By: Robert Schmidt, M.A.
Published in The Atlantic today, http://www.theatlantic.com/features/archive/2015/03/the-irrationality-of-alcoholics-anonymous/386255/?utm_source=SFFB.
A few thoughts:
1. Why does it matter whether or not addiction is a disease? Labeling it as such only serves to leverage payment (rightly so) from health insurance providers for treatment.
The use of the word “disease” should be a non-factor in the treatment of individuals who are tasked with creating unique personal narratives on their alcohol use in the evidence based psychological treatment models that Gabrielle Glaser correctly references here.
Although, it is also clear that Glaser is a big supporter of the use of medication treatments for alcohol and substance use disorders, a topic which deserves consideration in long form on another day.
2. Glaser argues that AA takes a cookie cutter approach, recommending complete abstinence for those who might be better served by “moderation” styled approaches. However, there is another side to that coin... Yes, there is a danger that complete abstinence is an overreaction for some and that this approach is really meant for those on the “severe” end of the bell curve, but so is harm reduction! The whole idea of moderating one's use and limiting harms is based on the precedents set by the needle exchange programs and the legislating of prostitution in Amsterdam. So, it is the same thing all over again: we are basing our treatment recommendations on evidence collected at the “severe” end of the spectrum, only this time we are taking the risk of under prescribing instead of over prescribing levels of abstinence.
3. To say that AA is unscientific is a lazy criticism. After having successfully met the standards of certain prescribed phases of scientific rigor, treatment approaches are labeled as “evidence based.” There are several factors that are considered in this process, including the efficacy of the treatment as well as the cost and the ease with which it can be dispersed.
Efficacy is in interesting term which the Ms. Glaser uses several times: either incorrectly, or misleadingly. Treatment efficacy refers to either the statistical significance or (preferably) the statistical effect size of a treatment in a controlled setting. To be clear: efficacy studies are conducted in laboratories. So to say that there is no proven efficacy for AA is misleading because it cannot be conducted in a controlled setting. AA has long been implemented in the public sphere, so to bring it into a laboratory setting would be to alter it fundamentally. It is impossible to measure the efficacy of AA, because there is no way to design an experiment for it.
Scientific investigations of treatments outside of the lab (ie, real world applications of treatments) are known as “effectiveness studies.” This is an important distinction because in order for a treatment to be labeled with an “evidence based” endorsement it must first have been validated for efficacy and then for effectiveness.
This is important because of all the qualities that should be celebrated about AA (and there are many), perhaps the most heroic is the fact that AA is widely available and accessible: even to those who subsist on the lowest rungs of our socio-economic ladder. The value of that quality cannot be overstated.
Note: I strongly believe that the average individual in our culture does not fully appreciate or even understand exactly how rigorous the scientific process actually is. Science moves at a much slower pace than most people think. And, when considering the science of psychology, we are talking about something that is so complex and difficult to control for that it has only really been in existence for about 60 years (give or take).
And, even that doesn't distinguish it from medicine very much. A prominent neurologist recently told me that 90% of the treatments he recommends for his patients are not evidence based: these are treatments like acupuncture, physical therapy, dieting etc…
Glasser also references several studies comparing the long term outcomes of AA to evidence based treatments saying that AA's success rate is likely in the single digits. Three things to to keep in mind here: A) "success" is a loosely defined term, B) follow up's rarely go past six months, and C) outcome measurements are inevitably based on self reports, (ie. asking the alcoholics how much they have been drinking: ie, asking them to lie).
4. Glaser’s criticism of alcohol use disorder treatments as having been corrupted for years by the ubiquity of AA, fails to acknowledge the importance of that ubiquity. She is solely talking about the implementation of alcohol and substance use disorder treatment in centers and practices which actually collect money for their services. And undoubtedly, she has a strong argument in her call for quality assurance here.
However; when one decides to use their finger to plug a hole in the dyke, there is always a good chance that a new leak may spring elsewhere.
Does the promotion of medication treatments not serve to further empower the greedy pharmaceutical companies that make up so many of the top Fortune 500's already? The same companies that so mishandled the AIDS epidemic in the 80’s and 90’s that they are responsible for the deaths of tens of millions in Africa http://fireintheblood.com/ . The same pharmaceutical companies that produce Oxycontin, Percocet, Vicodin, and Xanax...
Does the promotion of evidence based psychological treatments such as CBT and Motivational Interviewing ensure that those techniques will be carried out with any more standardization than the current approach?
I will tell you that it does not, because I have studied these techniques in depth and I have worked in centers which utilize them. In my experience it is just as easy for someone to say they are doing CBT and actually do nothing, as it is for them to say they are doing AA and do the same.
What is the current approach anyway? I have traveled the country visiting treatment centers and I have taken courses on the treatment of substance use disorders in multiple settings at the graduate and the undergraduate levels. It seems like everywhere I go my colleagues are speaking in the same voice as Glaser in this Atlantic article. I rarely hear professionals say that they are using AA or the 12 steps anymore. Mostly everyone is using “evidence based” treatments now, and mostly everyone who actually works in the field (unlike Ms. Glasser who is a journalist) is aware of the changing trends towards evidence based treatments and harm reduction. As a matter of fact, I doubt there is any one who would really argue against the need to be more scientific.
Yet, we are still fighting an uphill battle. It would be naive to think that we only need to do X,Y, and Z in order to reduce the impact of alcohol and substance use on individuals and on our society. It is a gigantic problem because it is not simply solved. Let’s not be so reductionist about this and let’s make sure that before we go ahead and decide that AA (something that is widespread and free and already functioning well) is no good, let’s make sure we really mean it.
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