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The Gulf Between Science and Recovery.

11 February 2014

I’m going to pick on a friend here, which isn’t fair, really. Drugmonkey is a prominent addiction researcher who does important work studying things I can’t begin to understand about the brain and how it reacts to intoxicants. He’s supportive of recovery however it occurs, and is deeply committed to finding ways to improve the lives of addicts and alcoholics. And he’s a scientist. So he likes his treatment to come with evidence. That’s reasonable and appropriate. It’s right. I wouldn’t be picking on him here if I didn’t think it was constructive.

Sadly, addiction science and addiction scientists seem to have a view of addiction that is completely out of step with how I understand addiction to work based on my personal experience, and the experience of my fellow members of AA. Tonight’s “discussion” (mostly me firing off a few dozen tweets) began with Dr. Monkey tweeting a link to this article. Now, the AA described in this article bears little resemblance to the AA I’ve experienced in a dozen states and at least 4 countries. The second paragraph describes a meanness and intolerance in AA I’ve neither witnessed nor heard tell of.

The description of Dr. Dodes’ work – if accurate – describes conclusions perfectly in concert with AA’s teachings (“In his view, addiction is a compulsive disorder, an attempt to cope with anguish by engaging in ritualistic behavior that is soothing and predictable, despite ongoing negative consequences.” This sentence might as well have been lifted from AA literature.) and yet presented as if it’s some deep and novel and contradictory revelation. In fact, it sounds to me precisely like what AA has been saying for four-fifths of a century.

When we got on to discussion of what does work, and what AA is, he tweeted this:

This is, to me, perfectly representative of the gulf between science and recovery. AA doesn’t “work”. Don’t get me wrong. AA works. AA works in the sense that when an alcoholic has come to the place we come to, of spiritual desolation and depravity, when we drink for total obliteration, when we cannot live with alcohol, but we don’t know how to die, AA allows us to return from death to life. It does so by allowing us to marshal resources otherwise unavailable to us. By providing a framework of action and accountability and social support that allows us to change when we cannot change on our own. Recovery is not about strength. In fact, for alcoholics like me, we cannot recover until our strength is proved utterly useless.

This is another thing the article, and many addiction researchers don’t understand. And that is: AA is not for everyone. The article discusses those “alcoholics” who spontaneously stop drinking or return to normal drinking. I’m happy for those people, and there are many of them. They did not, obviously, need AA. Far from claiming that total abstinence is the only way, and that the only way to quit drinking is through AA, our literature explicitly states that any who can go out and “drink like a gentleman”, or quit without the steps, has our blessing! AA is the net that catches us when everything else has failed.

I think those with medium-to-long term sobriety in AA will look at that tweet above and immediately shake their heads and think, “That won’t work.” AA works in large part because we do not attempt to impose the program on anyone. I do not believe that the twelve steps are magic in any way. I think they address precisely what Dr. Dodes wrote above: the compulsion to treat our real problem in a soothing way that doesn’t solve any problems and creates more of its own. And I suspect that any simple and structured framework that does that would work.

As the worst of the worst alcoholics, we can achieve long-term sobriety only by daily adherence to some structured program, supported by those who know the same depravity and who have walked the same path to light as we have. The program must address our underlying issues: resentment, depression, anxiety, abandonment. It must acknowledge that relapse is inevitable without lifelong commitment to principles that are bigger than we are. As soon as we believe that we have defeated alcoholism, we are defeated by it. And I believe it must be social. We recover only among our own kind.

Any attempt to distill the “essence” of the twelve steps to a pill, to a treatment regimen, is doomed from the outset. There is no such essence. The steps don’t “work”. They don’t cure us. AA doesn’t “work”. Not like that. There’s no way to take the program of AA and turn it into a medical treatment. AA works when medicine fails. It works when alcoholics come to that sunken road. Death or recovery. It’s a difficult choice. And many of us make a different one from the one I made. Usually because they do not realize they’re at the point yet of making that choice. Sometimes because they actively choose an alcoholic death.

AA works. Because it provides a framework, a social structure, that alcoholics can seize when and if they choose to. Some believe it works because they surrender to God, though that is not my personal experience. We do not impose our steps on anyone. We could not if we wanted to. It won’t work. We do not advertise or promote ourselves. We are simply here. Living ordinary lives. Sober. If you have decided you want what we have, and are willing to go to any length to get it, then you are ready to take the steps.

If you haven’t decided that you want what we have, or if you are not willing to go to any length to get it, then AA isn’t for you. And that’s ok. Many may recover in other ways. Many may die. Many may not need “recovery” as we think of it. AA isn’t for every problem drinker. And not every problem drinker is an alcoholic as I understand it. The medical definition of “alcoholic” is not the one we use in AA.

