The Controversial Heretic Who's Taking On AA

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The Controversial Heretic Who's Taking On AA

By Stanton Peele 05/19/11

For three decades, psychologist Stanton Peele has riled the recovery movement with his relentless attacks on abstinence and A.A. Critics have dismissed him as a self-promoting quack. Now he's firing back.

 

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Dr. No: Stanton Peele Takes on the "Addiction Establishment"

Ever since Bill Wilson published A.A.'s Big Book in 1938, Alcoholics Anonymous and its numerous 12-step spin-offs have dominated the national discourse about addiction. Afflicted with a condition that most physicians considered untreatable, many addicts and alcoholics ended up in sanitariums and prisons. A.A. offered them a glimmer of hope. In the past few decades, the fellowship has provided a sanctuary for three generations of addicts, who have sought, and often found, sobriety in its rooms. At the same time, Wilson's pioneering program of spirituality and abstinence, and the disease model of addiction he endorsed, have spawned a lucrative industry of medical professionals, rehab centers, and treatment programs. America alone is home to 20,000 rehabs that earn over $20 billion a year. Every day, an estimated 750,000 people check in to treatment programs across the country—most of which strictly adhere to A.A.'s 12-step traditions.

Founded in an Akron hospital room, A.A. has gone on to become a world-wide phenomenon. Today there are thousands of 12-step meetings in nations from North Korea to Nepal. (There are twelve A.A. meetings every day in Teheran alone.) But despite A.A.'s growing influence, not everyone approves of its approach. In recent years a growing group of scientists, activists and social workers have criticized the group's all-or-nothing approach to abstinence and it's religious view of recovery. But few critics have been more vocal than Stanton Peele. In hundreds of books and articles, and on his website, the 65-year-old psychologist-cum-lawyer has argued that addiction is not a progressive, lifelong medical condition, as many experts contend,  but a negative pattern of behavior—a “problem of life” that often resolves itself organically, or can be mastered through psychological treatments like cognitive-behavioral therapy.

Noting the relatively low success rate of most 12-step programs, Peele claims that abstinence-only programs may even be harmful to many addicts, who internalize their inability to maintain continuous abstinence as a personal or moral failure. When pressed, Peele admits that A.A. does work for some people. But at the same time, he has famously decried the program as “a religiously rooted folk movement…[whose] success is not one of clinical outcomes but of public relations and cultural appeal.”

Last week, in recognition of his long-time labors, we included Peele in our list of the 10 top addiction experts in America. Not surprisingly, his appearance sparked a fire-storm of condemnation from many readers, who denounced the doctor as a hater, an opportunist and a quack. True to form, Peele didn't take the criticism lying down. In response, he sent us a treatise that he hoped "would accurately articulate my view of an addiction model for the 21st century." We agreed to run it.  Some of Peele's positions will no doubt be troubling to people in the recovery community. But while we suspect that most A.A. stalwarts are unlikely to be swayed by his arguments, there's no denying that to a surprising degree, many of his once-heretical beliefs have increasingly been adopted by mainstream medicine. Whether or not you agree with him, it's a safe bet that his alternative approach will be at the center of the most critical debates in the coming decades. So let the fireworks begin. 

The Gospel According to Stanton Peele

1. Addiction is not caused by substances.

When I started working in the addiction field in the early 1970s, heroin was the only substance viewed as addictive.

When I started working in the addiction field in the early 1970s, heroin was the only substance viewed as addictive. In the ensuing four decades, the range of addictive substances has expanded exponentially—and in directions that were entirely predictable. Cocaine was widely considered to be a non-addictive drug, until  I called smoking addictive in 1975—some 13 years before the Surgeon General finally recognized nicotine as an addictive chemical.

Now, for the first time, the new diagnostic manual for the American Psychiatric Association, DSM-5, due out in 2013, labels compulsive gambling as an addictioon. The doctors who are putting together the manual are still debating if sex, eating, shopping, video games and other activities completely unrelated to drugs or alcohol should also be classified as addictions. Ultimately, I believe, they will be. Why? Because addiction is about the intensity of the harm people experience from their (often uncontrollable) involvement in a certain activity—not the activity itself, whether it’s consuming narcotics or liquor or online pornography.

This reclassification of addiction by the DSM is nothing short of revolutionary. Don’t let the technical terminology fool you. The DSM is a cultural document of awesome power: it defines the many disorders for which people are diagnosed, treated, insured, and medicated. Even more importantly, it provides a scientific template for how we think about ourselves, our health and  even our values. (For more about the current DSM controversies, see my 2010 article in  Psychology Today.)

