I’m constantly referencing this study in my writing, so I figured I should post up the main information from it here.  The study is an analysis of data from 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, or NESARC for short.  This data is relevant because it comes from a survey representative of the US population as a whole – unlike many addiction studies which only survey people who go through treatment programs.  Those studies often find that people relapse quickly without continued treatment, leading to the erroneous assumptions that addicts can’t quit without treatment, or that addiction is a chronic disease, and especially that abstinence is necessary and that successful moderation is rarely attainable – among other nonsense.   But what we find when we broaden our scope, like in this study, is that the majority of people with Substance Dependence (as defined in the APA’s DSM-IV) actually quit on their own without any sort of treatment or 12-step involvement.  Here is the most important table from the study, so you can look at the numbers yourself:

It’s important to realize that this is representative of the general population.  They are questioned about past substance use and diagnosed with the DSM-IV criteria for Substance Dependence.  This study proves a few key points that directly contradict the common knowledge about addiction:

Point #1: Most People Cease to Be Substance Dependent

Figure 2

The fact is that at any given time, of people who could be classified as Dependent in a time prior to the past year, only 25% of them are still dependent.  That leaves the other 75% as no longer Dependent.  This one fact proved by this study offers a lot of hope for those with substance use problems.  The odds are that you are three times more likely to end your addiction than you are to continue your addiction!  We know this from the data above and in Figure 2 (shown to the right).

Point #2: You Have A Better Chance of Ending Your Addiction If You Are Never Exposed To Treatment Programs or 12-Step Programs.

The study breaks the total group down into those who have received treatment (including 12-step group involvement) and those who haven’t ever received treatment.  If you look at the numbers I highlighted in blue on the table above you’ll see that 23.8% of those who were never treated are still dependent – yet 28.4% of those who have been treated are still dependent.  This means your chance of resolving your substance use problem may be better if you simply avoid treatment!

The recovery culture claims that you cannot end your addiction without treatment or 12-step meetings, but the facts show that a higher percentage of people end their dependence without ever getting this kind of “help”.  Moreover, in raw numbers, most people stop without treatment.  If you look at the table you’ll see that the total number of people participating in the study is 4,422, of which 1,205 have been exposed to treatment, and 3,217 have never been treated.  That means that in this study, 2,451 people ended their dependence without treatment, while only 862 ended their dependence with treatment.  Another way to express this – 73.9% of those who end their Substance Dependence do so without treatment!

Point #3: Long-Term Success Is More Likely Without Treatment

If you look at the numbers I highlighted pink in the table above you’ll see that they represent success rates at various intervals since onset of dependence.  What this means is when we look at the first number, for example, we learn that 64.9% of people who have received treatment, and whose addiction started sometime in the past 5 years, are still dependent.  The interesting thing about this is that the number is exactly the same for untreated individual whose addiction began in the past 5 years!  So in the early years, there is no difference in outcome whether you get treatment or not!  The numbers stay close for people whose problem started 5-9 years ago (with the untreated group doing slightly better), but when we get to the group whose substance problem began in the range of 10-19 years ago we start to see a massive gap between the the treated and untreated subgroups – at this point we see that only 9.4% of the untreated group are still dependent, while at the much higher rate of 27.3%, those who attended treatment and 12-step meetings are nearly three times as like to have been dependent in the past year!  What does this say about your long term chances of success in the conventional recovery culture?  This group is no anomaly either, when we get to those whose problems started 20 or more years ago we see the untreated group doing great with only 4.3% still dependent, while the treated group is now doing more than 3 times worse with 13.6% still dependent.

The recovery culture has advocated longer and longer stays in treatment, to the point that they’re now telling people to mortgage their homes to pay for a full year of inpatient treatment, and then coming up with all sorts of “aftercare” plans for out patient treatment, sober living houses, long-term pharmaceutical treatments, and a lifetime of 12 step meetings.  Meanwhile, the facts are the facts, and the numbers above prove that they should really be advising us to stay away from treatment for the rest of our lives, if we want long term success.  But if you want a life of “recovery”, maybe you should stay in treatment.

Point #4: Moderate Use Is A Possible and Probable Outcome For Resolution of Substance Dependency

In the table above,  the groups of numbers directly below those highlighted blue represent non-abstinent recovery from Substance Dependence.  A large number of people fit into this gray area where they are drinking, but not to a threshold that qualifies them as addicted.  The categories are defined in the study as follows:

Five categories of past-year status were used in this analysis:

1. Still dependent: had 3+ positive criteria for alcohol dependence in the past 12 months.

2. Partial remission: did not meet the criteria for alcohol dependence in the past 12 months, but reported 1+ symptoms of either alcohol abuse or dependence.

3. Asymptomatic risk drinker: past-year risk drinker (see definition above) with no symptoms of either abuse or dependence in the past 12 months.

4. Low-risk drinker: past-year drinker with no symptoms of either abuse or dependence and who was not classified as a past-year risk drinker.

5. Abstainer: did not consume any alcohol in past year.

People with PPY alcohol dependence were classified as being in full remission in the past year if they were in categories 3, 4 or 5. They were classified as being in recovery if they were in categories 4 (non-abstinent recovery, i.e. NR) or 5 (abstinent recovery, i.e. AR).

It should be mentioned that the Partial Remission category has a relatively low threshold, in that respondents may fit the category by reporting only one symptom of the DSM-IV Substance Abuse and Substance Dependence criteria – i.e. – if you drink, and you have an argument with a family member about drinking – then that would be a “symptom” of Substance Abuse, and you would be considered to be in partial remission.  But who’s to say the fact that you got into an argument with a family member means that you are anywhere near “dependent” on a substance?  Many in this category could be safely considered moderate users.

Also, you should know that “Asymptomatic Risk Drinkers” are those who didn’t have any symptoms of abuse or dependence, but drank at these levels: for men- drank more than 14 drinks per week on average or had 5 or more drinks in one day at least once in the past year.  For women – drank more than 7 drinks per week on average or had 4 or more drinks on a single day in the past year.  Notice that you don’t even have to drink every day or drink the 7 or 14 drinks per week, you can be considered an asymptomatic risk drinker in this study if you have one day of somewhat heavy drinking.  So – pop open five beers over the course of a 4th of July picnic, or finish off a bottle of champagne  on New Year’s Eve, and bingo, you’re an asymptomatic risk drinker.

I bring all this up not to criticize the study, but only to show that the lines in between “Still Dependent” and “Abstinent” aren’t so clear.  What is clear,  is that there are a large number of people who fall between these two poles, and thus a large number of “moderate” drinkers.  This is important to realize, since the recovery culture doesn’t allow for moderation as a success story – they believe it’s abstinence or nothing, and in fact they actively teach people that once they’ve been Substance Dependent, a single drink will rapidly escalate them back into full blown substance dependence.  The facts show that this clearly isn’t the case.  Moderation is possible, and indeed a probable outcome for people experiencing DSM-IV Substance Dependence.

