Questioning the 12-Step Orthodoxy

By Stanton Peele 03/24/15

Six myths about the disease model of addiction refuted.


Gabrielle Glaser has written a piece for The Atlantic, “The Irrationality of Alcoholics Anonymous,” criticizing AA and the 12 steps in terms of their measurable impact and asking whether other options (SMART Recovery, CBT, etc.) are better, or should at least be presented equally with AA. 

An answer to Glaser in New York magazine, “Why Alcoholics Anonymous Works,” by Jesse Singal, reveals that the Cochrane Collaboration, which had previously found 12-step treatment ineffective, is preparing a new review this fall that will reverse this opinion based on results measured with TSF (twelve-step facilitation) interventions. 

TSF treatments are not widely heralded. In fact, Singal makes TSFs sound sketchy: “They’re generally oriented toward preparing participants for the (potentially weird-seeming, especially at first) culture and philosophy of 12-step programs like AA.” Why prepare people for a therapy that doesn’t make sense to them?

In addition, as reported by Singal, outcomes for the Cochrane review are measured strictly in terms of abstinence. This seems impossible at this point in history, when harm reduction has become the guiding principle for policy—although American treatment has yet to catch up with this development. If the success of our policies and treatments are assessed strictly in terms of our ability to get people to quit all substance use permanently, we might as well give up. According to the latest national survey, fewer than one in five of those classified as alcohol dependent finally quit drinking altogether.

But I’m not so concerned with these dueling assertions about AA/12-step effectiveness. And neither, so it seems, is the world. What I mean is that, as the appearance of Glaser’s article in such a prominent place indicates, the emperor’s clothes are being carefully examined and found to be less than claimed. As a result AA—which is built on an all-in or all-out model—will never be the same in the U.S.

When I began questioning AA and the 12 steps 35 years ago, referencing research counter-indicating the major elements in the 12-step approach (i.e., that alcoholism is a disease and it requires total abstinence), all hell broke loose. To challenge AA was to risk one’s career, as the Sobells and others (including me) discovered. And I have continued to attack the disease theory in prestigious academic publications, albeit with little overall impact on public consciousness.

Flash forward to the present. Recently, AA’s sacrosanct image has been muddied; its underpinnings are being scrutinized. Now, there is no turning back. AA’s influence has already been waning somewhat in the U.S., since it could hardly continue the complete hegemony over the field it has enjoyed (although it is still growing worldwide).  

Despite the only incremental decline in AA’s influence to date, the possibility that AA will ultimately be eclipsed is inevitable. People typically speak of the need to accept AA’s pre-eminence in America and to integrate the disease theory with modern psychology and neuroscience along the lines outlined by Nora Volkow. But it is impossible to reconcile the disease theory with what we know from a half-century of research underlying cognitive behavioral therapy.  

This basic psychological research, along with humanistic philosophy, tells us that self-efficacy is the essential element in change—indeed, to being human. The following are six myths about addiction that contradict what we know about human behavior and change, all foisted on us by AA and the 12 steps, which Ilse Thompson and I refuted in our book, Recover! Stop Thinking Like an Addict:

1. Addicts are different from normal people and can never be like them. It is true that some people regularly drink and use substances compulsively, at least for a period in their lives. But this is not true of the majority of people who experience addiction problems.

Moreover, regarding others—or oneself—as fundamentally different is a burden, an unnecessary identity that is as damaging as a negative drug or alcohol habit. This identity does nothing so much as to guarantee that you will continue to behave in this guise. As we say in Recover!, “it can be as hard for you to remove your addictive thinking and identity as it is to rid yourself of the addictive behavior—harder.” And, yet, “above all, you should realize, addiction is not a core identity any more than a flabby thigh or a crooked nose. They are all superficial characteristics, not foundations on which to build your identity.”

2. Hitting bottom is necessary in order to change. A primary concept, oft repeated, is that addicts are only able to recover once they have hit bottom. Obviously, people quit at all stages of addiction. And who can determine rock bottom, anyway? Like an addict identity, this concept is harmful. As we noted in Recover!:

"Aside from exposing it as logical nonsense, we believe it is even more important to reject this crazy notion of hitting bottom on the grounds that it is irresponsible and dangerous. If you believe that you must hit bottom before you can recover, then you have to pursue the scorched earth policy of self-destruction that can be fully demonstrated only by bankruptcy, homelessness, communicable diseases, driving accidents, rape, prostitution, prison, brain or liver damage. . . In fact, when you think about it, unless you are dead, things can always get worse."

We can take from an infinite number of examples in the case of George W. Bush: "I wasn't a knee-walkin' drunk," the former president told Matt Lauer in an interview promoting his memoir, Decision Points. "I could easily have a beer or two, or a martini, before dinner." 

What made Bush quit drinking at age 40? Some loose talk at a dinner party embarrassed him in front of his family, an experience he refused to tolerate. And, so, for a Bush, looking foolish in your parents’ eyes was hitting bottom. This is just one illustration of the steeped personal meaning in a person’s decision to quit (or to cut back) an addiction. (Bush may have sanitized his motivations to quit: “Laura Bush’s famous ultimatum to her husband, ‘either Jim Beam or me,’ is often cited as the turning point when George W. Bush went from the spoiled and heavy-drinking scion of a famous political family to the self-made man who would ascend to the presidency.“ But he still wasn’t a staggering, fall-down alcoholic.)

