Interior States

by Meghan O'Gieblyn

  The whole idea made Jean uncomfortable. How did people get better by recounting the worst moments of their lives to strangers? Still, she went. Each member’s story seemed worse than the last: One man had crashed his car into a telephone pole. Another described his abusive blackouts. One woman carried the guilt of having a child with fetal alcohol syndrome. “Everybody talked about their ‘alcoholic brain’ and how their ‘disease’ made them act,” Jean told me. She couldn’t relate. She didn’t believe her affection for pinot noir was a disease, and she bristled at the lines people read from the Big Book: “We thought we could find a softer, easier way,” they recited. “But we could not.” Surely, Jean thought, modern medicine had to offer a more current form of help.

  Much of AA’s philosophy is built on the principle of “identification”—seeing yourself in the stories of others—with newcomers like Jean being encouraged to “look for the similarities.” But according to Glaser, identification is precisely the problem. One of her favorite ways to criticize AA is to refer to its “one-size-fits-all” approach. Evidence-based treatment, in her view, should treat each alcoholic as a unique case, helping her discover the cause of her own drinking and developing customized recovery goals, whether the aim is abstinence or moderation. And it is this mode of treatment that distinguishes Your Empowering Solutions (YES), a treatment center on the Palos Verdes Peninsula, California, for which Glaser reserves her most ebullient praise.

  The chapter on YES, entitled “Twenty-First-Century Treatment,” follows the story of Joanna, a mezzo-soprano who enrolls at a time when she has been drinking roughly three liters of chardonnay a day. Joanna is immediately impressed by the “bright, modern office,” the friendly staff, and the positive vibes (“even the magazines were upbeat”). She’s given a personalized therapy regime, which consists mostly of discussing her life goals with her psychiatrists—a technique called “motivational interviewing”—though she also takes a lot of long walks on the beach, listens to meditation CDs, and eats big salads at local cafés with her two psychiatrists. “There was no dining hall, no other patients she had to make small talk with: just Joanna and her two shrinks.” During her treatment, Joanna comes to a series of realizations, including the epiphany that drinking is preventing her from using her leisure time efficiently. “In addition to adding more exercise and eating better, she wanted to finish decorating her master bedroom, organize her belongings better, and hang pictures that had been sidelined next to the wall for years.” She leaves the center at the end of the week with a customized treatment plan and a prescription for naltrexone, an opioid antagonist Glaser claims can help alcoholics drink in moderation. “As she returned to Pennsylvania, she felt armed with knowledge—about herself, her personal development, and the vision she had for her life.”

  The reader is left to wonder why a woman who decided to spend $10,000 on addiction treatment needed a doctor to help her realize drinking was interfering with her life. But Glaser’s case studies are rife with simplistic moments of revelation. Many of the women she writes about find help via online recovery programs that rely on cost-benefit analysis to show users how their drinking is irrational. Fully autonomous and empowered by data, these women rigorously check their stats and make adjustments accordingly, sometimes aided by doctors who are less figures of medical authority than hired number crunchers or benign spirit guides, facilitating their personal journey. When Jean, the floral designer, returns to the bottle, Glaser proudly notes that her doctor “calls this ‘research,’ not ‘a relapse.’ ” (Members of twelve-step programs also refer to relapses as “doing more research,” though the tone is notably less sunny: “I saw Bob’s car outside the liquor store this morning. Guess he went out to do some more research.”)

  If addicts are engaging in behavior that is detrimental to their interests, Glaser insists, it must be because they lack the information or insight to make educated choices. The same conviction lies behind a spate of new mobile apps for addicts—programs like recoveryBox, a toolset that enables users to track their behaviors each day, rating their anxiety and depression levels and categorizing each action as either “green” (taking medication, exercising), “yellow” (engaging with triggers), or “red” (relapse). Based on these self-reported actions, the application will alert the user when he or she is entering a risk zone. “Breaking habits requires knowing why we do what we do, when do we do it and coming up with goals to break unhealthy behaviors,” reads recoveryBox’s website. A similar assumption underlies A-CHESS, a smartphone app for alcoholics that can track when the user is nearing a bar or tavern and alert their counselor. The app is said to reduce the risk of relapse by offering reminders that “encourage adherence to therapeutic goals” and providing users with “individualized addiction-related educational material.”

  For all the bluster about modern science, though, such approaches to addiction are far from original. Throughout early American history, alcoholics were exhorted to overcome addiction through willpower and sedulous self-monitoring. In fact, the charts and cost-benefit analyses Glaser recommends resemble nothing so much as puritan temperance tracts. These pamphlets, which bore titles like “Practical Facts for Practical People,” sought to reform addicts with ample doses of logos, arguing that drunkenness interfered with one’s health and productivity. Some, like “The Cost of Beer,” laid out the economic costs of drinking in precise dollar amounts, demonstrating that drunkenness was inefficient. These pamphlets and lectures amounted to little more than pep talks, but they were girded with the authority of science. Preachers peppered their sermons with quotes from scientists and doctors, and one of the leading early temperance organizations was called the Scientific Temperance Federation of Boston. The idea was that if people were informed about the costs of their bad decisions, then they would have no choice but to turn their lives around. It was precisely the failure of such methods that caused addicts to gravitate toward mutual aid societies like AA in the first place.

