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The Sober Truth About AA and the Rehab Industry

12-step programs and rehabs fail almost all the time.

I am pleased to announce the release today of my new book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry.

In it, I describe the stunning facts about the current national treatment approach for addiction. AA has a success rate between 5% and 10%. An exhaustive scientific review by the prestigious Cochrane Collection, of all AA studies over 40 years, found even worse results, concluding that, "No experimental studies unequivocally demonstrated the effectiveness of AA" in treating alcoholism.

Practically no studies that support AA meet ordinary scientific standards, and all suffer from serious scientific errors. Most cover only a short time for this lifelong condition, or they are spoiled by a failure to account for "selection bias,” or they base their data on self-reports without independent verification, or they commit the grave error of discarding data that does not fit the authors' conclusions. (Invariably people who are happy and sober are glad to let the researchers know how they're doing, whereas people who have resumed heavy drinking are far less likely to respond to researchers' questionnaires or phone calls. Yet in reaching the statistical conclusion that AA (and rehabs) are successful, these people are regularly ignored.)

A logical error arises from these acrobatics with the data: studies tend to show that the people who remain in AA longest are the most likely to succeed. Pro-AA researchers conclude from this that everyone should stay with AA. Of course this is basic, flawed circular reasoning. The people who stay are precisely the 5% to 10% who are doing well. Their success says absolutely nothing about the 90% who cannot make use of the program and have therefore dropped out.

This book also undertakes a clear-eyed review of the rehab industry. These pastoral retreats typically charge exorbitant amounts for the same 12-step program you can get for free in a church basement, adding irrelevant extras such as horse therapy, reiki massage and ocean adventuring to justify the cost. The data is scarce on these programs by design: it turns out that practically none of them have studied their own outcomes or, if they have, refuse to publish their findings. This has not stopped many of them from claiming fantastic success rates. The rehab industry is unregulated and can claim whatever it wants.

There’s no question that 12-step programs have saved people’s lives. But sending everyone with an addiction to AA or its cousins is simply bad treatment that does harm to the 90% who cannot make use of such programs, and are led to believe they are the ones who are failures, because the program is never wrong. It is time to change the national discussion about what is appropriate treatment for addiction, and I hope this book will provide a starting place.

Posted on Thursday, March 27, 2014 at 12:48AM by Registered CommenterLance Dodes, M.D. | Comments11 Comments | References53 References

When Mice Are Men and When They're Just Mice

Be careful what you believe.

 
A recent report about creating stem cells from ordinary tissue in mice created a great deal of scientific excitement as a possible medical breakthrough for treating human illnesses (though there is now some doubt about its findings). Scientists routinely study mice and rats, not out of a deep interest in rodents, of course, but because we and they are mammals, so we share a good deal of biology. And sometimes the rodent findings work fine for humans, sometimes not. A well-known example from the 1990's was the huge optimism that cancer would soon be cured because of the work of Dr. Judah Folkman with mice. His approach (angiogenesis inhibition) basically stopped cancer in its tracks. A modest man, when questioned about the applicability of his work to humans, he famously demurred, saying ”If you’re a mouse and you have cancer, we can take good care of you.” As it turned out, he was right to be cautious; his approach did not cure cancer in humans.

It makes sense to experiment with rodents before trying ideas in humans. But it is a serious scientific error to generalize these results to humans unless they can be shown to apply to our species. Sadly, this is just the kind of very bad science that has taken over the addiction field. Neurobiological researchers have claimed for years that rat behavior to seek drugs is the same as human addiction, without the slightest awareness of how different that is from human addiction. Indeed, of all the ways one should not generalize from rats to people, complex behavior is the most obvious, since the one way that we are least like rats is that we have giant brains capable of human psychology, while rats have brains the size of a pea.
 
It is true that we share the more primitive parts of our brains with other mammals, and that includes the mammalian reward pathway that is central to the neurobiological view of addiction. But if we were driven simply by reward-seeking caused by release of a neurotransmitter (dopamine), as is the case for rats, we would no longer be human. Rats scurry about looking for drugs when excited by the brain stimulation the researchers found. Humans with addictions plan their behavior, often hours or even days in advance. Humans also shift behavior away from drug use to non-drug compulsive acts like gambling, shopping or cleaning. The fact is that if the "brain disease" theory that applies to rats were actually true in humans, there would be no civilization. We would be controlled by our dopamine releases and would run around doing whatever our neurotransmitters demanded. We would act like rats.

