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Has The Medical Profession Asked WHY ?

Question:

Note: The writer is commenting on my recent essay “AA is a cult?“, and is addressing alcohol addiction and Alcoholics Anonymous with her statement below:

I would like to ask Dr. Dombeck a question. We hear all of the time that “treatment works”. However, we also hear the miserable statistics of relapse back into destructive drinking and drug use. People are told when then enter treatment, “only 1 in 10 of you will make it”. My question is, has the Medical Profession asked WHY? Have they asked why treatment fails so many? Have they asked why so many people relapse back into destructive drinking and using of drugs? Does the medical profession REALLY BELIEVE it is because these people are all constitutionally incapable? Does the medical profession REALLY BELIEVE it is because these people haven’t gotten “right with God”? Does the medical profession REALLY BELIEVE it is because these people don’t attend AA meetings and “share” their stories? Have they even considered that the treatment itself is ineffective? Somewhere around 93-95% of the treatment centers in this country use 12-step facilitation. Sorry, I guess this is more than one question. I just find it hard to believe that in the 21st century the medical profession would treat a disease with faith healing. I really do, and I’m trying hard to understand.

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Answer:

I’ll do what I can to answer your questions here. Please keep in mind that I cannot speak for all doctors, and that I do not know all the answers. Just some of them. Also keep in mind that a treatment is something different than a cure. A cure is something that works 100 percent of the time – you take the cure and you’re done. There is no cure for addiction; there is only treatment. Addiction is kind of like cancer: a serious and persistent illness. You can go into remission (and many people do), but you always remain in a heightened state of vulnerability for a new “outbreak” of the condition compared to someone who never had the condition in the first place. Treatments don’t work 100 percent of the time, but they do work some of the time, and that is why we recommend them. The right question is not “why doesn’t treatment work?”, but rather something more like “what combination of treatments will give patients the best chance of successfully managing their problems?”.

Your questions are:

has the Medical Profession asked why treatment fails so many?

Yes, of course. Trying to improve treatment successes is a major drive of all clinical research. The question is asked constantly, and even small changes in treatment technique that lead to more people being successfully helped to stay off drugs or alcohol (in this context) tend to be widely adopted and to make the originator of the new technique famous. Treatment professionals are conservative, however, in that they don’t want to start recommending unproven techniques. Generally, there needs to be well regarded research that demonstrates that a new approach has merit before it is widely adopted. In the recent generations, numerous new techniques for treating addictions have been developed, including relapse prevention and motivational interviewing. There are also trends towards using mindfulness approaches to increase awareness throughout many forms of therapy over the last 15 years. There is no silver bullet, however, and the siren cry of addiction remains very strong.

Have they asked why so many people relapse back into destructive drinking and using of drugs?

Yes, of course. The reasons why people relapse back into drinking and drugs are fairly well understood today. Addiction is known to be more than just a physiological habit, but also a strong set of psychological habits, a self-identity and a lifestyle. All of these habits must be altered before the addict is free. This means, the addict needs new friends, new means of coping with stress, new relationships with his or her environment and new ways of thinking about everything. Some addicts remain vulnerable to new outbreaks of addiction also because they were born differentially sensitive to their drug of choice’s effects. No superficial approach to treating addictions will work for the most part, and no short term treatment will tend to have a good effect – in both cases, because superficial or short term treatments are not powerful or long enough in duration to change all these habits; to change the addicts’ mind and body.

Does the medical profession REALLY BELIEVE it is because these people are all constitutionally incapable? Does the medical profession REALLY BELIEVE it is because these people haven’t gotten “right with God”?

The “medical profession” (I’m speaking more for psychologists than medical doctors here, but I think they’d agree) does not think of addiction in terms of moral failure, sin or God, but rather in terms of bio-psycho-social disease states, and rewards and punishments. People stay addicts because for them the rewards of using a drug outweigh the many punishments that they must endure to continue using the drug. Most treatments for addiction are aimed at trying to change the addicts perception of rewards and punishments for using their drugs. Addiction programs try to make people accountable by doing drug tests; they try to make people aware of how they relapse by teaching relapse prevention. Drugs may be given to the addict that make it feel nasty to take the drug (antabuse). Detoxifications are programs that help people through the worse of their withdrawals in a safe manner so that they don’t get quite so punished by their bodies for remaining clean. Even jail time is theoretically a punishment or consequence for using.

