Sobriety, Addiction Treatment, and Secular Exclusion (Part Two)
Let’s start with my second point, that AA (which I will focus on as a case study rather than try to individually address all 12-step programs) just doesn’t work. I want to begin here because I know that this claim will strike some people as hard to believe, given AA’s supremacy on the substance abuse treatment scene, and the longevity of its reign. I’ll start by saying this: When I say that AA “just doesn’t work,” I do not mean that it has never worked. It has worked for many people, full stop. What I do mean when I say it “just doesn’t work” is that it does not have nearly the success rate that you would expect from a program that presumably specializes in helping individuals to achieve sobriety.
How do I know this?
In recent years (very recent years, as a lot of this research has come out since I quit drinking), there has been an increased amount of attention paid to the efficacy of 12-step programs in treating addiction. This research can be quite difficult due to the anonymous nature of most 12-step programs. What we do know is that Alcoholics Anonymous ( otherwise known as “The Big Book” ), AA’s primary guidance tool for helping individuals achieve sobriety, states in the forward to the second edition that 50 percent of individuals who join AA achieve sobriety “at once” and 25 percent more struggle at first but eventually achieve sobriety. According to this document, 75 percent of those who “really tried” found the AA 12-step method to be effective long term.
Sounds pretty good, right?
There are two problems to note here. First, there is no information provided to indicate where AA actually gets these numbers. Second, and far more problematic, AA is only reporting numbers for those considered to be “really trying.” Individuals who are “really trying,” by AA’s programmatic definition, means individuals who are attending meetings, staying in contact with their sponsor, and abstaining from alcohol. If you stop attending meetings, fall out of contact with your sponsor, or start drinking, AA considers you to have left the program, thus not “really trying.” This means they do not take your outcome into consideration when self-reporting their success rates. Put more simply, a program that claims to help people achieve sobriety excludes from its self-reported success rate individuals who fail to achieve sobriety. Which seems to me to be… well… kind of missing the point?
This is a problem beyond just AA’s self-reported numbers. A series of academic studies that have purported to demonstrate the effectiveness of AA’s treatment model have come under scrutiny in recent years for not including in their final reporting the outcomes of patients who started drinking and stopped responding to their surveys. For a famous example of these analyses, see this comparison of treatment outcomes for problem drinkers seeking help.
So what is the real success rate of AA?
Lance Dodes, the Harvard addictions researcher I quoted earlier, wrote a book along with his son Zachary entitled The Sober Truth , in which they studied the 12-step program industry . According to the Dodes’ research, the actual long-term success rate of AA, taking into account relapses and dropouts, is somewhere between 5 to 9 percent. While such a percent recovery rate is certainly well below the 50 to 75 percent self-reported rate that AA publishes, it is also nothing to scoff at.
It is worth taking a moment, however, to put this into perspective. One study that Dodes cites in his research places the rate of “spontaneous remission” of alcohol abuse disorder (i.e., cessation of alcohol-related substance abuse without any intervention at all) between 3.7 and 7.4 percent. Another study places the success rate between 4 and 18 percent. The fact that AA’s actual success rate is well within the measured range of individuals achieving sobriety without any treatment at all is, needless to say, not encouraging.
What makes this even more troubling, given the lack of evidence for efficacy, is AA’s popularity with the U.S. criminal justice system as a referral for those struggling with addiction. AA reports that they have somewhere in the neighborhood of 1.5 million active members in the U.S. alone. From public records, we know that around 12 percent of all AA participants in the U.S. are court ordered. This means that at any given time, over 150,000 individuals in the U.S. are attending AA as a requirement of their parole/probation, with little evidence that this will ultimately lead to a recovery from addiction.