The numbers also suggest that the all or nothing message of the recovery culture is a powerful one – for better or for worse.  The percentage of abstainers in the treated group is nearly 3 times that of the “never treated” group (35.1% vs 12.4% respectively), which some may look at in isolation, and declare that treatment is clearly successful.  But, with 28.4% still dependent, the path of treatment produces nearly 20% more failures than the path of no treatment (23.8% still dependent).  This is not shocking, when you consider that those who attend treatment are taught in no uncertain terms, repeatedly, that a single drink will lead to a complete loss of control over drinking.  Likewise, the “never treated” individual has less exposure to the all or nothing recovery message that a single drink will lead to full alcoholic breakdown/relapse, and accordingly, more of them fit into the area between the 2 poles of dependency and abstinence.  When we sum up the 3 middle categories (2, 3, & 4 on the list above), we see that 63.8% of the “never treated” group fit into the middle, while only 36.5% of the treated group fit into these middle categories.  While the all-or-nothing message may push more people towards abstinence, it may also push more people towards full blown Substance Dependence.  Furthermore we may interpret the subcategory data relating to time since onset of dependence as evidence that the all-or-nothing message delays progress, as I discussed in point #3 that in the long run, as we look at people who are further and further away from the time when their substance dependence started, the percentage of treated individuals who are still dependent (13.6%) is more than 3 times higher than the percentage of “still dependent” in the never-treated group (4.3%).  They start out with identical success rates, but over time, the untreated group clearly does better – what happens in between for the treated group is debatable, but I believe the all-or-nothing message sends them on a roller coaster ride between periods of struggling to painfully hold onto abstinence one day at a time, followed by explosions of full blown “addiction”.  Were they able to accept a something in between these two poles, they might just live and learn, and get to a happier life free of Substance Dependence sooner, as the never treated individuals seem to do at a better rate.

Some may take issue with my further interpretations of this data, and they may have legitimate points, which is why I posted the table for you to look at and judge on your own, and cited the source below.  The basic point though, I believe holds strong: most people recover from substance dependence, with or without treatment.

Source: Recovery from DSM-IV alcohol dependence: United States, 2001–2002 Deborah A. Dawson, Bridget F. Grant, Frederick S. Stinson, Patricia S. Chou, Boji Huang & W. June Ruan Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA

Link to PDF of full study as published by the NIAAA.

Does this say anything about 12-Step based help?

Yes, it absolutely does. A later paper by the same author about the same date broke down the kind of help received by the treated group. Of that 25.5% who sought help for their alcohol dependence, they included:

3.1% who had participated in 12-Step programs only, 5.4% who had received formal treatment only and 17.0% with both 12-Step and formal treatment. Based on the most appropriate model, help-seeking increased the likelihood of any recovery [hazard rate ratio (HRR) = 2.38], NR (HRR = 1.50) and AR (HRR = 4.01).

So 20.1% attended 12-step meetings, and only 5.4% went to treatment without also attending 12-step meetings. That means approximately 80% of the treated group attended 12-step meetings. Surely, these results apply in some way to the effectiveness of AA. What’s more, approximately 80% of treatment programs use a style of counseling called Twelve Step Facilitation, which promotes the teachings of AA, and most other substance dependence counseling methods employed in formal treatment programs also involve teachings from 12-step programs. So it’s safe to say that the rest of the group who didn’t attend AA meetings were nonetheless taught the principles of AA while in treatment.

The majority of the treated group was definitely indoctrinated with the 12-steps of Alcoholics Anonymous.

SOURCE: Estimating The Effect of Help Seeking on Achieving Recovery From Alcohol Dependence.

Limitations (section updated Oct 17 2012)

This study doesn’t give us all the answers, but it’s one of the most solid pieces of information we’ve got in the world of addiction.  There is plenty more information I’d like to know, but this is still enough to draw some very important conclusions from.  With that said, there are limitations I should make you aware of in the interest of open debate.  It doesn’t count people who are currently institutionalized i.e. prisoners.  Nor does it account for deaths caused by substance use.

The deaths point is important, because many people bring that up as a big gotcha when discussing these figures. However, I recently attended a talk given by Stanton Peele at NYU where he mocked the claim that deaths account for what appears to be success among the untreated population – he wrote about this in one of his HuffPo columns:

The research led the NIAAA to announce its discovery that “alcoholism isn’t what it used to be,” reversing decades of the NIAAA’s forceful adherence to disease and abstinence memes. Meanwhile, the NIDA’s National Survey on Drug Use and Health shows that peak abuse of and dependence on drugs and alcohol occurs from ages 18 to 25, and declines by a third after age 25, and by half after age 30.

…Meanwhile, how many times have I heard harm reduction people account for the decisive fall-off of substance abuse with age: “Why, they all die!” (One in 10,000 people in this age group dies per annum due to drug overdoses, which occur mainly for older abusers.)

I liked Stanton’s point, and he linked to the CDC as his source for the 1 in 10,000 number for that age group: link.

Also, a new study out of Germany on alcoholism mortality rates concludes that treatment makes no difference in the mortality rate of alcoholics:

Annualized death rates were 4.6-fold higher for women and 1.9-fold higher for men compared to the age- and sex-specific general population. Having participated in inpatient specialized alcohol dependence treatment was not related with longer survival than not having taken part in the treatment. Link

So much for the claim that the success of untreated alcoholics over time is a mere illusion created by their rapid death rates! In light of this, we need to wonder whether the absence of data on prisoners may be just as insignificant to the analysis of this study.

The results discussed above are for alcohol users. What about drug users? Well, it appears more NESARC data has poured out, showing at least that recovery from drug use is highly probable – even more so than from alcohol. The same sort of data hasn’t been released regarding treated vs untreated, unfortunately.  With that said, alcohol and illicit drugs affect the brain in nearly identical ways, they are used for the same reasons, they effect people’s lives in the same basic ways (with the exception of the illegality of drugs and the extra consequences that imposes), quitting drugs or alcohol is achieved in the same way, and both addictions are “treated” in the same way professionally (except for the exceptions some make in separating drug addicts from alcoholics in an attempt to preserve the fragile egos of some alcoholics).  So, NESARC hasn’t yet given everything I want in a study, but personally, I feel safe concluding that the same basic principles apply across substances, given the current information. I’ll be adding an analysis of the NESARC drug data zoo, and will link it here when I do (2/11/2014).

For those who would dismiss the data because they don’t know exactly how much treatment the treated group received, I would say this: show me the treatment that gets a better than 75% long term success rate, and then we can talk. Even Hazelden, the gold standard of treatment, doesn’t claim a higher than 60% success rate, and personally I think that claim is bunk, since I’ve called and asked for supporting documentation on that claim more than once and they’ve refused to provide it (and by supporting documentation, I don’t mean that I want to see their surveys, records, etc – I just want to see what their criteria was and how they came up with that number – yet they offer nothing but the number itself).

Comments

  1. Stephanie says

    While I hear you on the all or nothing perspective being problematic, but you are assuming that all addicts are created equal because they meet criteria based on the DSM-IV. Its most likely that those who go to treatment are more ill than those who don’t. I do think that its possible for people to return to moderation after meeting the basic criteria for dependence. However, if my life had spiraled so out of control that I lost much of what made me human and a substance was involved, I’d be pretty scared to ever ingest anything ever again. I do happen to be a substance abuse counselor, so I maybe somewhat biased… my folks ask me if they need to stay abstinent forever… my answer is much like what I have written and I ask them if they want to risk it. Its up to them in the end. I’m just a person with some data to offer.

    • says

      “I’d be pretty scared to ever ingest anything ever again. I do happen to be a substance abuse counselor, so I maybe somewhat biased… my folks ask me if they need to stay abstinent forever… my answer is much like what I have written and I ask them if they want to risk it. Its up to them in the end. I’m just a person with some data to offer.”

