Monday, November 1, 2010

Some Contentions/Misconceptions about AA and Mainstream Treatment

This is Part II of a look at some often-heard (or, at least, posted on the internet) statements that might elicit much doubt in people pursuing mainstream treatments for alcohol/drug problems -- with my attempt to provide balance. The last post focused on statements regarding the nature of alcoholism/addiction and recovery. The subject of the current post is statements about AA (and other self-help groups) and about treatment approaches.

AA loses many of its attendees shortly after their first exposure to the program, and 95% by the end of the first year.
It’s been my repeated experience that most people don’t like AA when they first attend, and not surprising that many drop away, especially if they are far from feeling ready to embrace a goal of abstinence. I wonder if the percentages often quoted are misleading, since my experience is that many of the same people return and connect to AA months or years later. Those who find another program for the same purpose, such as SMART, may find that their needs for recovery support are well met there. And while AA has been so successful that there are now over 115,000 groups meeting regularly around the world, more alternatives are clearly needed. (Here in Massachusetts, the only non-12 step peer program that has any kind of meaningful presence is SMART Recovery.) The early dropout rate (but not necessarily the outcome) is probably somewhat lower for professionally-run programs, where there would be a stronger sense of obligation (to a particular person) to continue to attend. But I don’t know of any professional program that offers groups available so conveniently and frequently over the long term (and if there is one, it would involve ever-escalating financial burden).

If a medication treatment was only successful on 5% of patients (the percentage of new AA attendees still regularly attending a year later), it would never be FDA approved.
I’m not so sure about that. If there were a medication that was highly effective for 5% of those with a given illness, and if no other treatment were more widely effective, I think it would be approved. The fact that people drift away from AA does not, by the way, prove that it is ineffective, only that people tend not to keep up the new behavior. You’d find a similar trend, for example, in how many heart patients who have never exercised are still going to the gym regularly a year after they begin – that doesn’t mean that exercise is ineffective, only that it’s difficult to get people to stick with it. Nevertheless, let’s keep looking for treatments that are more likely to keep alcoholics/addicts involved, and that have a salutary effect on their alcohol/drug use.

Twelve step programs teach people that they are powerless, which leads them to keep relapsing because they don’t think they have the power to stop drinking.
The AA notion is that the alcoholic is powerless over drinking – i.e., once s/he begins to drink, s/he loses the capacity to exert control. (For other 12-step programs, substitute the other addictive behavior for the object of powerlessness.) This does not mean that one is powerless of everything in one’s life. In fact, it clarifies the importance of one’s ability and personal responsibility to do what it takes to avoid taking the first drink. (But it takes a lot more than for a non-alcoholic to make that choice.)

AA should not claim to be the only way to recover. People should not be told that they are doomed to failure or death unless they keep coming. Most people drop out – they should know that AA is not their own option.
I don’t believe that the founders of AA ever took the position that they had found the only way for anyone to get sober – just that it was the only way that had worked for them. The 12 steps are phrased not as “You should” or “You must,” but as “We did” – in other words, here is our example, which you may or may not find applicable to yourself. Certainly, it is not uncommon to hear someone say that those to fail to make use of AA are destined for failure, but this is the opinion of individuals, not the program. It is likely based on having seen many alcoholics who did not stick, and whose lives continued to deteriorate. But AA itself, in its recurrent surveys, indicates that only a minority of new attendees form a lasting connection with the program. People getting ready to take a shot at sobriety who do not already have a positive connection with any particular approach should certainly be informed about the full range of options for treatment and support, none of which has consistently been proven superior to the others. [See below, discussion of Project MATCH.]

Treatment providers get attached to their own ideas about what should work, sometimes from their own personal experience, overriding their objectivity and thus shortchanging those who come to them for help.
Yes, this is in the realm of “cognitive dissonance.” We are all inclined to want to stick with beliefs into which we’ve already invested a lot of time, effort, etc., and to be motivated to dismiss or ignore contrary evidence. But it is equally true for those who firmly and vehemently embrace alternative perspectives and treatment approaches. My two cents: Whenever someone says, “I know the right way, the only way, the unimpeachable truth” – it’s a good time to politely excuse yourself and briskly walk away.

So-and-so’s exciting new form of treatment is the one that really works. OR: No treatment works for alcohol or drug dependence.
Project MATCH was a large, seminal multi-site study of over 1700 patients conducted under the aegis of the National Institute on Alcohol Abuse and Alcoholism for several years beginning 1989 (findings reported in 1996). Most people anticipated that certain treatment approaches would work better for certain patients considered well-matched (who would be considered well-matched based on characteristics such as severity of drinking, cognitive impairment, conceptual level, motivation for change, gender). As it turned out, all 3 treatment approaches (12-step oriented, cognitive behavioral, and motivational) were about equally effective, regardless of patient characteristics. The degree of improvement, regardless of type of treatment, was considered impressive because of dramatic and sustained reduction in drinkin (though unfortunately there was no control group of patients receiving no treatment). Many studies have found that more treatment is associated with better outcomes than less treatment, and in this respect AA has some advantages, since it is (a) free, thus cost is no obstacle and (b) more available than any other resource (with regard to numbers and frequency of accessible meetings).