To some extent, the new DSM guidelines are merely reflecting the popular view that recognizes that addiction can appear almost anywhere in our high-tech consumer society. So it’s not too surprising that the head of the DSM-5 Substance-Related Disorders Work Group, Dr. Charles O’Brien, a respected University of Pennsylvania psychiatrist and researcher, has added gambling to the list of medically recognized addictions. He said he made his ruling because “substantive research” indicates that “pathological gambling and substance-use disorders are very similar in the way they affect the brain and neurological reward system."

O'Brien's assertion that intense activities like gambling and powerful drugs like cocaine are addictive because they stimulate similar neurochemicals and brain pathways challenges the establishment view of addiction. Arguing that high-order brain processes are the most important factor in determining addiction contradicts the long-held view that addiction is largely a biological problem. This profound shift in our understanding of addiction promises to permanently transform the addiction landscape in the 21st century. But to get there we’ll have to ignore decades—and perhaps centuries—of suspect science, that blames addiction entirely on genetics.

2. The truth is, most people recover naturally from addiction.

Last year, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) published an astonishing document entitled “Alcoholism Isn’t What It Used to Be” based on a massive survey conducted by the National Epidemiologic Study on Alcohol and Related Conditions (NESARC) Government researchers interviewed some 43,000 Americans about their lifetime alcohol and drug use. In summarizing the results, Dr. Mark Willenbring, the NIAAA’s director of treatment and recovery research, said: “Twenty years after onset of alcohol dependence, about three-fourths of individuals are in full recovery. Only 13 percent of people with alcohol dependence ever receive specialty alcohol treatment.” In other words, contrary to the heavily marketed view of alcoholism as a creeping disease that relentlessly drives a person to a Leaving Las Vegas denouement, some 75% of all alcoholics overcome their “disease” without formal treatment in a hospital or rehab center or lifelong twelve-step practice. For this majority, alcoholism may be a terrible condition, but it's also not permanent—indeed, very often, it's self-resolving.

These new facts, coming from the highest level of our public health establishment, demand a sea-change in our thinking about addiction.

This isn’t to say that treatment can’t be helpful. I myself have created a treatment program that has been utilized by thousands of addicts. But much of the new medical evidence suggests that our view of addiction as a disease is simply wrong. At best, our current addiction treatments support the acceleration of the underlying natural recovery process. But this fundamental change in our perception of  addiction presents a quite dramatically different picture of both addicts and and their would-be helpers.

3. Harm reduction is the most important 21st-century innovation in addiction policy and treatment.

In writing, researching and treating addiction, everything I do is predicated on the assumption that the abstinence-only approach is hopelessly unrealistic, imposing an all-or-nothing edict encourages addicts to  view recovery as never picking up another drink or drug for the rest of their lives. By solely promoting abstinence, we misconceive the possibilities for change, creating treatment goals that are usually quickly violated while misallocating our efforts and resources. For example, it is much wiser to help people (particularly young people) to develop skills in daily living and to achieve specific short-term goals than to focus on their never  drinking or using drugs again. It is also cheaper and more efficient—residential therapy is simply far too expensive to work as a public-health measure.

Taken to an extreme, as in the twelve-step custom of counting the days since you last used (and marking milestones with “coins”) —even a single relapse can erase many months of hard-earned sobriety. Consequently, A.A.'s insistence on abstinence seems to me  not only cruel but self-defeating. (This fixation on purity runs deep in the American character with its source in the spirit of Protestantism and the Calvinist doctrine of predestination—salvation completely independent of your own actions—but that’s another story, although not irrelevant to the particular religiosity of A.A.)

Let’s look again at the facts. In his summary of the NESARC research, Willenbring writes: “More than half of those [alcoholics] who have fully recovered drink at low-risk levels without symptoms of alcohol dependence.” This supports the view that moderation is a productive, achievable goal for many of those diagnosed with alcohol dependence—particularly younger drinkers and those with a less long-standing or severe dependence—but who are classified as alcoholics and subjected to treatment nonetheless.

The increasing acceptance of harm reduction reaches far beyond this group of moderators, however. Even for people who remain addicted or fully alcoholic, reducing the potential harm to which they are vulnerable—for instance, by providing clean needles to injecting drug addicts to help them avoid infection with HIV and hepatitis C—is a crucial public health technique.