      Are you offering “data” or fear and self-doubt?

      -Steven

  2. Martin says

    Numbers can be twisted to make anything seem credible. What I see here is someone condemning treatment. This is what causes people to die you moron! I am a person in recovery from drugs, and yes alcohol is a drug. My life was twisted from multiple decades of abuse. I tried the Army and couldn’t quit, I only attained brief periods of abstinence and every time I returned to active addictionit only got progressively worse. Every corner of my life was negatively impacted by addiction spiritually, financially, emotionally and physically I was damaged. I knew I was a hopeless addict I spent almost 40 years wreaking havoc in the lives around me and I knew I was meant to die an addict. I finally worked up the courage to kill myself and I did! I was resuscittated and sent to treatment it was in treatment that I learned of Narcotics Anonymous. By completely immersing myself in Narcotics Anonymous (a 12 step program) I have now achieved the longest period of abstinence that I have ever known. You are an idiot whose beliefs will send people back to active addiction and eventually jails, institutions and death. You shouldn’t be down playing treatment you should be promoting any form of treatment that a person like me chooses to achieve his/her goals of abstinence. I would revel in the opportunity to meet an asshole like you. This would give me the opportunity to practice patience, tolerance and forgiveness spiritual principles I learned about in Narcotics Anonymous. Have a great day and I thank god for people like you to keep the fire inside me alive. God Bless the rooms of Narcotics Anonymous, the 12 steps, sponsors, homegroups and service these are the things that keep me clean!!!!!!!!!!!!!!!!!!!!!!

    • says

      I don’t think I really need to reply to this, but I can’t resist highlighting a quote from it:

      “I would revel in the opportunity to meet an asshole like you. This would give me the opportunity to practice patience, tolerance and forgiveness spiritual principles I learned about in Narcotics Anonymous.”

      My emphasis added.

      -Steven

      • Don says

        I wonder if Martin has ever gotten to the real root causes of his addictions. If saying, “I would revel in the opportunity to meet an asshole like you”, is accepted as a practice of “patience, tolerance and forgiveness spiritual principles”, I would consider steering clear of that 12-step program.
        -Don

    • Joe says

      “You shouldn’t be down playing treatment you should be promoting any form of treatment that a person like me CHOOSES to achieve his/her goals of abstinence.”

      I can’t make things bold to show my added emphasis, so CAPSLOCK does it…

      I believe all of the philosophy on this site is about choice. Martin, if you are now sober, you chose to be. NA or AA may have provided support, tips, etc., but they did not stop you from falling into a destructive pattern again – you chose to change.

    • George says

      I’ve so thoroughly enjoyed this discussion as it brings some things to light I was not aware of.

      In my teens I sought help for my abusive tendencies which were alcohol, cigarettes, and various other substances such as heroin, mda, lsd, cocaine, cannabis, and some prescription pills from time to time.

      I visited a drug and alcohol counselling center and was assigned a therapist (licensed social worker). About the same time I also visited a licensed family psychologist / psychiatrist and they both had no problem with me seeing both at the same time since the psychologist/shrink was mostly about my marriage and the abuse counsellor was mostly about substances though there was plenty of crossover.

      My abuse counsellor believed that (this was in 1973/74) AA was potentially helpful for people who believe they needed to have an “addict identity” for the rest of their life. She advised me that I did not have an incurable disease but that if I went to AA they would convince me that my abuse of substances was a lifetime addiction/sickness that could never be cured. She, however, believed that I could be cured of the abuse if I wanted to be — but that it would not be helpful to be around people who believed I could not be cured if I wanted to be free of addictive proclivities.

      She helped me understand that my addictions were my attempts to solve problems with solutions (getting high) that did not actually solve my problems but quite likely made them worse. She helped me understand that I could beat addiction if I was committed to it.

      The Dr. (Psychiatrist/) that I was seeing helped me discover that I was responsible for my decisions. Showed me how blame shifting was a disempowering illusion that by blaming someone or something other than me — I could avoid being responsible for failure. But that I could not take credit for success if I would not take responsibility for failure. He helped me realise that, though I was not conscious of my manipulations, I was not only responsible for my failures but also the backlash they caused in my relationships.

      It took me about four years to completely resolve my issues after I ceased therapy. I really didn’t stop therapy but stopped seeing therapists and began reading everything I could about psychology and personal achievement. More of a self help program.

      About two years into my quest for recovery I just stopped drinking. I had no further desire to drink because I realized fully that overindulging did more harm than good. Since my realization was really a catharsis and not just an intellectual discovery — I did not have to make any effort to stop drinking. I just didn’t care if I drank anymore so I didn’t. After about six months of abstinence I had one bottle of beer. I had no urge to have a second until about a month later. After that I’d have one beer once or twice a month. The desire to keep knocking them back was gone. I shared a bottle of wine with dinner once in awhile but the urge to get drunk was gone and now, well over 30 years later, I rarely drink. Like maybe once or twice a year. I’ve often gone two or three years without a drink but only because the urge to have one was too weak to bother. After a couple years of no drinking at all I had about four sips of wine during two different meals over the last three days with my wife who sometimes orders wine with dinner. We live in wine country so there’s no shortage of great wines and wineries available. We live within 30 minutes of more than 50 wineries.

      Next I quit smoking. That was about a year after I quit abusing alcohol. I put a sign on my fridge saying “I’ll never smoke tobacco again”. Though I had at least one dream a year that I started smoking again (until about five years ago when I had the last dream) I never smoked another cigarette and do not expect I ever will. I quit smoking in 1978. I made an honest appraisal of the habit paying particular attention to what I liked about smoking. I’d seen too many people not quit by focussing on what was bad about smoking but that seemed to produce disempowering guilt in potential quitters. I chose instead to look honestly at what I liked and did not like about it. I liked a lot of things but in the end I could not find enough things to like about smoking to ever want to smoke again. It was not until I concluded that I did not ever want to smoke again that I was empowered to quit. So for me total abstinence is about keeping a commitment that I’d arrived at honestly and proving to myself that cigarettes have no power over my decisions. I could go back to occasional smoking I suppose but why? There is nothing I like about it anymore.

      As for the other substances I only tried heroin a couple times and didn’t really like it. Without going into a long story I quit all the other substances by January 1980 and never abused again.

      After being told by my therapist that I had an addictive personality and that being free of addiction meant not just quitting the substances but it also meant making changes that would help me abandon the idea of replacing my addictions with shiny new addictions (like work, sex, video, porn) that people often replace their old addictions with. For me I think that was the key because I have not observed addictive tendencies in my behavior for at least 25 years. (since my late 20’s)

      Obviously I’ve had lots of interest in beating addiction, understanding addiction, and many dialogues about the topic since then. I’ve helped a number of people quit various addictions along the way without my actually having sought out such opportunities. In the process I’ve also learned how to talk to addicts in a functional way without becoming unwittingly involved in supporting their addictions.

      Which brings me to my point in making this post… Is it possible that those who seek treatment for addiction are more often people who have seen too much failure to kick it on their own so they seek help because everything they’ve tried on their own has failed? Would that not put them in a category of “tough cases”. I mean if 75 percent of the people who have not sought treatment can kick it on their own — could that leave the 25 percent who, failing to help themselves, seek help. Would not that category of person be less likely to kick the addiction because they’ve already tried “self help”. Remembering that all help is “self help” then seeking help from someone else doesn’t change the fact that this sort of person has already proven that they cannot help themselves. This group I think tends to look for ways to manipulate the social environment that provides the help so that they can enjoy the social experience but also continue to enjoy being stoned. They already believe they are hopeless so they put their hope in others which can lead to many false conclusions — one of them being that there is something other than “self help”. Frankly it looks like seeking help for many is an elaborate means of blame shifting often referred to as co-dependence.

