The Sober Truth
Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry
By Lance Dodes
and Zachary Dodes
Beacon Press. 179 pp. $26.95.
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Reviewed by Evi Heilbrunn
When the Prohibition Act was repealed in 1933, an old issue arose: What to do about the drunks?
Within a few years, Bill Wilson, a religious fundamentalist and an alcoholic himself, established Alcoholics Anonymous (AA), a program that guaranteed results if its participants followed 12 steps based upon the meaning of the Twelve Apostles.
Almost a century later, AA remains the main source of help for alcoholics despite the evidence cited by Lance Dodes indicating that the 12-step program fails to work for most people.
That view is a key takeaway from The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, the latest book on addiction by Dodes, a recently retired psychiatrist and Harvard professor, coauthored with his son, Zachary Dodes.
The book centers on the cultural and medical history of Alcoholics Anonymous, the progenitor 12-step program that has come to serve as the backbone of America's substance-abuse treatments.
Dodes cites work showing that the success rate of Alcoholics Anonymous is less than 10 percent. The Cochrane Collaboration, in a 2006 review of nearly 40 years of work, found that "no experimental studies unequivocally demonstrated the effectiveness of AA."
For Dodes, 12-step programs and drug-rehab centers both fail in one major way: they do not focus on individual recovery. Whether attending a meeting in a church basement or strolling the groomed grounds at the Betty Ford Center, the 12-step model is rooted in shared feelings and discipline. The AA bible, the "Big Book," says "rarely have we seen a person fail who has thoroughly followed our path."
But it also warns that "there are such unfortunates," implying that if AA doesn't work, the fault lies with the drinker. Also troubling to Dodes is that counselors, therapists, and psychologists - those who could most help the afflicted - are rarely involved in the Alcoholics Anonymous model.
Dodes claims that instead of focusing on the root cause of a patient's addiction, public officials and professionals continue referring addicts to the free 12-step approach. The psychiatrist proposes that these programs not remain the sole prescription for addicts. Instead, he champions individual counseling. Likewise, rehab centers should adjust their focus from the group to the individual, making psychotherapy the backbone of the experience.
What individual counseling may accomplish is getting to the root of an addict's problem. According to Dodes, abstinence is not the solution and may just spur addicts to revert to their old ways. Alcoholics Anonymous' abstinence prescription, then, sets people up to fail.
To move past an addiction, one must understand what the addiction - the activity, the drug, the food - signifies. "Every addictive act is a substitute for a more direct behavior," Dodes writes. "When people act directly, there can be no addiction."
Looking forward, the Affordable Care Act's requirement that insurers to cover psychological services and substance-abuse care may lead to more affordable, individual treatment options.
Historically, though, the free aspect of Alcoholics Anonymous may be what makes it the most attractive, first step.
" 'No cost' is huge," said Emily Duffy, a behavior health consultant at 11th Street Family Health Services at Drexel University, who often refers patients to Alcoholics Anonymous. While individual therapy may work for some, the expense far exceeds what many in these meetings can pay.
The burden of addiction may also be easier to swallow in a room full of other addicts. "You have a common story, a common experience," Duffy added.
Put in that light, Alcoholics Anonymous can be one of many steps involved in grappling with a problem that requires "ongoing management and maintenance in care," said Lee Kaskutas, codirector of training of the Alcohol Research Group and an Associate Adjunct Professor at U.C. Berkeley.
Some 5 million people attend meetings every year and anonymity is a core part of each one. From its earliest days, Alcoholics Anonymous was about offering an open space for a marginalized group, where they could speak freely and emotionally, away from a society that shunned them.
Kaskutas emphasized that experimental studies are just one measure - among six - to evaluate Alcoholics Anonymous' effectiveness. "Higher response rates and follow-periods" in studies could challenge Dodes' conclusion that Alcoholics Anonymous' success rate is under 10 percent, she said.
She noted that there will always be those who are turned off by AA's religious undertones.
But ultimately, "choice is really good," she said. "Some people need that white-coat therapist," while others want a program that's "free and in the neighborhood."