  * * *

  —

  The promise of self-mastery has long occupied the American imagination. In “The Way to Wealth,” a collection of maxims eventually added to his bestselling Autobiography, Benjamin Franklin offered rigorous self-scrutiny as a method for curtailing vice and achieving commercial success. A century later the transcendentalists, led by Emerson and Thoreau, would privilege the virtues of “self-reliance” over ties to any community, tradition, or institutional authority. (“Trust thyself,” boomed Emerson: “every heart vibrates to that iron string.”) Closer to the time of AA’s founding, the American individualist creed had trickled down into the works of popular self-help gurus like William Walker Atkinson, whose 1906 book Thought Vibration held that “every man has, potentially, a strong Will, and…all he has to do is to train his mind to make use of it.”

  It is no accident that Alcoholics Anonymous originated during the 1930s, at a time when the deprivations of the Great Depression caused Americans to question many of their long-held assumptions about such matters. The sociologist Robin Room has noted that the program’s philosophy deeply resonated with the generation of men whose motto “I am the master of my fate, / I am the captain of my soul” had failed to protect them from economic calamity. AA’s founder, Bill Wilson, was a stockbroker whose personal nadir coincided with the crash of the market, and in his autobiographical writings he often conflated the failure of this national ideology with his inability to master his own drinking. “A morning paper told me the market had gone to hell again,” he wrote of a relapse in 1932. “Well, so had I.”

  Shortly after his spiritual transformation, Wilson read William James’s The Varieties of Religious Experience, a book that offered a humble alternative to the prevailing ethos of self-determination. James believed that American life was marked by “over-tension,” a vestige of the Protestant work ethic. “Official moralists advise us never to relax our strenuousness,” he writes. “ ‘Be vigilant, day and night,’
they adjure us; ‘hold your passive tendencies in check; shrink from no effort; keep your will like a bow always bent.’ ” For James, this obsessive self-monitoring leads to an impasse of the will, a continuous battle between the spirit and the flesh. It was not modern science but rather ancient religion that provided James with the imagery he would use to describe these warring desires. He found in the works of spiritual writers repeated examples of the condition he called “the divided self.” The words of the apostle Paul were emblematic: “I do not understand my own actions. For I do not do what I want, but I do the very thing I hate.”

  James believed that for individuals who were enslaved by such a condition, no amount of rationalizing could help: “Peace cannot be reached by the simple addition of pluses and elimination of minuses from life.” The divided self, he argued, could be made whole only through an anti-moralistic method, a process of surrender that reoriented the attention onto an external objective, thereby transcending the old, rigid patterns of thinking:

  Give up the feeling of responsibility, let go your hold, resign the care of your destiny to higher powers, be genuinely indifferent as to what becomes of it all, and you will find not only that you gain a perfect inward relief, but often also, in addition, the particular goods you sincerely thought you were renouncing. This is the salvation through self-despair, the dying to be truly born….To get to it, a critical point must usually be passed, a corner turned within one. Something must give way, a native hardness must break down and liquefy; and this event (as we shall abundantly see hereafter) is frequently sudden and automatic, and leaves on the Subject an impression that he has been wrought on by an external power.

  * * *

  —

  The idea of the sundered self resonated with Wilson, who had been baffled by his own “incredible behavior in the face of a desperate desire to stop.” His own Iliad of addiction, which appears in the first chapter of Alcoholics Anonymous, reverberates in the personal narratives that appear in the book’s subsequent pages. The alcoholic comes up with rational theories about his drinking and embarks on experiments designed to master it: drinking only beer, exercising more, going to psychoanalysis. “But there was always the curious mental phenomenon,” Wilson writes, “that parallel with our sound reasoning there inevitably ran some insanely trivial excuse for taking the first drink. Our sound reasoning failed to hold us in check. The insane idea won out.” To be an alcoholic, Wilson argues, is to confront the essentially irrational side of one’s nature. Looking deeply into the self only draws one further into the realm of the absurd.

  In order to escape the endless cycle, the addict had to train his or her gaze away from the self, directing it toward a higher power and the still-suffering alcoholic. This concept was, as much as the program’s spiritual emphasis, an application of James’s ideas (later in life, Wilson would claim that James was “one of our founders”): rather than focusing on one’s own internal war, the alcoholic externalized that struggle by working with another man who was worse off. Those who complain that the program is run by “nonprofessionals” often miss the fact that, according to Wilson’s model, the primary beneficiary is the provider of aid, not its receiver. AA has often been labeled a “self-help group,” but it is in fact the opposite: a fellowship for people who have utterly failed in their attempts to help themselves.