      The subject works to create the illusion that someone else may succeed where they have failed. They have not come to terms with their own failure sufficiently to help themselves kick the addiction during treatment. If such a person get’s a particularly good practitioner the practitioner may help them to self empower by restoring their own ability to hope and believe their way to success. Such practitioners are rare. I think the people who seek help tend to be tougher cases. The support system they’ve engineered to perpetuate their addiction remains stronger than the support system for success. An easy case may have only a couple reasons for continuing an addiction and only a minority of people in that person’s social group supporting the addiction. A hard case may have a combination of physical pain, emotional pain, tumultuous relationships with a majority of people, minimal social skills for conflict resolution. In short they are so messed up that drugs actually make them feel more normal. How can you quit something that makes you feel better about yourself without finding a way to feel better about yourself without drugs?

      My point is simple. If you are stuck in addiction and you can’t kick it yourself then you seek help or your destructive behavior may get you into treatment that is court ordered or happens because people orchestrate an intervention. Either way the treatment is not sought freely by the person with the addiction. The help seeking group have probably concluded that they cannot do it themselves. In fact I think many of them set out to prove that they are incurable because it gives them an excuse to keep doing what they really want to. Involving others through help seeking is often just a more convincing way of proving their problem is not solvable. If too many people in their social arena are convinced they need help people often seek help just to please the people nagging them. Their real agenda though may not actually be success — it may just be a way to add more evidence to support their core belief that they are a hopeless case.

      Therefore is help seeking not more likely to attract people with that kind of agenda than those who really want to kick the habit? If you really want to kick the habit and believe you can then are you not more likely to kick the habit without involving the help of others? Isn’t the greatest power for kicking addiction proportional to the degree of commitment that person is capable of?

      You referred to this as “severity” in your discussions but I’m thinking that maybe the definition of severity needs scrutiny. Perhaps a better definition of severity would focus more on the number and complexity of emotional, intellectual, spiritual, and social support factors that inspire substance abuse rather than the duration, quantity, or degree of danger a particular substance provides.

      I think the most distressing aspect of addiction is the sense of disempowerment, and accompanying guilt, that the subject experiences when they believe they don’t have control of their behavior. They live in fear of themselves knowing they will probably do something destructive that they can’t stop from doing, or are already engaged in doing something destructive and fearing the inevitable consequences. Either way they believe they have no power to stop hurting themselves — whom they care very deeply about. I think that alone is enough for many to take a drink just to assuage the guilt somewhat.

      I think 12 step programs appear to help people because the admission that they don’t have power over the substance is somewhat of a reality point for them. There is a lot of power in admitting a weakness they could not previously admit. For some that alone is enough to take back responsibility for their decisions and move on without having to forever attend meetings in order to cease abusing.

      I’ve never heard of a 12 step program that has a path that empowers people to be cured. I imagine that’s because they teach their adherents to believe that they’ll never regain their power over their decisions about the object of their addiction. This is like a life sentence for abuse. How does anyone ever believe they have a completely normal life as long as they MUST also believe they are an addict for the rest of their life?

      How do these folks ever think they are all they can be? How do they ever believe they are living their true potential? There is no freedom greater than the freedom to say “no” while retaining the freedom to also say “yes”. How does anyone find true peace and confidence who believes that their addiction will screw them over badly unless they remain so afraid of the substance that they must never go near it. Seems like such people live in fear of disastrous punishment for even a single mistake.

      Personally I’ve never shared my story with 12 steppers because I didn’t want to interfere with any beliefs they depend on to stay sober or straight. Actually I tried it once in 1975 at a restaurant table of people during a seminar break. I got attacked verbally by several people at the table that insisted I was either lying about my addiction or that I was never an addict. After that I decided not to discuss my experience because I decided there was no point in attempting to convince people who believe differently than I.

      However I’ve always wondered about the seemingly obvious deficiencies in 12 step programs. Now, having read this discussion, I’ve at least somewhat of an explanation as to why so many treatment programs fail to break the addictions people have. What I’m left with is a hypothesis that perhaps the fact that the high correlation between seeking treatment and not beating the addiction is related to the type of people who seek treatment. I think the majority of people who seek treatment may well be doing so because their recovery needs (if any) are different than the roughly 75 percent who quit abusing before seeking treatment. Also were the category of “treatment seekers” adjusted to reflect the number of people who were forced to seek treatment by a court, a threat, or other form of coercion? Every single one of those people are automatically in a group destined for a higher failure rate because the sense of personal responsibility for their success (a major success factor) is distorted by their beliefs about the influence of external forces.

      I think the poor success ratio of these programs may be due to treatment seekers being in a category that has filtered out large numbers of success stories who never sought treatment. That could logically leave a much greater density of people who, on some level, don’t want to quit, are afraid quitting will make them more powerless, or who perceive themselves as being too weak to quit.

      It almost seems appropriate to get people that think they are too weak to quit to admit they are powerless over the substance. But shouldn’t the next step after admitting a loss of power — would be how to take back their power. 12 step programs address that with their steps and they do help to a degree but their agenda is not to make free people. They may say it is but insisting that addictions cannot be defeated but only minimized by abstinence while serving the life sentence of the 12 step hopeless addict who will never recover but just get sober.

      The hope necessary to completely set people free has been replaced by a belief that squelches it. 12 steppers generally consider the risk of exposing people to that sometimes uncomfortable truth to be too great a risk to take. Perhaps that is true for the majority of these folks. Perhaps 12 step prison is the only thing that will ever keep them from repeat offending. Personally I think it comes down to time, energy, and expertise. It is tough to find treatment that is sufficiently potent to break through with the tough cases and perhaps that is the main limitation in our system for handling tough cases — the extent and quality of treatment available for them is a lot more scarce and may not be found in sufficient amounts in any treatment programs.

      It seems that the majority of programs out there appear to be 12 step programs or something with a different name but structured similarly. I think that having extreme beliefs (many of them objectively unproven) about addiction such as those propagated through 12 step programs is perhaps one of the greatest obstacles to successful treatment because they offer no path to permanent recovery — or perhaps we should say normalcy?

      How does anyone who lives in fear of ever touching that substance again manage to live a fully realized life? I don’t see how people can sustain a sense of empowerment if they believe that there are aspects of their lives (that others have control of) that they’ll never have control of.

      Personally I would find true empowerment in my life if I were to believe that, because I was once a person with an addiction, it means that I’ll always be an addict even if I don’t exhibit any of those characteristics.

      People abuse for different reasons. My hypothesis is that those who abuse because of serious social issues may find it hardest to beat addiction without first resolving the social issues. For example the stories about manipulative, lying, stealing, cheating, ruthless tricksters addicts are are so prevalent because the behavior of addicts who seek treatment does fit certain patterns. However the addicts I’ve know who did not seek treatment but quit on their own did not have the same degree of social retardation that the treatment seekers I’ve known.