Ultimately, however, treatments are outside efforts at changing an addicts perception of the rewards and punishments for using. If the addict doesn’t buy into these efforts, then they won’t sink in and the addict will find a way to get back to using (because his or her analysis of the costs and benefits will remain unchanged). It’s not totally this simple or rational, but it is sort of this way. Ultimately, if the addict doesn’t choose to take responsibility for being clean and sober; doesn’t decide to do so because he or she fundamentally understands that it is in his or her best interests to do so, then he or she won’t remain sober. Treatment doesn’t work all the time because it cannot be continually imposed from the outside all the time but instead has to be chosen to be internalized and lived. getting sober is ultimately a choice that people embrace or don’t embrace; it is not something that (most of them) are incapable of doing. God may be a path towards sobriety for many, but sobriety is an individual choice that the addict makes, not God.

Does the medical profession REALLY BELIEVE it (relapse) is because these people don’t attend AA meetings and “share” their stories?

Attending AA and sharing your story is helpful to an addict because it continues to help the addict maintain a heightened awareness of the negative consequences of drinking and drugging, it keeps them from being isolated and unsupported, and it gives them much needed opportunity for reality testing. There is no special magic in the AA program beyond these things, I don’t think. These things are, however, in very short supply in the world outside the doctor’s office and the AA meeting room, and without this sort of support, relapse is probably going to happen. Professional treatment is too unsustainably expensive and spaced out in time to handle the day to day needs of most addicts. Addicts need a lot of support, and AA is a place that it can (hopefully) be found in some measure.

Have they even considered that the treatment itself is ineffective?

I’m not up on any studies that have ever tried to measure the success of AA. I don’t think most professionals look at it as a perfect program. Instead, my impression is that it is looked at as the best widely available ‘daily support’ program. Kind of like when Churches run soup kitchens and preach at people while they eat. Or – like when television shows are broadcast for “free” in exchange for subjecting you to a thousand commercials. These programs are not necessarily the best of their type possible. Instead, they are the best available for the price point.

As for the “treatment” being ineffective, well that is up to the addict in some respects. No treatment is going to convince someone who doesn’t want to be convinced. And even a somewhat flawed treatment can be helpful to an addict that does.

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Comments
  • Jill

    Dr. Dombeck, Thany you for responding to my post. I appreciate it. I am sad to say your answers are what I expected. I was hoping you were really going to investigate this and perhaps join others in the field to bring a change to addiction treatment. Informed consent is glaringly absent in drug treatment and that is wrong. People have the right to know about other treatment options other than 12-steps and it is unethical for a treatment provider to tell a patient that they must "work the steps or die". Especially when that patient has worked the steps 5 times before and it didn't work then. In typical fashion, blame the client for treatment failure, claim that all people with addiction are alike and all need the same thing (support groups, sharing stories , changing people, places and things). By far the worst is to tell people that they need to change their entire way of thinking because their thinking is no good. It is unreasonable to assume that simply because somebody becomes addicted to a substance that they are incapable of being competent, thinking Human Beings. These are exactly the things that scream cult. Encourage the person to abandon their friends and family and to bond to their new family. Encourage the person not to trust their own thinking so they will be more amendable to conversion and manipulation. Because when they think, "hey, somethings rotten in Denmark here", they will quickly see questioning the program as a "symptom of the disease" and stop thinking. This is the goal of a cult. If the medical profession does not see addiction as a sin, why do they provide 12-step treatment? Do you know what the steps entail? Why are people to do a moral inventory for a disease. What do confessions to a sponsor have to do with treating a disease? For that matter, what does driving your Sponsor around town, mowing his lawn and loaning him money that he will never repay have to do with treating a disease? What does seeking and channeling God have to do with treating a disease? I agree that faith in God can help people through difficult times. However, I don't believe that faith in God is a billable diagnosis. I do appreciate your response even though I am disappointed. I strongly encourage you to read the Orange Papers. It is a well written, well documented online book about AA. It says everything I want to say but can't find the words. In particular the chapter "The Effectiveness of 12-Steps" will lead you to the studies done on AA. http://www.orange-papers.org/orange-effectiveness.html You do bring up a good point when you talk about the cost of treatment. AA is free. I guess you get what you pay for. And Dr., please stop calling people with addictions "addicts". That is a very derogatory term. You say addiction is about self-idenity. Well, adopting a derogatory term as your sole idenity is defeating. Thank You

