The Sober Truth

by Lance Dodes

  In terms of treatment, admitting that one suffers from these character defects is also irrelevant. Of course, the goal of treatment is to understand oneself better, and a candid self-evaluation comes with the territory. But the suggestion that one could ever cure an addiction by trying to be less critical of people, or by gossiping less, or by trying to think positively, is nonsensical. And the implicit message that addicts must catalog their flaws to get better is disrespectful.

  What’s really behind the “character defects” myth is the old idea that to beat addiction, you should try to be a better person. From there it’s a short leap to the inference that addicts are bad people. This notion wends its way through the Big Book in any number of places, and reaches back through time to the Oxford Group and its foundational emphasis on sinning and salvation. It is a moralistic approach designed to engender contrition, compel surrender, and ultimately to rebuild people as better citizens. But it has nothing to do with addiction.

  MYTH #9: ONLY AN ADDICT CAN TREAT AN ADDICT

  This has been one of the most widely believed of AA’s myths and one that continues to do harm. The assumptions behind it are twofold: (1) only an addict can understand and relate to the experience of addiction, and (2) the only counselor an addict will trust is someone who has been through that experience.

  To the extent that any part of this myth has merit, it lies in the second assumption. It may be hard for some people with addictions to place their trust in the hands of someone who has not experienced addiction. This usually has to do with the shame an addict may bring to the therapy: If I feel so terrible about myself, you must feel the same way about me, unless you have the same problem. Of course, personally having an addiction is irrelevant to the ability of therapists, and part of any good therapy is working through mistrustful feelings together and ultimately developing a lasting trust based on compassion, insight, and a shared goal.

  But the first assumption is fundamentally wrong: there is no truth to the notion that one must be an addict to treat an addict. Since addiction is a psychological phenomenon, it stands to reason that the best person to treat an addict would be someone who has trained in psychology. Of course that person might also be an addict, but his or her personal experience is essentially irrelevant. To elevate a personal history of addiction into a credential on its own is to miss out on the manifold benefits of professional training.

  The idea that only an addict can treat an addict has led to the rise of thousands of “addiction counselors” whose only credential is their status as recovering addicts. At minimum, this treatment community does a disservice to addicts by practicing therapy without formal education; at worst, some of these recovering addicts may be seriously unfit to perform this work. A common consequence is counselors who simply repeat the Twelve Steps and recommend whatever worked for them, then express bewilderment and frustration when it doesn’t work for their patients.

  This philosophy appears in the sponsorship model as well, which relies heavily on the notion that someone who has remained abstinent must possess useful wisdom that a newer member can use. But sponsors regularly impart their personal experience, not wisdom gathered from knowledge or a deeper understanding of the problem. And sponsors may eventually succumb to relapse, which is something few professional therapists have to worry about.

  In the end, the myth that only an addict can treat an addict is also an insult. The idea that having an addiction makes people so different from others that only other addicts could possibly understand them is demeaning. Nobody would ever suggest that a doctor must have had cancer to treat cancer, yet in the 12-step model, addiction is accorded this special designation of “otherness.”

  MYTH #10: “THE DEFINITION OF INSANITY IS DOING THE SAME THING OVER AND OVER AND EXPECTING A DIFFERENT RESULT”

  This homily (often apocryphally attributed to Albert Einstein) has found its way into popular culture, but it claims a special place in AA, whose members use it as a cudgel against themselves and each other for drinking when they should know better. Those of us who work in clinical psychiatry could tell you that this isn’t remotely close to the definition of insanity. Doing the same thing over and over again and expecting a different result is, at worst, a symptom of self-deception, or perhaps unfounded hope.

  More to the point, addiction itself isn’t a remotely insane thing to do. Addiction has its own logic and its own purpose, as we’ve seen. And although addicts may engage in deeply destructive behavior, crazy they are not. People with addictions are usually quite aware of the reality and consequences of what they’re doing, including the painful knowledge that it “makes no sense.” They might feel crazy, but once an addict understands the psychology behind his or her behavior, that feeling often gives way to a more empowering sense of personal insight.

  Like so many of the other myths detailed in this chapter, the insanity myth is too often used as a way to diminish addicts and to scold them for their behavior. Like the other AA credos we have examined, this one implies that addiction is a purely conscious choice, that willpower (or turning your will over to an omnipotent Higher Power) is all you need to quit, and that recognizing the irrationality of your behavior should be enough to jar you out of your addictive haze.

  MYTH #11: “DENIAL AIN’T JUST A RIVER IN EGYPT”

  This expression wasn’t coined by AA, but it has been adopted by the recovery community. AA’s literature often mentions denial as one of the key personal defects that lets addicts persist in their behavior. (The fourth edition of the Big Book even has a section called “Crossing the River of Denial,” which begins, “Denial is the most cunning, baffling and powerful part of my disease, the disease of alcoholism.”) It isn’t hard to imagine where this myth came from. It’s based on a genuine phenomenon, namely that people with addictions often deny that, in fact, they have an addiction. But this denial is less about a failure to recognize reality than a natural need to reject the label “addict” and all the baggage that comes with it.