      The addicts I know that kicked booze and/or drugs in 12 step programs, and still attend 12 step meetings decades after abstaining, have obvious social deficiencies they constantly fight to compensate for, and even though they’ve managed to remain sober — still seem to retain their social dysfunction even though their lives are not as messy as when they were abusing. I’ve gotten used to long stories about their addictions, their challenges, and ultimately how much better they are now than they used to be. Lots of stories about how life is just getting better and better for them. I wonder if it’s really me, and not themselves, that they are trying to convince.

      The adicts I know that keep relapsing also, without exception, have noticeable social problems. Often a seriously inflated idea of how great they really are along with an almost desperate need to tell everyone how good they are now. Discussions about their 12 step programs take on religious tones where the feeling of false humility in the air is palpable. There seems to always be a ton of underlying guilt that they cannot escape from no matter how much they proclaim they are better off than before. I’ve yet to speak to one that doesn’t have a grudge or an axe to grind with at least one socially identifiable group in society. I’ve noticed a very distinct “me” and “them” mentality with than types of people.

      My guess is that the group that can recover from substance abuse with what appears to be a 75 percent success rate was probably struggling with abuse because of more transient personal reasons or issues than the hard core addicts who are more desperate. For example: Most people tend to grow out of antisocial behavior as they mature. It seems they’d also grow out of the addictions (dependencies) that helped them cope with the social issue(s) they faced.

      Consider also that those who have serious social problems may have little or no social success outside of a 12 step program so they feel compelled to belong to one because it’s the only social group that will continue to support them emotionally even when they cling to their addictions.

      Problem is 12 step programs thrive on keeping their adherents captive to attending meetings because of a belief that their condition is unrecoverable. Therefore the group meetings help to replace the social needs their addiction is helping them cope with. They get the social support they need and the very idea of leaving that support seems life threatening. Therefore having a 12 step club that tells them they cannot be functional unless they attend meetings for the rest of their life, along with an assigned “best friend” (otherwise known as a sponsor), is going to be a major relief (support) to anyone wanting a more functional social experience than their highly destructive lives created from abusing. Why would anyone want to leave that unless they became more socially functional outside of the 12 step group than in it?

      Therefore it may seem essential to many who seek treatment to keep their addiction, perhaps even engineering relapses (not necessarily consciously) to prove to themselves that they cannot do without the 12 step social experience. Consider that the 12 step experience around which most recovery programs are modeled is a social environment that encourages honesty, healthy conflict, well managed confrontation, making peace, forgiveness, absolution, making amends, self acceptance, dropping judgmental behavior, being less critical, being more loving, encouraging the development of intimacy with others, taking emotional risks, communication, dialog, being real, being positive, considering others, practicing integrity, learning to take care of yourself, and so on.

      What we have in 12 step programs is really a religion that points to a path of freedom, and attempts to instill the values of freedom, but retains an enslaving factor — best summarized by the line in the song from Hotel California — “you can check out any time you like but you can never leave”. I think it is this enslaving factor that diminishes the hope of ever being completely normal. I think that destroying this hope by preaching that addiction is unconquerable is an attempt to rescue people from having their hopes dashed. I think it fails because learning to deal with having your hopes repeatedly dashed is an essential strength building, maturing process, that when removed from the equation leaves people too weak to completely break free. Hope is one of the most invigorating, motivating, forces known to man. When a strategic element of hope is removed from the equation it weakens people over the long term in order to protect them from short term failure. I think this single trade is perhaps responsible for more treatment failures than anything else. Better to let people get their hopes up, fail, and teach them how to recover from it than try to protect them from having unrealistic hopes and then teaching them out to recover from the unrealistic hope and set more realistic goals.

      In life most of us can only learn with some degree of certainty what hopes are unrealistic by failing to achieve them. If we treat people with addictions as though they are too weak to handle having their hopes dashed — how hard are we making it for them to live beyond the beliefs we insist they hold in order to remain in the club? What we are saying to them is that they are in a special group of people called “addicts” and there is no way out. They are told that they must see themselves as more limited than people who are not “addicts”.

      The idea is that you can force people not to have unrealistic hopes by teaching them to lower their expectations of themselves. Trade sobriety for freedom. “You cannot be free from addiction but you can be sober.” Settle for that because it’s better than attempting the impossible. Why is it impossible? Because we say it is and we know because we have clubs all over the world who are proving it every day. However we don’t tell you that your odds of success are (at best) no better than if you don’t join our club.

      • Lynn says

        George, you comment is more than a year old, so don’t know if you will see this. But, just in case, I wanted to let you know I fully appreciate your entire comment and agree with every single, well thought-out word. Sincerely, Lynn

    • says

      You stopped because you made a decision to do so. Nobody is discounting the benefit of support from people, encouragement, etc.; not isolating oneself. But it still comes down to a decision to say no. I would say stop beating a dead horse. You stopped using. Celebrate that.

  3. says

    Dear Mr Slate,

    Great to see someone willing to think outside the box, although it is perhaps injudicious to jump to absolutist conclusions from a single, cross-sectional and (as you correctly identify) methodologically flawed study with indistinct categorisations.

    Point 1: The data you quote represents past-year status or period prevalence. It does not represent lifetime risk, for a condition which commonly (usually) recurs.

    Point 2: Causation and correlation are different things. For instance, severity would feasibly be associated with treatment-seeking, as one possible confounder.

    Point 3:See point 2 and point 1.

    Point 4: I think the jury is still out on whether, at the population level, abstinence or harm-reduction is preferable with regards to alcohol (Ritter, 2006).

    Looking at the same table in isolation, I might choose to conclude:
    1. People who have had some form of treatment are 3 times more likely to be abstinent (although we don’t know for what proportion of the sample this is the goal)
    2. The majority of those ‘never treated’ are either still dependent or in ‘partial remission’.
    3. Those ‘never treated’ are 2.4 times more likely to fall into the category of drinking at risky levels.
    4. Those never treated are more likely to be drinking in an unsafe fashion (ie. categories 1, 2 or 3).

    Personally, I would agree with your core philosophy of empowering addicts in recovery, and that there is MUCH room for improvement in how we conceptualise, understand, prevent and assist people in recovery, however they may choose to define their own recovery process. Change is needed.

    Constructive and open-minded research, debate and transparency will help us get there. Current treatment models are profoundly flawed, I’d agree. We, perhaps, need to think more of the role of comorbidity in recovery, given that this is the expectation, not the exception (Minkoff, 2001)

    References:
    Minkoff K. Developing Standards of care for individuals with co-occurring psychological and substance use disorders. Psychiatr Serv.2001;52:597–599

    Ritter A., Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug Alcohol Rev 2006; 25: 611–24

    Yours faithfully,

    Dr Mathew Carter
    Australia

    • says

      Thanks for the engaging comments Dr Carter.

      First, I would reply by saying that I haven’t formed my opinions on this one study alone, it just happens to be a particularly noteworthy example, and one of my personal favorites. This study is of course a snapshot of past year substance use status as of the time the data was collected – which could cause one to wonder “was this just the state of things in 2002?” However, a similar study was done (by the same researcher) of data collected in the 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES), and the results were nearly identical.[1] The fact that the data of snapshots taken 10 years apart is nearly identical, is a powerful indicator of its significance. To some degree, this addresses your opening and Point 1.