Bush never entered AA or a rehab. But one person who was in-and-out of rehab and participated in AA for much of her life was George McGovern’s daughter, Terry. Yet, at age 45, she hit the ultimate rock bottom, freezing to death in the streets of Madison, WI after leaving a halfway house. About her death, father George—who was convinced, like his daughter, that she had a lifelong disease—said, "She knew what makes a good person. She knew what compassion was about. She knew what it meant to love other people. But she fell short of loving herself."

3. Recovery is bestowed by a force outside yourself. When addiction is seen to be a disease, something that clearly cannot be treated from within, you must turn yourself over to recovering addicts and alcoholics and addiction experts—and, most famously, to a “Power greater than ourselves,” in order to become whole again. What a pernicious, anti-humanistic idea! From this perspective, any efforts you make for yourself prove that you are foolish, stupid. Is there any more denigrating statement in the addiction field than, “Your own best thinking got you here?" Where but in a 12-step room or support site would this mantra be considered therapeutic or helpful? 

4. Addicts are powerless and cannot control themselves. When laws were passed forbidding smoking in work places, bars, and restaurants, a hue and cry was raised: “But smokers are addicted—how can they control or restrain their urge to smoke?” What a quaint way of thinking, everyone now recognizes. People do what they have to do (or at least 95 % of them) to live their lives, keep their jobs, avoid being arrested, and not get thrown out of their homes by their non-smoking spouses. To accomplish this, they bide their time until it is possible and appropriate to go outside to smoke. That is, unless they have been convinced that they are powerless, which is where the crazy idea that smoking regulations were doomed came from in the first place. And no addiction is harder to regulate than smoking, with its instant, easy direct access to the lungs, bloodstream, and brain.

5. Addiction is always an incurable, progressive, fatal disease. Here’s an exercise I do—last month in San Francisco at the International Cannabis Business Conference. I asked, “What is the hardest addiction to quit?” The audience—many of which I reckon have experienced a number of forms of addiction—shouted in unison, “Smoking!” “Oh,” I said, “How many of you have quit smoking?” In a group of 750 people, perhaps 400 raised their hands. “How many of you,” I continued, “relied on a therapy, medical or otherwise, or a support group to quit?” Two or three people raised their hands.

Now came the hard idea to convince people of: “A smaller percentage of smokers—only perhaps half—have quit smoking mostly on their own than have those addicted to alcohol, heroin, cocaine, meth, and crack. The figures for those drugs are around three-quarters.” The data for this assertion is now abundantly clear. It comes from three major national surveys of mental health and drug use, as analyzed here by Gene Heyman, and here by researchers at the National Institute of Alcohol Abuse and Alcoholism.

6. Recovery is a lifetime process that must include lifetime abstinence and 12-step work forever. According to 12-step recovery, you are as likely to relapse 25 years after quitting your drug of choice as two hours afterwards. And, among the many strange messages AA prides itself on, this is perhaps the strangest: “While you are here (meaning a 12-step meeting) your addiction is in the parking lot doing push-ups.” Why is this message drummed home, even while you are supposedly undergoing the therapeutic process of leaving your addiction behind? Because AA, 12-step rehab, and addiction medicine want to convince you that you can’t survive without them. The disease theory is all about how addicts are never free—even after they stop drinking and using.

And, should you slip and use again, even once, after 25 years, you are back to step one, day one of your recovery. There is no more pernicious, disempowering, untrue—yet at the same time self-fulfilling—idea in the recovery lexicon.

So, then, what is wrong with the disease model of alcoholism and addiction? Aside, that is, from its primary tenets being contrary to fact and discouraging of recovery? That it conveys a vision of human beings—those addicted temporarily (for example, the 90%+ of Vietnam vet heroin addicts who quit their addictions at home), or long-term (like street inebriates who are able to cut their drinking substantially when provided with secure housing where they may drink)—as hopeless victims. And, yet, every detailed study of people who actually experience addiction shows this degrading pessimism is not true—as did Heyman’s finding through three national surveys that people can quit addictions at every stage of their habit and after any length of time being addicted.

As Ilse and I say in Recover!:  

"Isn’t it better to start from the belief that you—or your spouse, or your child—can fully and finally break out of addictive habits by redirecting your life and thinking? It may not be quick and easy to accomplish, but it happens all the time. In this book we show you how, including particularly mindfulness exercises and meditation."

And the only thing that can reverse this truth about our human potential is the continuing ascendance of the view that addiction is a disease, which is now beginning to be reversed in the case of the 12 steps in the U.S., although it is still growing through our unthinking allegiance to addiction neuroscience’s warmed-over, thoroughly disproven claims. What worse endeavor could scientists conceive than to convince people that they are unable to halt or change their self-destructive behavior—even as so many people have done, and continue to do, throughout history?

The inappropriateness and destructiveness of the disease theory of addiction applies not only to those who fail at it, like Terry McGovern and so many others—many more than a majority, even according to those who support AA and the 12 steps. The disease view, by pervading the consciousness of our culture, makes it more likely that people will succumb to addiction as an overpowering disease in the first place. And, finally—and perhaps seemingly stranger—the disease theory can be most malicious for people who feel it has “saved” them. For most of these people would have overcome or outgrown their addictions on their own or with the help of sensible, time-limited treatment, as this woman did. But, instead, many are now stalled in an addict identity ad infinitum.

Stanton Peele last wrote about how the legalization of drugs challenged the brain disease theory and the link between the disease model and the War on Drugs.

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