  Recall that reversing helplessness is a core element in the psychology of addiction. Asking an addict to admit that he has an addiction understandably creates strong resistance, because it feels to him like being asked to admit helplessness itself. But when people understand how addiction works psychologically—as a fundamentally healthy drive to feel empowered when it seems like there is no other choice, I have often seen their denial melt away. It turns out that AA’s emphasis on denial is misplaced; denial itself isn’t the problem—it’s shame, coupled with a lack of understanding of the nature of addiction that makes “denial” necessary.

  The denial myth is yet another way that addicts and their loved ones infantilize and insult those who suffer from addiction. It fits all too well with the narrative of addiction as a form of “insanity” performed by people with “character defects,” whose experience is so alien than only a fellow addict can ever save them. These ideas are understandable expressions of frustration recorded by people who look at the seeming illogic of addiction and throw up their hands in exasperation. But they do terrible harm to the very addicts whose recovery depends on understanding themselves without judgment.

  Addiction seems to hold a special place in the American imagination. It is categorized as somehow different and separate from the problems and symptoms we all suffer. Partly as a result of this singular and mysterious strangeness, addiction is treated less like a common psychological symptom and more like a cultural one. In the absence of sophisticated knowledge, platitudes and homilies rush in to fill the void, many of which obscure far more than they illuminate. Folklore and anecdote are elevated to equal standing with data and evidence. Everyone’s an expert, because everyone knows somebody who has been through it. And nothing in this world travels faster than a pithy turn of phrase.

  CHAPTER NINE

  THE FAILURE OF ADDICTION RESEARCH AND DESIGNING THE PERFECT STUDY

  ONE OF THE MOST galling aspects of the current approach to addiction treatment is how little
research is being done to seek better solutions. Despite all the failings of research on 12-step effectiveness, the field has come to a consensus around the idea that 12-step programs are useful and have been sufficiently studied. A review of the most recent three years (2010–2012) of the American Journal on Addictions shows no articles on or about 12-step programs. Two articles about 12-step treatment were published over the same period in the Journal of Substance Abuse Treatment, but neither examined either the effectiveness or mechanism of action of AA. There are, however, a number of papers whose purpose is simply to support 12-step treatment; Christine Timko, for example, published an article in the Journal of Drug and Alcohol Dependence with the stated goal of implementing and evaluating procedures “to help clinicians make effective referrals to 12-step self-help groups.”1

  Addiction research has for years followed the prevailing trade winds in popular science, folding itself into ever smaller cul-de-sacs of genetics and biochemistry. Studies of this kind are easy to fund (because they suggest pharmacological solutions supplied by drug manufacturers) and widely cited, helping to perpetuate the illusion that someday advances in molecular science might reduce complex human behavior to the ingredients in a few synaptic cocktails.

  Alas, these approaches are doomed by their reductive scope and hampered by an issue of expertise. The research is inevitably conducted by biologists who have little or no training in the psychology of human addiction. This is not to say they aren’t competent scientists. We become experts in the things we do; these researchers are without question the world’s foremost experts on the study of rat brains. But to apply a rat-based dopamine study to a deeply intricate problem like human addiction is to neglect the wealth of knowledge and experience we have gained from treating humans.

  The big problem that underlies such half-a-loaf takes on addiction is the absence of psychological awareness in the major addiction journals. This neglect is no accident: views not fitting with the present biochemical paradigm are simply not accepted for publication. (I have witnessed this firsthand as both a reviewer and an author.) What passes for psychological insight in the professional addiction literature are virtually always simple questionnaires that rank people according to superficial traits such as “interest in risky activities.” This absence of sophistication makes it impossible for these journals to recognize or meaningfully engage the psychology behind addictive behavior; there is simply no room for that conversation.

  The other seismic shift in scientific literature that has strangled attempts to treat addiction from a psychological perspective is the injection of numbers into anything and everything that will harbor them. Most people who do good work in education or the humanities know that deeply significant truths cannot be measured. Great teaching, for example, is hard to quantify. Most good, worthy, and verifiable ideas don’t belong in a spreadsheet. Yet as a result of insecurity or ignorance, the majority of scientific publications today won’t even consider a paper that isn’t larded with numbers from top to bottom.

