Monday, October 25, 2010

Responding to Anti-Abstinence and Anti-AA Claims

If you were to web-search topics like AA and sobriety these days, you would actually come across more web sites challenging prevailing treatment approaches and beliefs (including the “Disease Model”) than representing the points of view of the vast majority of professionals in the field. I suppose the same may be true for other conditions – there must be loads of sites touting the efficacy of exotic cancer treatments or of zinc or Vitamin C for the common cold (neither of which are regarded as helpful by actual experts).

As you can surmise, I’m probably closer to the mainstream in my ways of looking at alcoholism and drug addiction. But I have never been a “joiner” or a “true believer” in pretty much anything, and I like to think that the plus side of my chronic uncertainty is that it keeps me inclined toward objectivity, or at least willingness to hear many sides of an argument. I feel like most of what I’ve concluded was learned from listening to and observing my patients in the last few decades. I also hate contentious squabbling, perhaps a result of my own upbringing in an alcoholic family, and unfortunately for me there is quite a lot of infighting among those who share a wish to reduce the human suffering that flows from addictions (or, for some, substitute “a wish to attain wealth or reputation by marketing solutions to addiction”).

As I’ve mentioned in a previous posting, we never suffer a paucity of new books exclaiming, as if they were the first to discover a truth, that alcoholism is not a disease, and that its most prevalent support group, AA, is wrong or bad or at least misleading. The latest to be sent my way, whose title is fairly gentle in noting that AA is “not the only way,” comes from a young woman who begins the book with her own extremely chaotic story of drug abuse and bipolar disorder, a story that one senses is far from having reached a stable denouement. She goes on, in this book that carries endorsements from two prominent behavioral addiction psychologists, to convey a series of positions, opinions and “facts” that are very much in accord with many of the aforementioned web sites. The problem with these kinds of assertions is that, just like many that come from the AA side of the fence, they don’t provide any kind of balance. It is like looking to the Republican or Democratic National Committee for a “fair and balanced” perspective on our national interests. [Let me mention, although I am refraining from advertising this book, put out by a small Alaskan publisher of all alternative-addiction-treatment books, that the bulk of the book provides a fine compendium of alcoholism treatment providers who offer alternatives to AA.]

Reading the introductory section of the book inspired me to repeat and offer some counterpoint to a number of antagonistic contentions that one hears redundantly, and which must be quite confusing to the consumer seeking some kind of map for navigating alcohol/drug treatment territory. The bold-faced statements are my way of restating these assertions, and do not represent my own perspectives, which are summarized in the paragraphs that follow each statement. Some of my perspectives are based on available research; many of them are based on my clinical experience.

Since there are many arguments to address, I’m breaking this entry into 2 posts. This one will address the phenomenon of alcoholism/addiction. The next one, coming soon, will address various perspectives on the value of AA, and by extension NA and other 12-step programs (the most commonly recommended and widely utilized kind of help for these problems).

Some Contentions/Misconceptions about Alcoholism/Addiction:

Alcoholism is not a progressive disease because it is not always progressive.
True enough that there are plenty of cases where an individual may actually be drinking less alcohol, or less frequently, later in life than earlier. I can think of a couple of atypical cases I’ve seen where people who exhibited daily uncontrolled drinking through their 30s were drinking only once a week, and often fairly lightly, at age 60. Please note: (a) These cases are atypical, not the rule; (b) When I’ve seen this phenomenon, generally the less severe drinking remains an unstable, unpredictable pattern.

77%, or 82%, of all kind of figures, of those with alcohol problems recover on their own.
It does seem that some people do, though these high figures raise questions about methodology and interpretation. To the extent that many alcoholics are recovering spontaneously, that’s great. (I’d like to meet them!) My guess, however, is that most of these are alcohol abusers and not alcoholic in the sense that most of us in the field understand the term (close to what the current diagnostic manual calls “alcohol dependence”). These days, someone can do a questionable study (almost always knowing what they want to prove before they begin – on either side of any dispute) and post their findings, which before you know it go viral and are being quoted as fact.

A very large epidemiologic study (known as NESARC) begun in 2001 initially found that 75% of those deemed alcohol dependent in community samples (simply by virtue of self-report in retrospective interviews) were in better shape (not necessarily in consistent recovery) during the year just before the interview than they had been the year before that. Most of these individuals had never entered any kind of treatment. But when these people were re-interviewed a couple of years later, the majority found that their drinking problems returned. So, while it does seem to be true that most problem drinkers never get help, it does not mean that most of them recover in a lasting way. Existing treatments leave much to be desired, but seem to be better than no treatment. It’s worth mentioning that almost everyone who comes to see someone like me has already tried more than once to overcome the problem on their own, often with temporarily good results that did not last. Finally, there is also no question that environment plays a major role. A move to less stressful circumstances (famously, soldiers who leave a war zone), to less enabling circumstances (such as a new, less codependent spouse) may very well have a more powerful impact than treatment.

Treatments that focus solely on alcohol and drugs can do someone a disservice by not treating a co-existing mental illness such as a mood disorder.
True. But people seem so much readier to view depression as an illness than to see alcoholism/addiction in that light. On what basis? Over the years, many substance abuse treatment settings have ignored other mental health disorders, and it is at least equally true that many mental health treatment settings have completely ignored their patients’ alcohol and drug problems. Both are cases of “not my department” or of “when your only tool is a hammer, everything looks like a nail.” Ignoring either kind of condition reduces the chances of a good outcome.

Alcoholic drinking is a learned behavior, not a disease.
It turns out that many things in life are more complicated than that. Behavioral conditions, including addiction, depression, anxiety, and more, develop as the result of multiple converging factors, including both biology and learning, and might not express themselves if either of those factors were absent. But let’s compare a learned behavior that has a biological component (e.g., chronic smoking) with one that probably does not (e.g., driving on the right side of the road). One person gives up cigarettes; the other moves to England (where they drive on the left). They both now have an opportunity to relearn the habituated behavior in question. Let’s look in on them a month later – see any difference?

There is no science behind the assertion that addiction is a disease.
Aside from semantics (e.g., addiction is clearly not the same kind of disease as the measles), the evidence of important genetic/neurobiological factors in addiction has been accumulating for many years, and is overwhelming. The best central resource for reviewing this information yourself is NIDA, the (highly scientific) National Institute on Drug Abuse ( NIDA is quite open to acknowledging a large range of treatment options, and always looking for whatever shows promise.

The idea that all alcoholics must seek abstinence is a myth; lots of alcoholics become normal drinkers.
Actually, there is little evidence that moderate drinking is a workable goal for the vast majority of alcoholics. Even those studies indicating that some return to moderate drinking, upon further examination, find that (a) this only happens for a small minority, generally somewhere between 5% and 20%, and that (b) as time goes by, those moderate drinkers tend to slide back into alcoholic drinking – so it matters at what point in time you look at outcomes. The consensus among most professionals in the field is that (a) abstinence is by far a more stable outcome, and that (b) those who do return for non-problem drinking for any period of time had fewer symptoms of dependence in the first place – in other words, might not have been considered clearly alcoholic in the first place. For essentially normal drinkers who happen to abuse alcohol enough to cause problems (such as a drunk driving arrest), yes, they may very well return to moderate drinking just by gaining maturity or learning from experience.

Next post: Some Contentions/Misconceptions about AA and Mainstream Treatment.