(It should be noted that several court cases have challenged the constitutionality of requiring AA/NA attendance as part of a plea/parole/probation mandate on First Amendment grounds, arguing that AA is sufficiently religious to qualify as a violation of an individual’s rights. For an example of this see the case of Barry Hazle Jr . )
The Moralizing of Addiction
Another major problem with the AA 12-step model is the moralizing of addiction. According to AA’s 12-step guide to recovery, addiction isn’t a medical or psychological issue, but rather it is a moral defect. AA’s steps 4 through 7:
4. Made a searching and fearless moral inventory of ourselves
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs
6. Were entirely ready to have God remove all these defects of character
7. Humbly asked Him to remove our shortcomings
(The capital H in “Him” is not a typo. It appears in the literature. More on that later.)
Additionally, the very first paragraph of chapter 5 of The Big Book contains this rather ignominious quote: “Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty.”
This quote demonstrates exactly what I mean when I talk about the moralization of addiction within 12-step programs. If you “fail,” with failure being defined narrowly as encompassing essentially anything other than complete and permanent abstinence, it is not thought to be because you simply made a mistake while trying to beat one hell of a disease. It is certainly not thought to be because the program itself is flawed. This failure is thought to be because you are “constitutionally incapable of being honest” with yourself. Not only is this false, but it is counter-productive to effective recovery. Nearly EVERYONE stumbles at some point in their road to sobriety.
The problem with our societal tendency to view addiction as a moral failing rather than a treatable psychological or medical condition extends beyond the unfortunate overlooking or non-use of empirically supported treatments like therapy or medication. This moralized view of addiction is so prevalent in the U.S. that, according to the Center on Addiction and Substance Abuse at Columbia University (CASA), American medical professionals routinely fail to diagnose alcoholism as a potential cause for a given set of symptoms common to alcohol dependency.
In a survey conducted by CASA , the authors noted that “94% of primary care physicians (excluding pediatricians) failed to identify addiction as a possible diagnosis when asked to offer five possible diagnoses of a patient with symptoms of risky alcohol use.” Viewing addiction/alcoholism as a moral failing is so persistent in the U.S. that even medical professionals may be less likely to consider alcohol dependency as a medical diagnosis, and thus many doctors are potentially misdiagnosing and mistreating patients suffering from addiction.
Perhaps not surprisingly, given the incredibly low diagnostic rates among American doctors, a shockingly low percentage of the overall referrals for addictions treatment in the U.S. come from healthcare providers. The CASA study mentioned above found that only 5.7 percent of all referrals to publicly funded addiction treatment programs in the U.S. came from healthcare providers.
Accentuating the point, in this same study the single largest source of referrals for individuals to publicly funded substance abuse treatment programs came from the criminal justice system, which accounted for nearly half of all referrals and significantly more than community resources, addiction treatment providers, healthcare providers, schools and employers combined.
Consider the implications of this, both for addicts and for those tasked with treating addiction. Addicts are often being forced to seek treatment, which is not conducive to recovery, and the treatment counsellors are often first encountering their clients in an adversarial setting. Yikes…
The Exclusion of Secular Individuals
Before I knew anything about the inefficacy of the 12-step model, I already knew that AA was not for me. This wasn’t because I didn’t take sobriety seriously. I absolutely did and still do. Rather, many of the steps already struck me as excluding non-secular individuals like me, an atheist.
Over half of the 12 steps directly implicate God or a higher power. Reading on, in Chapter 6 of Alcoholics Anonymous , during a discussion of how to approach those that one may have harmed during the course of their addiction, there is this not so subtle hint that AA might not be for secular folks.
To some people we need not, and probably should not, emphasize the spiritual feature on our first approach. We might prejudice them. At the moment we are trying to put our lives in order. But this is not an end in itself. Our real purpose is to fit ourselves to be of maximum service to God and the people around us.
My decision to quit drinking had nothing to do with fitting myself to be of maximum service to God, turning my life over to a power greater than myself, or believing that I needed any external intervention in order to “restore me to sanity.” Instead, sobriety was about reestablishing control over my life and proving to myself that I had the strength and the willpower to improve on my own. The very idea of turning my will and my life over to “the care of God” ran entirely contrary to what sobriety represented in my mind, not just from a spiritual perspective (or lack thereof), but from a philosophical approach as well.