I do not believe we will ever cure alcoholism. And if there were a pill I could take today that would allow me to drink like a normal person, I wouldn’t take it. I don’t want to drink like a normal person. I don’t want a medical recovery. My problem isn’t alcohol. My problem is me. Alcohol is how I tried to treat my problem for about twelve years. Now, I treat my problem by adhering to the program laid out in Alcoholics Anonymous. I cannot do this myself. Left to my own strength, my own morals, my own initiative, I drank. Left to my own strength, I will drink again.

I am sober because I came to a place where I could not live with myself anymore. I needed to address the sicknesses in my heart. I finally came to understand that alcohol, rather than assuaging that sickness, was the means by which I avoided confronting it. I gave up. And I did what I was told by people who had been where I was, and who had what I wanted. And I continue to today. Because I am not cured. And I don’t want to be.

8 Comments leave one →
  1. 12 February 2014 08:27

    Bravo, Dr. 24º!

    I drank when I was a girl and it was sometimes “fun,” I drank as a young single and it was seldom “fun,” when I still drank as a young wife and mother, it was rarely if ever “fun.” And yet I did it every single day. For years past the point of wanting desperately to quit. I sought help from the professionals and still I drank.

    When I knew I was well and truly f***ed, I came to AA. Thank God I found a solution there and have not had a drink since 1984. I really believe that AA is for only those, as you describe, who have tried nearly everything else.

    The DSMIV diagnosis of alcohol dependence has only vague similarity to the description of alcoholism in the big book. I think they are different things. I don’t believe AA would “work” for those who are just drinking too much. Most of them can and do quit, and as you say “our hats are off to them.”

  2. 12 February 2014 08:29

    P.S., How can an insurance company reimburse for something that is free? $30. a month to put in the basket? It would ruin us.

    • 12 February 2014 09:57

      Yes, I agree. And I made that point on twitter: it doesn’t cost anything. And we don’t want government money.

  3. 12 February 2014 09:40

    Thanks for making me think about this. I understand what you’re saying that you can’t impose AA on anyone. But I guess I agree with DM that you could get some sort of read-out about how effective it is for those who decide to join. What if you count the people that join AA and follow how many of them stay sober and for how long. You could then compare that number to other types of treatment and see how effective it is right…?

    • 12 February 2014 10:03

      I doubt it. The epidemiology gets really murky. First of all what does it mean to “join AA”? Not everyone who shows up once or twice counts, because they are usually not doing it for themselves, they’re trying to get out of trouble with family, or the law. Second, there’s the “lost to follow-up” problem. Many of your alcoholics/addicts are simply going to leave and never show themselves again.

      Next, almost every single sober member of AA should already count as a failure of other treatment. Several times over. Some (like me) will count as a “success” for multiple treatments (AA and a 12 step-based rehab)..

      Finally, AA and other treatments are generally designed to help different cohorts of people. AA is the last, only hope. When the only other treatment left is death or forcible incarceration. Treatment centers and medical treatments try to get to the addicts prior to that, before we’ve ruined ourselves. Before we have drunk the hope from our lives.

      You can’t medicalize AA. It’s not medicine.

  4. chall permalink
    13 February 2014 11:45

    This: “My problem is me. Alcohol is how I tried to treat my problem for about twelve years. Now, I treat my problem by adhering to the program laid out in Alcoholics Anonymous. I cannot do this myself. Left to my own strength, my own morals, my own initiative, I drank. Left to my own strength, I will drink again.”

    It’s my experience as well. the ‘problem’ is something else, alcohol is the ‘help’/crutch/what have you. And many of the ppl I’ve met who are still in recovery and not drinking are in most part humble and have accepted the fallacy of being human and the mistakes we make all the time. It’s the fear of not being loved for who we are, the anxiety of life and uncertainty, the depression of hardship etc… allwrapped into one nice little [big] bottle of “drink me and you will stop feeling bad for only just a second”. Or at least that is the message I’ve gotten from the al-alnon meetings and AA.

    and your point on “joining the AA’ is very important. There is such a sliding scale, what does it mean etc. I have some familjy that will never work with AA. something about it that has rubbed them the wrong way, I’m sad for it but myself I take stock in one of the main things I’ve learned. “You can never change a person.You can only change yourself and your approach to the person”. And that is hard enough….

    • 13 February 2014 11:48

      I didn’t recall that you’re in the program. Thanks for sharing here.

      • chall permalink
        14 February 2014 14:18

        I’m not “in the program” but I’ve visited and read a lot of the literature. Lots of the “depending on something” and the various steps have helped with awerness and probably (I think) stopped potential bad things. there was a time when I thought I could solve things by having one of my family members read and go to meetings, which is why I started in the first place. alas, it was “not for them” …

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