  • Ray Smith

    I think you're doing a disservice to your clients and readers if you're not up on the studies while promoting AA. The Harvard Mental Health Letter, Volume 12, Number 4, October 1995, reports that 80% of people who quit drinking do so on their own. Only 10% are ever treated and by AA's Board of Trustees and Harvard researcher, George Valliant, AA only works for 5% of the people who go there. Interestingly enough, quitting on ones own has 5% success rate. It's my opinion that the 5% that get sober in AA are the ones that are highly motivated to quit, the same as those who follow no program. Crediting AA for their sobriety is akin to blaming the rain on having your car washed. Valliant also reported a mortality rate for those in their first year of AA that was six times higher than those attempting to stop on their own. If you compare AA's 5% with no treatment's 5% and subtract the mortality rate of both, it indicates that AA has a negative success rate. When AA is presented as the only or the best method of recovery and a person fails to maintain sobriety, some become hopeless. See: http://www.peele.net/faq/aasuicide.html . According to NIMH, half of all alcoholics and up to 75% of all addicts have co-existing mental disorders. The is a large anti-medication, anti-therapy (and very vocal about it) faction in AA. An interesting study entitled "Attitudes of AA Contact Persons Toward Group Participation by Persons With a Mental Illness" can be found at: http://ps.psychiatryonline.org/cgi/content/full/50/8/1079 Kathleen Sciacca, MA, ( http://users.erols.com/ksciacca/ ) pioneered the use of an integrated treatment approach for dual diagnosis clients because the success rate for dual diagnosis clients in traditional 12step treatment was so much lower than AA's reported 5% that the numbers were unreliable. A good analysis of the effectiveness of 12step treatment can be found at: http://www.orange-papers.org/orange-effectiveness.html

  • hank henry schafer

    I am 61, fairly happy and normal. I'd like to add to Ray's comment, "There is a large anti-medication, anti-therapy (and very vocal about it) faction in AA." I have been labeled alcoholic, bipolar, Adult ADD, and probably BPD. After being warned that I would die if I drank, I thought the "disease" "progression" was real. That suggestion almost killed me. Now, after 7 years sober again last Oct., I drink a beer sometimes--no more than one/day and not often. I was told many times by aa oldtimers that meds "quiet the small voice of god." I spent 21 years mostly in aa. Half of those years were very seriously 12step fundamentalist: most while being married to a "recovering alcoholic", licensed M & Family therapist. I knew suicides and nearly became one several times. I have some ideas about why I am "cured" from the "fatal disease". Those ideas have to do with what I needed to do beyond medical therapy for my mental conditions. "Everything can be taken from a man but ...the last of the human freedoms - to choose one's attitude in any given set of circumstances, to choose one's own way."--Frankl "Men are disturbed not by things, but by the view which they take of them."--Epictetus

