Addiction pablum at the New Yorker

Maia Szalavitz

Last week, an extraordinary example of the sorry state of addiction coverage and treatment in the United States appeared in the New Yorker.

The story focused on “luxury rehab” as practiced in California’s Wonderland program; unfortunately, the magazine seemed to take the program’s outdated views on addiction as representing the consensus among addiction experts about the appropriate medical treatment for this disorder.

What’s sad and bizarre is that what would pass for alternative treatment in any other area of medicine — telling people to turn their lives over to God, meet, confess and pray, as 12-step programs suggest — is seen as top-notch care in 21st century America for drug problems.

While it’s true that 90 percent of addiction programs still push this approach, decades of research have shown that portraying the 12-step model of Alcoholics Anonymous as the only way to recover from addiction is not only inaccurate, but harmful. Twelve-step programs have not been found superior to other techniques, and implying that they are can do harm by making those for whom they fail feel hopeless and avoid help.

Nonetheless, there in the New Yorker is Wonderland’s executive director, saying that most addicts will relapse “until they finally surrender to the reality of doing it through AA.” In fact—unmentioned by the magazine — studies find that many, perhaps most, addicts and alcoholics recover without AA or any formal treatment program. Though there’s no doubt that 12-step programs are useful for some, they shouldn’t be seen as the only way.

The article did note that the “attack therapy” widely practiced in addiction treatment in the 1980’s and 90’s — and still common in care for teens — has “fallen out of favor.” But it didn’t mention that this is because research found it to be both ineffective and sometimes harmful.

Further, the line taken by many of the “experts” quoted in the article — that addicts “need frustration,” that “the more you cater to an addict’s demands, the more you support their disease,” and that they need to “Get with the program or get out”— is also unsupported.

The reporter clearly buys their approach, talking about how “granting so much agency” to addicts by allowing them to have their way in treatment might be problematic. But in what other conditions do doctors get to choose whether to “grant patients agency”?

If you went for cancer care and were told that you “need frustration,” and you must obey what the doctor tells you without question or “get out,” you would probably find such high-handedness unacceptable. It would certainly be seen as poor bedside manner. For addicts, however, such paternalism is not even questioned — even though, again, the research finds that empathetic and supportive care is more effective.

The New Yorker didn’t pull its punches on Wonderland — it noted the low success rate of residential rehabs and clearly highlighted the absurdity of some of its practices. But it could have done a much greater service by talking to academic addiction experts about why even the rich and famous don’t get evidence-based care for addiction.

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2 Responses to Addiction pablum at the New Yorker

  1. WonderingWilla says:

    I have always been dubious of 12 step programs being the only way, but I guess I have never heard about anything but 12 step. What are other approaches that have a better success rate?

  2. Maia Szalavitz says:

    There is a therapy technique called “motivational enhancement therapy” that is very successful. In Project Match, the NIAAA’s big comparative study on treatment, it did the same as “12 step facilitation” (basically, instruction in 12 step ideology and encouraging meeting attendance), but in fewer sessions, so you might argue that it was superior.

    Cognitive-behavioral therapy also had similar outcomes with 12 sessions of 12 step facilitation but without telling patients that they had to go to AA for the rest of their lives.

    Summarized here:
    http://books.google.com/books?id=5ToDgQ1RXZUC&pg=PA183&lpg=PA183&dq=project+match+cbt+mi+aa&source=web&ots=cHKa4vRdqv&sig=EDy7V0GUFkEcsNYDINEkocYTMes&hl=en&sa=X&oi=book_result&resnum=4&ct=result

    There’s also Community Reinforcement and Family Therapy (CRAFT) which has excellent results.

    No one has studied SMART recovery (a non-12 step self help group) http://www.smartrecovery.org/

    directly compared with 12-step programs, but it seems to do equally well.

    The thing with addiction is that with most approaches, about a third improve, a third stay the same and a third get worse. What this means is that there are no “knockout” treatments but a lot of things that help a good minority of people. So, if you shop around, you will generally find something that works.

    It’s not so much that one approach is better than another, but that different things help different people. And so saying that 12 step is the only way hurts.

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