book when we refer to certain rehabs that have a little more psychological sophistication than the rest. I am not an expert in the Passages perspective, but from what I understand and to their credit, they talk about factors in people’s lives that lead them towards addiction, rather than it coming from simpleness or badness or your neurology or whatever it is, so that’s good. Beyond that point, I am unaware of anything else they say that I would particularly endorse.
What follows is a brief summary of Dodes approach to treating addiction that he prepared for this interview based on his book, Breaking Addiction: A 7-Step Handbook for Ending Any Addiction.
True addiction (versus simple physical dependence) is neither more nor less than an emotional solution to manage feelings of intolerable helplessness. When people feel utterly trapped they have to do something, and if they feel they can't act directly to get out of that trap, then they have to do something else. The "something else" is, therefore, a substitute action (technically called a "displacement").
When people repetitively perform a displaced action to try to manage overwhelming helplessness, we call this driven, compulsive behavior an addiction.
To deal with it, first it's essential to identify the "key moment" on the path to addiction, which is when the thought of doing the act first appears. Then, it's necessary to look backward to what just happened in your life or feelings. If people do this enough, they can discover the theme that is behind their addiction: the kind of problem that makes them feel overwhelmingly helpless -- losses, humiliations, shame, having a feeling that they believe is wrong to have, and many others. It will be something that is unique to them. When they've identified this theme, they've found the precipitant of past addictive urges, and more importantly, future addictive urges.
Since addictions are substitutes for doing something to deal directly with these helpless feelings, the next step is to undo this substitution by taking a more direct action. This is often easier said than done, because there are usually reasons folks didn't take that direct action to begin with: it felt forbidden, or they fear it would drive people away, or it frightens them, or their style is to try to ignore conflict.
But there is always something people can do at these moments that is more direct (even if it is not perfect).
People find that when they take that action, their addictive urge almost always vanishes. This sounds like magic, but it makes sense: having acted more directly, they no longer need the substitute behavior. Here is just one (shortened) example, taken from my earlier books:
A woman always complied with her husband's demands. And every time she complied, she took her Percodans. Her addictive use of the drug was a response to feeling trapped by her own subservience: now she was doing something for herself, in her own control, for a change.
One day when her husband demanded she make dinner for guests at the last moment, she started to get her pills from the medicine cabinet. Then she stopped. We had been talking about her addiction, and now she recognized the pattern. She later told me, "I know the best thing I could have done was tell my husband to make his own damn dinner, but I couldn't do that, at least not yet. But I came up with another solution! I realized I could order in Chinese food. Once that occurred to me, I could just close the medicine cabinet and walk away." (Everyone is unique; for many quite different examples, see Breaking Addiction and The Heart of Addiction.)
For a longer term solution, once people become expert at knowing what overwhelms them, they can anticipate - sometimes days in advance - when addictive urges will occur. That way, they avoid even having to reach the stage of intense feelings. When folks reach that point, they have mastered their addiction. As an added benefit, they will have also come to know where they are most emotionally vulnerable, which is often deeply useful for avoiding other harmful patterns in their lives.