Of course, we know the "brain disease" theory is wrong for other reasons, since there are literally millions of examples of humans who have taken high doses of drugs like heroin and alcohol who never become addicts, something that should be impossible according to the "brain disease" theory.
Why do we accept such false ideas? Part of the answer is that we trust scientists to be careful with generalizing their results beyond what they have actually studied. And most scientists, like Dr. Folkman, are very careful to avoid that mistake. Another part of the problem is that we trust organizations that we believe have carefully vetted scientific information before endorsing it. Yet, there are some such groups that have simply endorsed the reductionistic brain disease idea without having done any independent study of their own, or even considered the error with such generalizations.

The mistake of thinking human addiction is the same as rat stimulation is a cautionary tale. We all need to question what we hear, even from people who are supposed to know what they're talking about, until we have independent scientific review from scientists besides those invested in their own views.
Posted on Thursday, March 6, 2014 at 09:29PM by Registered CommenterLance Dodes, M.D. | Comments5 Comments | References61 References

Don't Focus on the Consequences of Addiction

It's a waste of time.

 
Throughout my career as a therapist I've heard people describe the effects of their addictions — drinking, eating, gambling — with deep regret, shame, and anger. Anyone can understand their pain. And effects do matter: They color how we relate to the people in our lives, and how we gauge the risk of future behaviors. But focusing on consequences does not help to stop addiction. Indeed, it is a waste of valuable time that could be spent looking at its causes.

Looking at consequences also induces guilt. It's understandable that those who have been hurt by addictive acts will confront those who have hurt them. But no good therapist would make this mistake. Over the past 40 years I've never encountered an addict who was not already sadly aware of the damage he or she was causing. People suffering with addictions are neither evil nor stupid, and adding to their guilt is simply pointless. If guilt could solve addiction there would be no addicts.
 
It is far better to focus on the fact that addictive actions are not random. They are precipitated by emotionally meaningful factors: loneliness after being abandoned by a boyfriend or girlfriend, shame and anger after being treated disrespectfully, embarrassment after a humiliating loss, or a repeated feeling of being unheard, with a helpless sense you have no control over your own life. These emotional precipitants are what people need to recognize, explore and understand, so they can predict when they will next arise, always followed by addictive urges. If people can predict when their addictive drive will occur, they are much closer to being able to control it. (I described this process in detail in my book, Breaking Addiction.)

There are two other problems with focusing on consequences rather than causes. Since different addictive acts have different consequences, we have been misled into thinking they are different phenomena. Of course, this is not so, as we know from the fact that people regularly shift their addiction from one behavior to another. A variant of this misconception is that the dangerousness of the consequences matters to the cause of an addiction. I've heard people say that alcoholism couldn't possibly be basically the same as compulsive housecleaning, because alcoholism can kill you and housecleaning can't. But that's the result, not the cause, and in fact that very switch does occur (I wrote about one such case).

The closer we pay attention to the emotional reasons for the psychological symptom we call addiction, the closer we can get to mastering it. And in so doing, we save the time we would have wasted focusing on its consequences.
Posted on Thursday, March 6, 2014 at 09:28PM by Registered CommenterLance Dodes, M.D. | Comments3 Comments | References28 References

What Does Dropsy Have to Do With Substance Abuse?

When doctors don’t know the cause of an illness, they're stuck having to “diagnose” only its symptoms, not the source of the problem. That is just where we stand today with substance abuse, and it’s ruining our chance to treat it effectively.

For example, before we knew the cause of tuberculosis (a bacterial infection), it was named based on one of its symptoms: it was called Consumption because one of its main symptoms was weight loss. Naming the illness as a weight loss problem was not useful for either understanding or treating it. In fact, if doctors had tried to figure out the illness by looking into “weight loss” as the issue, they would never have discovered its true cause. The same thing happened with another commonplace “diagnosis” of the 19th century: Dropsy. This term referred to swelling, often of the ankles. There are several possible causes for this, one of the most common being congestive heart failure. But since doctors didn’t have a clue about this, they stroked their beards and sagely proclaimed that their patients had Dropsy. As with Consumption, the “diagnosis” was not just unhelpful, but thinking of the illness as a swelling problem could never have led to understanding it.