  • Butch

    I to was a Pro-AA man and went with all the milarky about both psychotropic and pain meds for way to long. And as I listened in meetings all over the East Coast the word was "Don't take them or they will lead to relapse." And in the quite corners or next to a few openminded oldtimers they said," Just do what you have to and don't tell anyone." So for years I was the real hard-liner refusing anything as I was told some others did and suffered with both mental and physical pain. So except for having some work done on my teeth I didn't take anything but Goodies Powders to relieve the chronic pain I had from a infection that I had probably had for years in my leg. (This also took a big toll on my bowls and rectum that I was told by other oldtimers builds charactor.)This hardline ideal also kept me out of seeking professional help for over 6 years until I move from the North to the South. Other than the total lack of observances of most of the Traditions it was also very noticible the flagrant abuse & non-use of accountability I had never seen before anywhere. Right off the bat I couldn't stomach people "sharing" that you'd better get, Jesus, or you will drink again and die. And even some still try to convince me that what I say next only happens in "Club" meetings besides the great amounts of relapses the people getting sexually cheated on or ripped off by others was even greater than the national crime rate I believe. So I was turned of by most everything I saw here, was very angry about the physical pain by itself, and now my spouse had found a new forum inwhich to learn mental spousal abuse that is so fondly named, "Women's AA or Alanon Meetings", and my depression was getting worse. Thus I got my first of 9 operations (one which was cause by my X when she pushed me down abusing me after I was trying to heal from a work related injury) and it was right around then I started to see someone about my depression which first was only about me not being able to work at my trade anymore. Now trying to raise a family, go to meetings and hear that BS, have a spouse sitting on her butt refusing work when we needed the money, relapsing, and abusing us all, made my life one living hell that sure wasn't God's making but I sure now know what some of it was. AA just saying,"Don't drink & go to meetings" or"Pray for them" and have patience. Well it had gotten to the point where I couldn't go to meetings much because I needed to be home to protect my kids from their "gotta go to AA dances" & stay sick the rest of the week mother. It was the hardliner AA had taught me to be, the secret keeper I wasn't supposed to be anymore, the psychological trama (I am still dealing with) of sitting around and attempting to act as if, plus the hopelessness that AA gives you when they do their good job of instilling fear about a disease that doen't exsist. Because of all the negative impacts that I know doesn't always happen to everyone, that before, during and after, I saved my ass and AA did none, the Fellowship did if any one thing helped. And these folks were hard to come by. Because if there is anything my God gave me the power to do, is make all those decisions and be here at this PC to say that if it weren't for the brainwashing I got in detox I could have saved myself a whole bunch of grief. And I thought my grief was over when I refused my grandmothers promises of a better life, all the firends I could muster, telling me I wouldn't have to die a horrible death and so much more if I only became a Jehovh's Witness. Now I know there are things just as bad and worse. So, Doc. Is there any web sites that you have visited to really get a grasp of what AA really is and isn't? And if you haven't I think you should so you can really see why people leave AA, how some relapses are 'caused', and what a lie the world is buying into that hurts more humans than has ever been reported and given to the public to see.

  • Mary Jane

    You need to add that addicts need a thorough physical and psychiatric evaluation prior to any support program. It could save a lot of people from agony, and some from death.

  • Ray Smith

    Since I last posted, another Federal District Court, the Ninth, has ruled that AA is at least "religious in nature" and mandated AA a violation of the Establishment Clause.

    Perhaps the medical community can reconcile forcing a client to give up their constitutional rights, but I'm uncomfortable with it as a consumer and as a mental health care worker.

  • Jordan

    I honestly do not care that these comments are like 4 years old. Because there are people like myself that stumble apon such comments. I am and alcoholic and a drug addict myself. The 12 steps of Alcoholic Anonymous was my solution. For me it was the only solution. I have been in rehab, IOP, and a Suboxone maintenance program. None of them ever worked for me. I spent years looking for doctors to tell me how to stop my mind from obsessing over drugs. I had a Mental Obsession a persistent and reoccurring thought that is stronger than and does not respond to reasoning. The only way this obsession stop was from a complete psychic change through the 12 steps. I went from stealing and IV Heroin abuse, to helping people and being of service. I'm only 19 years. I was shooting heroin at the age of 17. Tell me how many 19 year old heroin addicts medication has saved. When the twelve steps first came out Among the first 100, 50 percent got sober AT ONCE, 25 percent got sober after some relapses, and the other 25 percent showed improvement. How's that for statistics? 3/4 twelve steppers RecoverED. And o yes you can recover.

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