In the interest of fairness, I should mention that there are thriving agnostic AA groups throughout the world. (See, for example, here and here .) As with the melding of any two beliefs or philosophies, it is possible to adapt one’s own approach to an overarching philosophy in such a way that no contradiction is to be found, just like it is similarly possible to accept that you are operating within a contradiction and go on functioning in spite of that. There is nothing inherently wrong with this (in fact, we all likely do it without realizing it). If creating a secular version of AA helps some agnostics manage their life, I am all for it. I would never tell someone in recovery they are doing it wrong, just because I happen to find that their approach doesn’t work for me.
While it is undeniable that AA is rooted in Christianity — as was the Oxford Group , which both of AA’s founders belonged to prior to forming AA — it is noteworthy that ” as they understand Him” is a core part of the original 12 steps. While the capitalization of H, as I’ve noted above, leaves a not-so-subtle clue about the Christian roots AA is founded upon (Christians always capitalize the H in “Him” or “His” when talking about God), not all participants choose to read this passage as overtly Christian or even spiritual, and thus non-Christians are still able to follow the steps in a way that makes sense to them.
AA members will tell you that even if you are secular you are just as welcome as anyone else, and my experience has led me to believe that this is absolutely true. I’ve never met someone from AA or any other 12-step program who even hinted that my atheism would preclude me from involvement in their group. Even so, the language itself is so fundamentally at odds with my worldview that I have simply never found it useful to try and manage my recovery from within this philosophical structure. I now go into conversations about 12-step programs fully prepared to discuss the information that I know about the efficacy of this method, if the situation calls for it, while simultaneously being sincerely ready to tell anyone that if they think a 12-step program is what they need in order to get their life in order that I hope they do it. This, however, brings me to my final point.
The Implications of Failure
Because of the legacy of 12-step programs, there is often an all-or-nothing approach to recovery. Once you are an alcoholic you are always an alcoholic, and you either abstain from alcohol completely or you are still an active addict. I know this is true because I find that I have internalized it myself, even though I think it is a load of garbage. Due to the history of moralizing addiction, where any slip-up in recovery is treated as a moral failure and an abandonment of treatment altogether, we continue to believe that once someone has demonstrated that they are unable to handle alcohol for even a short period of their life that this necessarily means that they are permanently damaged and will never be able to drink responsibly again.
While it seems to be true that some people are genetically predisposed to a lack of impulse control which can contribute to addiction, and some may metabolize alcohol differently from others putting them at increased risk of abuse, it is also true that many (perhaps most) people who may go through a period of time where they struggle with unhealthy levels of drinking do not fall into these risk categories. With more empirically rooted approaches to treating addiction/alcoholism, for instance, it is common that addicts work with their doctor or therapist to set their own goals for managing their addiction. For some this may mean voluntary long-term/permanent abstinence, while for others this can just mean taking some time to change their patterns of behavior or addressing underlying triggers, then returning to drinking in moderation at safe levels.
Many factors such as stressful personal circumstances, social groups/habits, geographical isolation, or even simultaneously occurring mental health issues affect a person’s desire to drink, especially in excess. If, for example, someone has gone through their life drinking in moderation at safe levels, but then a divorce serves as a trigger that results in them self-medicating their anxiety/depression for a period of time (even a prolonged period of time), it is not necessarily the case that when this individual’s period of personal turmoil has passed that they would suddenly be incapable of returning to the safe level of alcohol consumption that they had previously maintained throughout their life. With the all-or-nothing 12-step approach, though, individuals are convinced that if they have struggled with alcoholism for any period of time during their life, they are therefore damaged and defective, lack control over their own life, are reliant upon a higher power in order to maintain sobriety, and should consider themselves to be an active alcoholic for the rest of their life.