Today, addiction specialists and nearly everyone on the planet believes that there is something called “substance abuse disorder.” We are again naming a symptom as if it is the problem. Since the focus of an addiction can, and often does, change from one drug to the other, or to non-drug compulsive behaviors like gambling, eating or sex, “diagnosing” a “substance-abuse disorder” is both superficial and harmful. Like Consumption or Dropsy, it misleads us into believing that somehow the problem is about substances. Drugs in fact have absolutely nothing to do with the nature of addiction; they are just one common form of the problem. And like Consumption and Dropsy, use of this misleading term interferes with understanding and treating people suffering with it.

As readers of this blog or my books know, addiction is neither more nor less than a compulsive behavior, identical with other compulsions and understandable in psychological terms. (As always, I am not referring here to either physical addiction, or the biologic illness OCD.) It is certain that true addiction is not a “brain disorder” as I’ve discussed extensively elsewhere, and of course it is also not a moral/spiritual problem. We need to be appreciating addiction as the compulsive behavior it is, and treat people by helping them to understand its psychological roots so they can predict when their compulsive/addictive urges will next arise. With that awareness, and some psychological work, people can effectively manage and ultimately beat their addictions.

It’s hard to buck any entrenched system, but let’s try to keep in mind that people who compulsively use alcohol or any other drug are just like everybody else, just with this particular way of managing overwhelming feelings. They do not have a “substance abuse disorder” because there is no such thing.

Posted on Tuesday, December 10, 2013 at 10:15PM by Registered CommenterLance Dodes, M.D. | Comments2 Comments | References3 References

The Politics of Addiction

It is ruining the field.

If the world were a perfect place, our efforts to understand ourselves would be based on reason, experience, and evidence, and free of the poisoning influence of politics. Alas, the world of addiction is just as beholden to political tradewinds as other fields.
Every field of inquiry is burdened by politics to some degree. But when people who are in positions of authority and power hold onto their views despite reason, experience and evidence, the result is that new knowledge, and the people who espouse it, are suppressed. This act, of clinging to outdated dogma, is where politics fights against progress.

Recently I read Nobel laureate Paul Krugman’s book “End This Depression Now!” Before describing his views, I must make a disclaimer: my own education in economics began and ended with a single college course I took 40 years ago. So I’m not writing to endorse or refute Professor Krugman’s views, but to underline his description of his field. He writes that in recent decades, macroeconomics became divided into two great factions described as Keynesians and non-Keynesians (after the economist John Maynard Keynes). The non-Keynesians, he writes, “Soon got carried away, bringing to their project a sort of messianic zeal that would not take no for an answer… [a leader of this group predicted] in 1980 that participants in seminars would start to whisper and giggle whenever anyone presented Keynesian ideas. Keynes, and anyone who invoked Keynes, was banned from many classrooms and professional journals… [non-Keynesians developed] quasi-religious certainty that has only grown stronger as the evidence has challenged the One True Faith.”
 
Anyone familiar with the addiction field will recognize this description immediately. But unlike economics, in addiction we have two sets of overconfident whisperers with a history of ignoring or suppressing other views. One of these groups are the followers of the “chronic brain disease” idea – a notion that has been repeatedly shown to be false (see other posts in this blog) yet still remains the official view of the National Institute on Drug Abuse and the American Academy of Addiction Medicine. The influence of this group has led many professional addiction journals to avoid publishing any contrary views for many years running. In fact, a recent review I conducted of all the major addiction journals for the past three years turned up no discussions at all of the psychology of addiction. (This isn’t because there were no articles submitted; my own paper describing the limits of both neurobiological and psychological views, which was published in a respected peer-reviewed journal in the United Kingdom, was turned down by every addiction journal in the US, because, I was explicitly told, it did not fit the editors’ narrow view of what was correct.)

The other powerful group is of course AA, and its 12-step brethren. Anyone who has tried to criticize the 12-step approach knows full well the hostile reception this produces from devoted members. In fact, because of my position as an independent voice in addiction, I have often heard from counselors working in addiction treatment programs around the country who tell me they are afraid to challenge the 12-step model for fear of losing their jobs.

Addiction deserves better. One online addiction website, The Fix, recently published my guest piece taking a critical look at both the official description of addiction in the new edition of the Psychiatry Diagnostic and Statistical Manual (DSM-5), and the brain chemistry people at NIDA. The Fix is a wide-ranging site that publishes a variety of views, some of which I don’t agree with, but that’s the point: like Psychology Today, it is a rare forum for contrasting ideas and discussion. We desperately need more open-minded resources like this, and a new national addiction conversation that doesn’t reflexively strangle dissent.
Posted on Tuesday, May 28, 2013 at 04:53PM by Registered CommenterLance Dodes, M.D. | Comments6 Comments
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