  The consequence of this institutional blindness to qualitative and nuanced thought is that research is typically limited to broad statistical studies that do not investigate causes or meanings. In addiction research, these large population survey studies never once ask any questions about the feelings inside the people they are examining. As a consequence, they are often astonishingly obvious or trivial. Here are just a few recent examples from the major addiction journals:

  “How Do Prescription Opioid Users Differ From Users of Heroin or Other Drugs in Psychopathology?” (Journal of Addiction Medicine)

  This article statistically analyzed over nine thousand survey records (no people were interviewed), concluding the painfully obvious fact that using drugs such as heroin and morphine is correlated with the likelihood of using other drugs, being depressed and anxious, and having a lower “quality of life.”2

  “Health/Functioning Characteristics, Gambling Behaviors, and Gambling-Related Motivations in Adolescents Stratified by Gambling Problem Severity: Findings from a High School Survey” (American Journal on Addictions)

  This article statistically analyzed data from a survey of over twenty-four hundred high school students. Its conclusion was that pathological gambling was associated with poor academic performance, depression, and aggression. The authors said their findings suggested a need for better interventions with adolescents who gamble.3

  “What Is Recovery? A Working Definition from the Betty Ford Institute” (Journal of Substance Abuse Treatment)

  This article states that it fills the (presumed) need for a standard definition of the word recovery. It solves this problem as follows: “Recovery is a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.” Incredibly, this paper is listed as among the five “most cited” references for the entire Journal of Substance Abuse Treatment.4

  “Effect of Alcohol References in Music on Alcohol Consumption in Public Drinking Places” (American Journal on Addictions)

  This paper describes a study designed to test “whether textual references to alcohol in music played in bars lead to higher revenues of alcoholic beverages.” The results were that “customers who were exposed to music with textual references to alcohol spent significantly more on alcoholic drinks.” Mind you, this article didn’t appear in a hospitality trade publication presumably because marketing people could have told you this already.5

  “Psychosocial Stress and Its Relationship to Gambling Urges in Individuals with Pathological Gambling” (American Journal on Addictions)

  The title of this paper gives promise that the study will employ some psychological sophistication. Alas, its conclusion puts such hopes to rest: “Patients with PG [pathological, or compulsive, gambling] displayed significantly higher scores on the daily stress inventory . . . than did healthy subjects. These findings support the role of psychosocial stress in the course of PG.”6 There is no mention of how this stress functions, why it drives addiction, or any aspect of human psychology that might help to explain and deepen the paper’s obvious conclusion.

  What’s missing from this literature is any study that revisits the fundamental questions once and for all: What is addiction? How should we treat it? Why does it occur in some individuals and not others?

  I mentioned earlier that in the 1990s, one attempt at such a study was conducted by the National Institute on Alcohol Abuse and Alcoholism. But the study, called “Project MATCH,” was severely limited in many ways. Most significantly, it looked at only three approaches: cognitive behavior therapy, “motivational enhancement” therapy, and 12-step treatment. It concluded that no difference in outcomes could be found among these. There was no control group and no psychodynamic group. Given the study’s design, it is not surprising that the results were so disappointing, and that serious questions have been raised about whether any of these treatments were effective at all.7

  What would it take to answer the question of how we should treat addiction? A definitive addiction study could potentially be designed, funded, and executed. A study of this kind would provide a blueprint for research panels at the NIH and universities and give lay readers a far better way to interpret the headlines that constantly trumpet yet another breakthrough about addiction. Most importantly, a truly meaningful study would be long enough to measure true growth and change, versus the prevailing short-term glances at transient benefits. Before discussing how such a study could be created, I must first address some key issues that have interfered with proper acceptance of serious psychological research in the addiction literature.

  THE MIRAGE OF “EVIDENCE-BASED” SCIENCE

  One of the impediments to including psychological understanding in addiction research is the wildly popular idea that only “evidence-based” treatment is worthwhile. It is useful to examine whether this idea has merit.

  Most people with a scientific bent would agree that science is based on evidence. Without strong supporting corroboration,
we would have no way to distinguish between a gut feeling and a solid result, and no way to separate personal bias from objective fact. But the value of evidence depends entirely on whether the data is meaningful—whether it is valid (bears on the topic) and important. No field, from the hardest statistical science to the “softest” sociology, is immune to abuses of the word “evidence”; some just do a better job of hiding their foundational biases than others. As we have seen, the use of “evidence” in addiction studies is no guarantee that the numbers will be treated without bias or even that they represent anything useful. As we have also seen, the majority of addiction studies covering 12-step treatment fail to pass basic threshold standards of experimental control and causal inference. Yet these flawed methodologies are not always apparent to the lay reviewer, and the press hardly helps matters with its ongoing confusion between controlled science and meaningless correlations. As a consequence, much of what we are sold under the billing of evidence is simply data. And data without context is noise.

  Consider just a few of the problems in widely cited articles on addiction (noted in chapter 5): compliance bias, lack of controls, inadequate length of study, ignoring data that would interfere with the study’s conclusions (dropout data, for instance), statistically dubious extrapolations, logically unfounded leaps from rats to people, and a number of advanced statistical regression methods designed to retroactively account for all of these (though these methods have had only mixed success—biostatisticians would be the first to admit that even the most sophisticated tricks of the field cannot “fix” a study that isn’t designed thoughtfully from the beginning).