In the preface of his new book, psychiatrist Lance Dodes cuts right to the point.
"Alcoholics Anonymous was proclaimed the correct treatment for alcoholism 75 yeas ago, despite the absence of any scientific evidence, and we have been on the wrong path ever since," writes Dr. Dodes. "Today, almost every treatment center, physician and court system in the country uses this model, yet it has one of the worst success rates in all of medicine, hardly better than no treatment at all."
It's quite an affront to an approach and an industry that tens of millions of Americans embrace — if not swear by. Consider that just last week, Gov. Deval Patrick declared opiate abuse a public health crisis in Massachusetts — and committed $20 million to increase drug treatment services — much of which will be spent on 12-step programs.
But Lance Dodes says 12-step programs are not only useful for very few, but they can also be harmful for many.
Note: Alcoholics Anonymous declined to participate in this conversation.
Dr. Lance Dodes, training and supervising analyst emeritus with the Boston Psychoanalytic Society and Institute. Recently retired assistant clinical professor of psychiatry at Harvard Medical School. Author of, "The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry."
On the effectiveness of 12-step programs:
Dr. Lance Dodes: "They have about a 5-10 percent success rate. I wouldn't say they are useless for everybody, they're useful for 5-10 percent. The problem is not those people who, by the way, should stay in AA if they're doing well, the problem is that the other 90 percent of people who are referred to AA — and that is almost everyone with an addiction — are being hurt by being sent to a program that can't possibly help them. Besides wasting time doing that, there are many other things that they could be trying, which they're discouraged from doing because AA — even though the individual people in AA may be kind and compassionate — AA itself is never wrong, according to AA. People are told, if you're not doing well then you have to work the program harder, go to more meetings, go to 90 meetings in 90 days. That would make sense if it made a difference to go more, but in fact that isn't the way it works. To encourage them to return suggests that if they're not doing well it's their fault, it's not AA's fault. Incidentally, that's the same problem the rehabs have and we all believe it. When celebrities go in and out of these expensive rehabs, we blame them. We say, 'Seventh, eighth, admission, what's wrong with these people? They're not staying with the program.' But no one says, 'Maybe the treatment is lousy.' Which is much closer to the truth.
How AA gained a place of privilege in America's health culture:
LD: "In the 1930s, when AA first began to be established and when the big book came out, almost all of the medical folks who looked at it thought it was garbage, including the American Medical Association. Ten years later, in the 1940s, they had completely reversed themselves, the AMA was endorsing it. In 1951, AA was awarded a Lasker Prize for its wonderful contribution to public health. In fact, there was no science that changed between the 30s and 40s. So what changed? This was the result of people like Marty Mann and, of course, Bill Wilson, who founded AA, having fabulous marketing skills and making connections with some very important people. The Rockefeller family, for example, helped to give money to support the publication of AA and a large number of institutions became imbued with the AA idea without any proof. Once it got established, it remained. And that is true to this day. If you look at state government agencies charged with addiction treatment, including Massachusetts, you'll find that they're filled with AA people. You're not going to get a scientific or a neutral hearing about what to do."
On what works for the people for are successful in 12-step programs:
LD: "It turns out that the 12 steps themselves actually are not the most important part. AA is correct when it describes itself as a fellowship. Mainly, it's the camaraderie and the support and the structure of AA that help people. If you interview the people who are doing well, that's what they mostly describe. When people were asked about the individual steps, they got a much more varied response. The majority of people said they were 'off-put,' that's their term, by all the references to God, which are shot through the 12 steps. The one step that was most endorsed was step four, which is taking what AA calls a 'fearless moral inventory.' The moral part should be left out, of course, but the idea of trying to understand yourself is sensible for anyone and is part of any good therapy. But there are some people who I think, psychologically, can make use of the 'higher power' idea. If addiction is a way of dealing with feelings of overwhelming helplessness, then you can see how having a higher power would be helpful for that. But it only works for some people. For most people, a symptom as serious as compulsive drinking can't be resolved by being in a fraternity, but there are a few people for whom that becomes deeply important."
On step one of the 12 steps:
LD: "A lot of people who can't make use of AA deeply resent step one, which is, 'We admitted we were powerless over alcohol, or over our addiction.' First of all, it's not quite true. I know what they mean, of course, but the solution to it is not to acknowledge powerlessness — for most people it's to be empowered. It's to find a way to deal with it. Which is how we deal with almost every emotional or physical problem in the world. You want to find a way to exert power over what you haven't been able to have power over. The powerless idea is really just a step on the way toward saying, 'Now we need to have a higher power.' You have to remember that Bill Wilson was a member of something called the Oxford Group, which was a fundamentalist Christian group, he later left it, but he said that AA was founded on the basis of the Oxford Group and it's taken entirely from those principles and that central principle is, 'The problems of mankind are caused by being at a distance from God. So, we need to get closer to God in order to solve our problems.' And that's the 12-step idea, turn your power over to a higher power. There's nothing wrong with that, inherently, it's just that it isn't that effective for most people. And many people are discouraged by the idea that they have to admit they're powerless."
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