Personally, I think that this approach is bogus and that it flies in the face of just about everything that we know about human nature. I think that people ARE capable of change and I think that just because you made a mistake (or even a series of them) during one point in your life does not mean that you are doomed to repeat it ad infinitum. BUT , I still don’t drink.
I think I probably could, but I have thus far chosen not to. I’ve made this decision because I saw just how badly my life can go when I over-indulge. I’ve decided that the benefits of drinking (occasional fun, ease of social interaction, the taste of whisky… because yum!) are far outweighed by even a slight chance that I return to my previous unhealthy level of consumption. I’m hyper-aware, though, that this fear that I’m only one slip up away from returning to alcoholism is, at least in part, based on the internalized terror that I have had pounded into my head for years: Once you are an alcoholic you are always an alcoholic. To individuals who were raised in the church and have gone through the often painful process of de-conversion, this internalized guilt, fear, and self-doubt will sound quite familiar.
When I quit drinking, I spent the first several nights staying at my mother’s house, in order to change my routine and have someone to talk to. I went to a doctor in order to determine how much damage I had done to myself physically. After talking to my doctor, I was given two options. The first was a very expensive in-patient facility that rehabreviews.com reports costs on average $16,800 for a 14-day stay. The second was to attend a free 12-step program that would take place entirely separate from medical/psychological supervision. I was uninsured at the time and certainly could not afford $16,800 for two weeks of treatment. I went with the 12-step program. However, put off by the innate spirituality, and deeply concerned by the obvious lack of expertise present in my group, I soon made the decision to leave this program as well and pursue my sobriety entirely on my own.
The lack of expertise in 12-step programs is a real problem. According to an April 2015 article in The Atlantic , there is no mandatory national certification exam for addiction counselors (in the U.S.). The 2012 Columbia University report on addiction medicine found that only six states required alcohol- and substance-abuse counsellors to have at least a bachelor’s degree and that only one state, Vermont, required a master’s degree. Fourteen states had no license requirements whatsoever — not even a GED or an introductory training course was necessary — and yet counsellors are often called on by the judicial system and medical boards to give expert opinions on their clients’ prospects for recovery.
For some perspective on this lack of a licensing requirement, in the U.S. all 50 states currently require training and licensing in order to be certified as a cosmetologist. Now, please do not interpret this as me denigrating cosmetologists. I am not. I am glad that individuals whose profession includes the application of potentially harmful chemicals onto the skin of their fellow citizens are required to have training and be licensed. I simply wish that the U.S. had at least the same standard for individuals who are going to be responsible for their client’s recovery from a deadly disease.
The entire 12-step model, sometimes referred to as the “mutual support model,” is predicated upon surrounding yourself with fellow addicts who have been through the same thing. While this support system is undeniably useful and has its place in recovery, it should be seen as a supplement to treatment rather than being conflated with treatment itself. Imagine if we treated any other mental health or medical problem this way. Imagine an individual struggling with suicidal thoughts working up the courage to go to a hospital and ask for help, but instead of being admitted and referred to a mental health professional they were just given a physical, discharged, and told to go to the basement of the local Methodist church every Monday and Thursday so that they could have coffee and donuts with a room full of other suicidal people, none of whom have any training or mental health credentials. We would justifiably be incensed if this were happening.
Twelve-step programs are to substance abuse treatment what abstinence-only curricula are to sex education. That is the level of empiricism and regressiveness that we are talking about. If you know someone who is struggling with addiction, particularly if they are struggling alone, be there for them. Secular support systems are few and far between, and I know all too well how hard it is to try to recover alone. But, also, if you know someone going through this, help them begin looking into more foundationally empirical addiction treatment programs. Programs like this do exist, and there are ways to get help with costs. By being there for someone struggling with addiction you might literally be saving their life.
You may now return to your regularly scheduled guilt-free cocktail.
(Check out CFIC’s previous takes on 12-step programs here and here .)
This article appears in the December 2019 version of Critical Links.