  * * *

  —

  When Alcoholics Anonymous was published in 1939, the American Medical Association declared it to have “no scientific merit or interest,” while the Journal of Nervous and Mental Disease called it a “rambling sort of camp meeting confession of experience.” Such perspectives, which resemble those taken by Dodes and Glaser, continue to find a sympathetic audience today, when confessing to being powerless over anything is regarded as a defeatist attitude starkly at odds with the mandate to better oneself through data and information. In fact, belief in the mantras of scientific self-empowerment is so strong that it often persists even when science itself seems to indicate what AA has always suggested: that the conviction that we can take control over our lives is—especially for addicts—largely an illusion.

  Indeed many neurologists now believe alcoholism is a brain disease that inhibits precisely the sort of “rational” thinking Glaser and Dodes insist upon. This is the contention of Markus Heilig, of the National Institute on Alcohol Abuse and Alcoholism. Heilig holds a PhD in psychiatric neurochemistry and has spent two decades working with alcoholics. Although there’s no indication that he has read Dodes or Glaser, the first chapters of his book The Thirteenth Step read like a bald refutation of their theories. Heilig thinks it is a mistake to encourage alcoholics to moderate or psychoanalyze their behavior; the whole point is that the addict lacks self-control. In fact Heilig goes further, dismissing the very notion of free will in a breezy eight-page chapter relaying the “astonishing” hypothesis that human beings are, in the words of Nobel laureate Francis Crick, “no more than the behavior of a vast assembly of nerve cells and their associated molecules.”

  One would think that Heilig’s biological materialism would make him partial to drug-related treatments for addiction. But while much of Heilig’s book is spent discussing the promise of such pills, he argues that medication is a long way from being able to address alcoholism in its full complexity, since (unlike other addictions) it does not interact with a specific brain receptor. Until the drug situation improves, Heilig recommends cognitive behavioral therapy. This includes strategies such as “fishbowl reinforcement,” in which clean urinalyses are rewarded by granting the addict the privilege of reaching into a glass fishbowl to retrieve a slip of paper that says “Good job!” or promises a small cash reward, and other methods like encouraging the addict to write a “set of screenplays” to help her avoid “relapse triggers.” “Use your creativity to develop what that alternative plot will be,” Heilig advises, “because it has to be one that works for you, and you are the expert on your own life.”

  Aside from the sheer silliness of such methods, a paradox lurks in Heilig’s logic. Aren’t such strategies a contradiction in terms for someone who doesn’t believe in free will? Heilig has considered this objection. While personal choice remains an illusion, he argues, recovery depends, conversely, upon the patient’s belief in their ability to choose, a concept he calls “self-efficacy”: “To get to their goals, people need to feel that they have an ability to influence the course of their lives.” Of the inconsistency in this reasoning, Heilig writes:

  I don’t know how to theoretically reconcile an understanding of the brain as a machinery that produces behavior based on the laws of nature, on one hand, with a view of the brain’s owner as an agent endowed with a free will to choose one behavior over another, on the other. It does not seem that anyone else knows the answer to this dilemma either, so I have decided not to worry too much about it for now.

  Heilig’s honesty is commendable, but it raises an obvious question: If the leading scientific experts contend that recovery from addiction depends upon belief in a fictional entity—free will—why is it any more “irrational” to believe in YHWH, the spirit of the universe, or the community of fellow alcoholics? If a fundamental barrier to recovery is distrust of one’s “self-efficacy,” wouldn’t it make perfect sense for the addict to mentally project that fictional power onto an external entity to whom she can then appeal for help?

  * * *

  —

  After his spiritual awakening, Bill Wilson was seized with fear that he was going mad. He had lost his desire to drink and felt he had experienced the presence of a higher power, but he also considered the possibility that he’d had a hallucination. When he described the experience to his doctor, the physician responded with an air of suspended disbelief. “Something has happened to you I don’t understand,” he told Wilson, “but you had better hang on to it.” It was this moment—rather than the spiritual experience itself—that Wilson would credit with
saving his life. “If he had said ‘hallucination,’ ” he wrote years later, “I might now be dead.”

  That physician, Dr. William D. Silkworth, would become a lifelong advocate for AA. When the Big Book was published, he wrote an introduction entitled “The Doctor’s Opinion.” The introduction is offered as a medical perspective on alcoholism, but Silkworth spends much of the chapter speaking of the limits of his own profession when it comes to curing addiction. “We doctors have realized for a long time that some form of moral psychology was of urgent importance to alcoholics,” he wrote, “but its application presented difficulties beyond our conception. What with our ultra-modern standards, our scientific approach to everything, we are perhaps not well equipped to apply the powers of good that lie outside our synthetic knowledge.” While Silkworth’s classification of AA as a form of “moral psychology” betrays some uneasiness with the program’s spiritual rhetoric, what ultimately convinced him was the evidence of the lives he’d seen changed. “We feel, after many years of experience, that we have found nothing which has contributed more to the rehabilitation of these men than the altruistic movement now growing up among them,” he wrote. The sentiment shares a bloodline with the pragmatism of William James, who held that “we cannot reject any hypothesis if consequences useful to life flow from it.”