      Beyond this, I would recommend Gene Heyman’s Addiction: A Disorder Of Choice, which contains a great review of the most relevant research which points to the same conclusions – that addiction isn’t “chronic”; that self-change is the norm; that treatment isn’t necessary, nor necessarily effective; and that abstinence isn’t necessary, nor the most likely resolution to the problem. I don’t have the book in front of me, and can’t remember all the studies covered, but the Epidemiological Catchment Area Study from the 80’s comes to mind as an example. Bottom line, there’s a lot of research out there which points to the same conclusions I’ve come to here; my opinions aren’t based on this study alone.

      On Point 1 “The data you quote represents past-year status or period prevalence. It does not represent lifetime risk, for a condition which commonly (usually) recurs.” – I think pairing this study with the NLAES study [1] strongly suggests that people tend to age out (or mature out) of addiction. That is, in snapshots taken 10 years apart, people who are surveyed at a longer interval since onset of dependence are far more likely to be recovered. If it was a lifelong or “chronic” disease, then we shouldn’t see this trend, and we certainly shouldn’t see it in 2 studies ten years apart.

      In NLAES, of those for whom dependence began within the past 5 years, 57.1% were still abusing or dependent on alcohol. In those for whom dependence began 20 or more years ago, only 12.4% percent were still abusing or dependent. In NESARC (the study covered on this page), on a similar measure, 64.9% of the ‘5 years or less since onset’ group are “still dependent” while only 6.9% of the ’20 years or more since onset’ group are still dependent. In both studies there are also ‘5-9′ and ’10-20 years since onset’ groups whose numbers evidence a steady decline of dependence with time since onset. Here’s a powerful trend shown in 2 similar studies 10 years apart.

      On Point 2 “Causation and correlation are different things” – my point exactly. When the same percentage of people are changing their habits without treatment, this data calls into question the entire notion that treatment causes recovery. Granted though “severity would feasibly be associated with treatment-seeking, as one possible confounder”, may be a good point – but as to whether it nullifies my points, I don’t think it does. Certainly the treated population runs the gamut in severity, from my experience. But what is severity anyways? – I find it to be very subjective and contextual. I’ve met people who have 3-5 glasses of wine once a week who have been to rehab and feel like their drinking is a very severe problem – and who am I to say otherwise? From their point of view, or context, it is severe.

      What would be traditionally considered an extremely severe substance use problem, say injecting heroin on a daily basis, has also proven to be a habit which people are able to solve on their own without treatment – if you’re familiar with the famous study of Vietnam era veterans – it showed that the vast majority quit using heroin without treatment!

      Then there’s some data from Project MATCH, which was the US government’s most expensive study of treatment to date, which strongly indicates that treatment has little to no effect. Although the lead researchers didn’t include a control group (which is ridiculous considering their budget), they wound up with an accidental control group anyways. A research report released in 2005 based on the MATCH data [2], found a significant number of subjects who went through intake, failed to attend even a single treatment session, yet were subsequently followed up with. It was found that these untreated subjects improved at a rate nearly equal to the treated subjects! In this study, everyone is a treatment seeker, and in fact by at least one measure (number of drinks per drinking day) the untreated group’s problem was somewhat more “severe” than those who attended the treatment to begin with. On the idea that treatment “causes” recovery, the researchers also noted that improvement for all groups happened in the first week before treatment, and that for the group receiving 12 weeks of treatment, there was only a 4% improvement over those following 12 weeks! If treatment was the cause, surely there would be a steady and dramatic rise in success throughout the 12 weeks (or maybe a huge jump at the end – but 4% total? come on!).

      These researchers [2] also mentioned that selection effects may come into play. Consider that the relative improvement of all groups in this study could be attributed to the fact that they were simply “ready, willing, and able” to change their habits, so they sought out treatment – because that’s what we’re all told by our cultural institutions we must do if we want to change such a habit. Or more simply – people who are going to quit, often choose to get treatment while they proceed to quit. If this is a real factor (which I believe it is), then that would confound our results as well, this time definitely giving undue credit to treatment.

      I’m not sure why you included point 3, or whether it is a ‘point.’

      On Point 4 – Believe it or not, I’m not a “Harm Reduction” advocate. Although I agree with some of its advocates’ premises, it includes a wide range of policies, ideas, and treatment approaches which I do not agree with or endorse. I am however an advocate of each person using whatever amount of substances that brings them what they want out of life – and I am an advocate of the belief that moderation is a completely acceptable goal. This is because:

      1) I’ve seen no objective (or even partially objective!) evidence that a “loss of control” exists.
      2) Evidence such as the above, which shows that people with past substance use problems have clearly demonstrated that a moderate usage outcome is possible and probable.

      Based on this – I would never propose to tell someone that they’re doomed to failure without abstinence. Such claims, if believed, decrease the quality of life of those who would be happier with moderate use, and may lead many of those to flip back and forth between extreme levels of substance use and abstinence – believing a middle ground is non-existent, while still desiring to use substances. That’s a dangerous self-fulfilling prophecy to create.

      On your list of conclusions:

      “1. People who have had some form of treatment are 3 times more likely to be abstinent (although we don’t know for what proportion of the sample this is the goal)”

      Agreed. Although as you said, we don’t know how many hold that as a goal. How many were convinced that this should be their goal? How do we know it is the proper goal? Would they be happier with moderation? Does the demand of abstinence lead to the lower rates of change seen in the long run with the treated group?

      It seems to be an arbitrary judgment to assume that abstinence is better than moderation.

      To look at the table “in isolation” as you said you would, is still to bring your own premises to it, just as I have. The difference in abstinence rates alone is only significant if you hold the opinion that abstinence is better than a moderate level of use – I do not hold that opinion – and I’m not sure how we could make that blanket judgment for people.

      “2. The majority of those ‘never treated’ are either still dependent or in ‘partial remission’.”

      As I discussed in the piece, the “partial remission” criteria is suspect. Going back to Dawson’s earlier NLAES study [1] – there are only 3 categories, rather than the 5 categories listed in the more recent one. In the earlier study, the categories were listed as: alcohol abuse or dependence; abstinence; and drinking without abuse or dependence. Fully half of the study population fit into that last category. It’s notable that the more recent study (NESARC) broke that last category up into three categories: partial remission; asymptomatic risk drinker; and low-risk drinker. I don’t know in which stage of the process, and by who’s design this change in study design happened – but it clearly changes the character of the results – which may have been intentional. Again though, you already have my criticism of the partial remission category in the original post.

      “3. Those ‘never treated’ are 2.4 times more likely to fall into the category of drinking at risky levels.”

      True, although I don’t know that “risk drinking” is bad, or a bad outcome, as defined in the study. Again, see my criticism of this category (and “partial remission”) in the original post above under “Point #4″ – the threshold for “risk drinking” is very low.

      4. Those never treated are more likely to be drinking in an unsafe fashion (ie. categories 1, 2 or 3).

      See my criticisms above. I don’t know that it’s actually “unsafe” or that even if it is riskier, that it’s not a level of risk the participants are happy with. It should be noted that we all happily take on risk regularly in our everyday lives because it’s worth the rewards – such as driving a car. The exposure to risk can’t be considered on it’s own to be “bad” without also considering the relative rewards to the person exposed to the risk – this would be a massive error of “context-dropping” – but then the entire recovery culture, with it’s demand for abstinence is guilty of dropping context and making judgments about what is or isn’t proper behavior for other people.