No one seriously believes that we’ll ever be able to eliminate drug use in this country, let alone drinking. Even A.A. acknowledges that most alcoholics don’t cease drinking for the rest of their lives. We need to accept this reality and expand our treatment and policy repertoire to emphasize harm reduction. Youthful problem drinkers usually find their way back to sobriety on their own, but even chronic street alcoholics can benefit from harm reduction. Recent research in JAMA demonstrates that wet housing—places where homeless alcoholics can drink freely—not only protects them from the dangers of the street and reduces frequent hospitalizations, but dramatically reduces their drinking! Yet, despite obvious results, most harm-reduction measures like needle exchange, wet housing and safe-injecting sites are too “controversial” to attract funding from risk-averse politicians It's time to stop and examine the .Liberating our thinking from decades of self-imposed blinders will allow us to become more creative, more compassionate, and ultimately more effective in our treatment of addiction.

4. Treatment is more than providing support for addicts to quit.

For many years, standard psychological treatment, particularly cognitive-behavioral therapy (CBT), has been long overlooked by professionals treating addiction. In fact, many psychologists, social workers, and other  trained professionals have shied away from treating alcoholics and addicts because they are intimidated by the disease label—and by scientific claims that addicts respond differently to human problems and life dilemmas than other individuals.

But when empirically evaluated, standard CBT approaches have proved highly effective in addiction treatment. After examining success rates of a large number o competing therapies, a recent study published in the Journal of Substance Abuse Treatment  identified five therapies that were  most efficient in treating addiction: Cognitive Behavioral Ttreatment (CBT), Community Reinforcement Approach (CRA), Motivational Interviewing (MI), Relapse Prevention and Social-Skills training. In contrast, A.A., disease education, and twelve-step rehab fare very poorly. However, few of these therapies are widely available, largely because, eight decades after its inception, A.A. has been resistant to medical and psychological advances that have occurred in the interim.

It might be possible to meld these techniques with traditional twelve-step treatment, as some rehabs claim to do, but the two approaches are basically incompatible. The behavioral model  of treatment allows patients to determine their own view of success--be it abstinence or moderation. But no 12-step program program allows this kind of self-determination. In fact, people who consider anything but total abstinence are attacked as being in denial or displaying “stinking thinking.” This kind of Harsh judgments of clients, their motivations and their feelings is, of course, not recommended in psychology.

5. Empowerment vs. Powerlessness.

Self-efficacy is a critical component of CBT, which strives to convince people that they have the capabilities and competence to manage their own lives. Any success is attributed to them and reflects back on their self-image; failure helps clients learn how to improve their self-management skills and rebuild their confidence.

The conflict between the twelve-steps model of powerlessness— “turning our wills and our lives over to our Higher Power”—and the emerging treatment strategy of self-empowerment isn't entirely irresolvable. For example, the solidarity and sharing components of A.A. fellowship may support the goal of self-efficacy. But it's worth considering whether salvaging bits and piece of A.A. is worth the trouble. In other words, if building empowerment through evidence-based therapies is the most efficient and realistic method to prevent substance-abuse—as well as to treat people who are already addicted or dependent—why should we cling to the twelve-steps abstinence model and message of surrender? Yes, it's true that many people have been helped by the A.A. approach, but a great many more have not—and there’s a growing recognition, especially among younger people, that for most people,  A.A. simply doesn't work.

So when the NIAAA declares that, “Alcoholism isn’t what it used to be,” what it's really saying, diplomatically, is that we are filling the minds of many addicts and alcoholics with notions that make it much harder for them to recover. Stinking thinking, indeed. Which brings us back to the massive transformation that is taking place in the medical definition of addiction. It is hard for any group of people to recognize the extent to which how they think about themselves, the substances they use, and their other involvements—not to mention the nature of addiction itself— effects the severity of their addiction and their chances for recovery. Coming to terms with this slippery truth will mark an even bigger revolution in addiction theory and treatment in the 21st century.

Stanton Peele is the author of nine books including, Love and Addiction (1975), The Meaning of Addiction (1985/1998), Diseasing of America (1989), The Truth about Addiction and Recovery (with Archie Brodsky and Mary Arnold, 1991), Resisting 12-Step Coercion (with Charles Bufe and Archie Brodsky, 2001), 7 Tools to Beat Addiction (2004) and Addiction-Proof Your Child (2007), as well as 200 professional publications. 

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