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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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.