      I think much of this comes down to one’s opinions of the various categories and standards involved. I’m willing to grant some credence to the DSM’s “Alcohol Dependence” diagnostic criteria as a good description of what a substance use problem usually looks like – but at the same time, I think it casts a pretty wide net – so if you no longer fit into it, it’s extremely likely that you no longer have much of a problem. Thus with that wide net, I think it’s unfair to characterize those who fall into the other categories of ‘partial remission’ and ‘asymptomatic risk drinker’ as not recovered.

      -Steven Slate

      [1] Dawson, D.A., Correlates of past-year status among treated and untreated persons with former alcohol dependence: United States, 1992. Alcoholism: Clinical and Experimental Research, 20, 771-779, 1996
      [2] Robert B Cutler and David A Fishbain, Are alcoholism treatments effective? The Project MATCH data. BMC Public Health. 2005; 5: 75.

      • says

        Steven,

        Thanks for your considered reply.

        We agree that if someone in recovery defines their goal as low level / controlled drinking and they can achieve that and maintain it, great.

        We disagree on whether “risky level drinking’ and “partial remission/partial dependence” are desirable outcomes or not, hence we will draw different conclusions from the same data. These types of drinking have clearly established causative relationships with cardiovascular disease, depression, various cancers and injuries to self and others. (Fergusson, 2009; Rehm, 2003)

        What constitutes treatment is a broad umbrella. A body of evidence including longitudinal prospective follow-up, much less prone to errors of bias and confounding than a single retrospective snapshot, does show those not ‘in treatment’ relapse more at 3 years (Monahan, 1996; Moyer, 2002; Weisner, 2003; Moos, 2006)

        The successful remission rates that you conclude from a *cross-sectional* dataset have been debunked by longterm (10+ years) longitudinal research proving the majority of those who remit without treatment will relapse (Moos, 2006; Klingemann, 2004). It is thought that those who succeed without treatment have greater social capital and a lesser history of alcohol related sequalae, producing a self-selection bias that can be misinterpreted as a causal relationship. (Moos, 2006)

        Your company sells CBT-based treatment programs. Surely you must agree that *some* treatments do help *some* people in recovery significantly, in achieving their goal to reduce or cease drinking?

        -Mathew Carter

        Refs:

        Fergusson DM, Boden JM, Horwood LJ. Tests of Causal Links Between Alcohol Abuse or Dependence and Major Depression. Arch Gen Psychiatry. 2009 March 1, 2009;66(3):260-266.

        Klingemann H, Aeberhard M. [Biographies and addiction careers 1988–2002. Longitudinal case analyses on male and female self-healers]. Abhaengigkeiten 2004;2: 52–63

        Monahan S, Finney J. Explaining abstinence rates followingtreatment for alcohol abuse. A quantitative synthesis of patient, research design, and treatment effects. Addiction 1996;91: 787–805.

        Moos RH. Rates and predictors of relapse after natural and treated remission from alcohol use disorders. Addiction. 2006;101(2):212.

        Moyer A, Finney JW. Outcomes for untreated individuals involved in randomized trials of alcohol treatment. J Subst Abuse Treat 2002;23: 247–52.

        Rehm J. Alcohol as a risk factor for global burden of disease. European addiction research. 2003;9(4):157.

        Weisner C, Matzger H, Kaskutas LA. How important is treatment? One-year outcomes of treated and untreated alcohol-dependent individuals. Addiction 2003;98: 901–11

        • says

          Matthew,

          I think we will definitely have to agree to disagree on those categories, my reasons having already been covered above. Also, I just can’t bring myself to decide whether the various trade-offs involved with different levels of substance use are worth it or not for any individual. An analogy may help to explain myself here. The cast of MTV’s Jackass suffer all manner of injuries due to their stunts. I would never want to suffer such injuries. But to them, it’s worth it, for whatever reasons – fame, money, ego, bragging rights, machismo, etc. The various scars they’re left with could certainly be considered an unfavorable outcome by many, but all that really matters is whether it was worth it from their own judgment. Likewise, someone may risk cancer by drinking, but they may view the risk as “worth it” when compared against whatever rewards they receive. So I think we have an honest philosophical disagreement here.

          I’m fine making my conclusions with a retrospective snapshot (and especially, considering that I’ve seen other snapshots coming up with nearly identical results). To distrust it, would be like distrusting demographic sales records indicating how many people downloaded a Justin Bieber song in the past month: The records would likely show far more 14 year olds than 40 year olds would have downloaded the teeny bopper’s tunes. However, you would have me believe that an equal number of 40 year olds are downloading Justin Bieber tracks, but we just didn’t happen to catch them at a time when they did so.

          On This: “The successful remission rates that you conclude from a *cross-sectional* dataset have been debunked by longterm (10+ years) longitudinal research proving the majority of those who remit without treatment will relapse (Moos, 2006; Klingemann, 2004)” and “those not ‘in treatment’ relapse more at 3 years.”

          I’m not able to track down or access the Klingemann study (and I happen to appreciate some of his work), but the Moos study is highly suspect. These aren’t just untreated self-changers who are relapsing after 3 years – specifically, they are people who sought treatment, but didn’t get it within the first year after seeking it. He doesn’t seem to give the numbers of how many got treatment after the first year, but indicates that some portion of them did – yet we’re now counting them as untreated self-changing relapsers? That study design is too strange for me to conclude that self-changers have a higher rate of relapse from it.

          My company doesn’t sell a CBT based treatment, but I don’t fault you for misunderstanding. First, we don’t “treat” anyone, because we don’t view addiction as a disease – thus we have no therapists, psychiatrists, doctors, or counselors. Second, our program is purely educational, and not at all therapeutic. Third, we agree with one premise of CBT, but we go so far beyond that, that it would be highly inaccurate to say our program is CBT based. CBT has an empowering message to a degree, but it tends to promote reactivity – the power of one’s thought is always placed only in reference to external things and events (this may also have the side effect of paradoxically instilling an external locus of control). Our Cognitive Behavioral Education (CBE) curriculum is designed to go beyond reactivity, and teach proactivity – so that among other things, people can learn to stop being ruled by circumstance and move on with their lives – so they can move towards building the life they want, rather than running away from a life they don’t want.

          I wouldn’t argue with any individual’s personal experience of whether a treatment helped them or not – except to say that all change is self-change, and they should give themselves the credit. You might think that a certain counselor, or treatment activity of some kind helped you to change – and if it helped you to realize something or look at things differently or whatever, then sure, it helped you. But I would argue with people who say that treatment is necessary or works on a whole- because I don’t believe it does, statistically – to the degree that it does “work”, in accordance with the data presented in NESARC and other studies, it’s only taking credit for change that would’ve occurred without it. That is, if 75% change with treatment, and 75% change without it – then it’s a wash. It’s like (and I know this is an imperfect comparison, because a cold is an actual illness) giving people a homeopathic remedy to get over a cold, and then attributing their recovery to it – even though they would’ve gotten over the cold on their own – and even though there is no evidence that any greater percentage of people get over colds with your remedy than without it. There may be some helpful practices in the treatment world here and there, but they’re far outweighed by the unhelpful and counterproductive practices in my opinion.

          The concession I will make to medicine, is that detox can be necessary, and helpful. But this has nothing to do with a long term change in one’s behavior which is supposedly addressed in “treatment.”

          -Steven

          • says

            I should also say that in the Moos study, this seems extremely noteworthy:

            “A total of 121 of the 628 baseline participants (19.3%) had died by the 16-year follow-up.”

            A 19.3% death rate over 16 years seems HUGE to me. Maybe I’m wrong, idk. But it’s so notable, that you’d think the researcher would let us know which percentage of those who died received treatment or didn’t receive treatment. I don’t bring this up to disqualify anything you’ve said, I just bring it up to say: WOW, I really want to know more about that. Did he address this somewhere and I just missed it?

            -Steven

          • says

            Steven,

            I suspect we’d both agree that much of the research in this area is methodologically unsound and of questionable use. As flimsy as a house of cards, in many respects.

            Dusting off my doctor’s hat, I’m pleased to note your perspective on the specific and limited role of detox in the short term, particularly with regards to alcohol, as the grand mal seizures that can occur in that first couple of weeks can be fatal. Unfortunately the medications we on occasion use to prevent such seizures are themselves very addictive, as you probably know!

            Personally, thanks for clarifying the role of your program, my own experience is similar, that personal empowerment is the key to recovery.

            When we break a leg we may need a crutch, to start walking again, but after a while the crutch slows us down. :-)

            I look forward to reading more of your blog.

            Best wishes,

            Mathew Carter
            Perth
            Australia

  4. says

    “does show those not ‘in treatment’ relapse more at 3 years”

    Addiction is not a disease. Relapse is not the appropriate term, but used by 12 Step proselytizers to legitimize their faith-healing. Moreover, why is it any of your business how someone chooses to live their life? I ask that you please refrain from responding with the ‘argument from authority’ typical of the quacks in your profession.

    • says

      Ryan,

      As a fan of constructive dialogue, I’m going to forgive the aggressive/passive-aggressive tone and respond. :-)

      I’m not, personally, a fan of 12-step programs, in terms of their dogmatic and religion based approach, and I do think we should scrutinise and dissect the 12-step model closely.

      I do speak as an ex-clinician, and I agree that the medical/biological model is not much use in addiction.

      I do speak as a multidisciplinary researcher.

      I also speak from personal experience. I’m sorry that you took offence at the terms I use to understand recovery, as I see it and as I have lived it.

      -Mathew

  5. says

    Sorry for misunderstanding. Most if not all clinicians and treatment professionals I’ve encountered on and off venues that consider pathways for “recovery” from addiction would not agree with you! As an exAA myself I must admit to my immense appreciation for websites such as this that tend to validate my very negative experience in “recovery.” Again I apologize for assuming your stance and my passive-aggressive retort. To say the least, I have immense anger towards the addiction and mental health industries, especially following the intentional death of a close family member after undergoing such “treatment.” I am pleasantly surprised at your apparent open-mindedness and wonder why I have never met or heard of a “treatment professional” (clinician) such as yourself who do not endorse the 12 Step methodology. Very scary stuff! Is attending over 1000 meetings and compliant with all dogmatic requirements for membership serve as familiarity sufficient to scrutinize the 12 Step “approach.” I feel inclined to pose more questions to an ex-clinician of your stature but will pause for the moment. My “disease” is getting tired and I am preparing for the 3 year benchmark which your study warns is the time I will “relapse.”

    • says

      Ryan,

      I am sorry to hear of your loss.

      That’s very kind of you to offer an apology, but it’s not really necessary, I’m pretty thick skinned :-), and I don’t claim any stature in particular, just an open and inquiring mind, as I suspect both you and the blog author also have, this is arguably more valuable in understanding or achieving this nebulous concept of “recovery” than any collection of post-nominals, in my personal opinion.

      Your duration of involvement with AA far exceeds what mine was, and you understand what AA is like from the inside far better than me. We have alternatives available to many here in Australia, although AA is still the only type of peer support accessible to many people.

      The 3 year cut-off in that study was probably arbitrary, it’s a trend more than a discrete time-frame.

      Best wishes

    • Don says

      Ryan
      It sounds like, after some difficulty, you have discovered some of your own “pathways” to success. I wonder if you might take the time to list some of the key things or processes that you have found to be helpful. I am new to this site but I have been working, on and off, at “recovery” for a long time without much success.
      Thank you for anything you can offer and best wishes to you.
      -Don

  6. says

    Thank you for your considerate response. I was worried of being labeled and rediagnosed as “passive-agression” has already been pathologized in the DSMV! Yes, my sister was very near to me. She had an inquiring mind too, but was told by certified physicians that it was a symptom of a “disease” that can’t be observed under a microscope but required soul surgery administered by “old-timers” who may or may not have been convicted felons or rapists. It hurts so much sometimes to think about. Best wishes your way too.

  7. says

    Now when I go to AA or NA, I make a pointed decision to state that addiction is a choice. I have yet been thrown out of a meeting. I get dirty indignant looks, but the “traditions” work in my favor in that I have ther right to speak my mind, as there are no “governing authorities”

    I go most of the time, because I’m bored and want to be around some people for awhile. Oh, here’s a tip: if you want to say something controversial at a 12 step meeting: wait until close to the end of the meeting, and then speak your mind. Most meetings don’t allow “double dippers”

  8. says

    I have also found that I have been working the “steps” my whole life. It was not some new concept that NA or AA introduced to me. Alot of the steps are just common sense. For example, I’ve done “service work” for years (giving to charities, helping the old lady across the street, etc.) – more meaningful, constructive, and altruistic, in my opinon, than volunteering at some 12 step function.

    Also, I never subscribed to the whole “work them in order” concept either. When the opportunity presents itself to do something like “make an amend” I do it…..or not.

    The underlying belief is that if you “work the steps” you get cured of the disease, if I am not mistaken. But that contradicts the whole disease concept: addiction is some inherent malady.

    I have come to my conclusions because of my “relapses”. They taught me the law of physics: with every action comes an equal (more or less) reaction.

  9. Clive Hallam says

    A really thought-provoking article by Steven Slate. As a commissioner of services in the UK, I have become increasingly concerned by the industrialising of treatment and the way in which, increasingly, authorities look to re-classify dependencies, risk, etc., to fulfil a requirement to a) demonise sections of society and, b) to provide quasi-jobs for individuals in a non-existant industry.
    More could be served by encouraging communities that care and jobs for those communities to aspire to. Here in the UK, with the demise of the coal industry in the late 1980s / early 1990s swathes of communities were left with little reason to exist. The vacuum left behind generated space for a trade in drugs, followed by a trade in treatment, which continues to this day. I started in the “industry”, as a naive individual in 2003 and have become increasingly concerned that we don’t really treat anybody, but often replace one dependency with another. Those who enter the system spend years swapping their substance dependence with dependency on services. What is concerning is that nobody seems to want to put effort into an active community that says “you’re worth something as an individual, and I’d like to trade your skills and knowledge for mine” – surely the best way of dealing with this situation.
    I also agree with the author’s concern over the way fear is used to drive those in treatment towards abstinence (if that paraphrase is wide of the mark, I apologise). Everyone is capable of singular attraction to certain things whether it is drinking, drugs, gambling, food are any number of other things, and I too do not subscribe to the diseases model. Everyone also has the capacity to make a change, however small or imperfect. People are usually able to make change earlier or later than their peers, where this is needed. This is just my view, I’m not espousing a creed, or doctrine, political or a scientific view. More, I’m concerned about a world where, increasingly, our right to self-determine can be eroded by the fears manufactured by those “in charge”.
    People are their own greatest recovery asset.

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