Open Book

12 Missteps?

The evidence that AA works is many steps behind

Magazine Issue
May/June 2014
Lance Dodes The Sober Truth

The Sober Truth: Debunking the Bad Science behind 12-Step Programs and the Rehab Industry
By Lance Dodes and Zachary Dodes
Beacon Press. 192 pp.

ISBN: 9780807033159
Out-of-control addictions and do-over stints in rehab have long been the tragic but all-too-familiar tropes in celebrity death narratives, with a sadly lengthening in-memoriam list that includes singers Amy Winehouse, Whitney Houston, and, most recently, the actor Philip Seymour Hoffman. Too closely related for comfort is another star-studded roll call, this one headed by entertainment figures like Lindsay Lohan and Charlie Sheen, who’ve become less renowned for their acting credits and more for their repeated flops at staying clean and sober, despite one stay after another at expensive, resort-like rehab centers in which 12-step approaches inspired by Alcoholics Anonymous (AA) provide the therapeutic heart of the program.

While these highly publicized cases would seem to raise questions about the AA model as the best addiction treatment regimen, that model has remained fundamentally unchallenged, both within the mental health field and in the culture at large. Still, so many failures at recovery simply do not gibe with AA’s sterling reputation. Does that mean all these celebrity cases are merely anomalies? Or, though it goes against conventional wisdom even to ask, does the 12-step approach have some basic flaws?

The blunt answer can be found on the very first page of The Sober Truth, a searing critique of the rehab industry by Lance Dodes and Zachary Dodes. “Alcoholics Anonymous was proclaimed the correct treatment for alcoholism over 75 years ago despite the absence of any scientific evidence of the approach’s efficacy, and we have been on the wrong path ever since,” the authors write. AA, they continue, has “one of the worst success rates in all of medicine, between 5 and 10 percent, hardly better than no treatment at all.” That record surely is nothing to brag about, much less emulate, and yet, the authors assert, the treatment centers that cater to the rich and famous largely base their own programs on the same 12 steps. Perhaps it’s no wonder then that, also like AA, these spa-like treatment centers rarely evaluate their own success (or recidivism) rates, even as they keep welcoming back repeat customers. Thus begins this eye-opening exposé of 12-step programs as an emperor-like treatment model clothed with scanty evidence to back up its outsized reputation.

Lead author Lance Dodes—a psychiatrist who’s treated addiction for 35 years and has a clinical appointment at Harvard Medical School—lays out an indictment as comprehensive as it is devastating. That’s another way of saying The Sober Truth is essential reading for any professional who’s considering treatment options for patients suffering from any form of addiction, alcoholism, or substance abuse.

To understand AA’s status today, Dodes says, go back to its origins, even before its founding in 1935 by Bill Wilson and Bob Smith. Wilson was an alcoholic, as had been almost every man in his family. He was also deeply religious. In 1934, he joined the Oxford Group, a Christian fellowship that encouraged moral rebirth through spiritual conversion. Then, while in the hospital trying to sober up under a regimen that included doses of belladonna, he experienced a vision of light that he interpreted as a sign from God to give up drinking. He’d found his mission: to help others find the same path he had by recruiting them to the Oxford Group and its religious ideas.

But the cure by conversion often failed, even after he joined forces with Smith to try to convince alcoholics to surrender themselves to a higher power as the first step toward letting go of drink. Nor was Wilson’s so-called Big Book—Alcoholics Anonymous: The Story of How More Than One Hundred Men Have Recovered from Alcoholism, which laid out the 12 steps (a number inspired by the 12 Apostles) and purported to prove their effectiveness through case histories (though according to Dodes, only about half remained sober)—an immediate hit. Published in 1939, the book was described by the American Medical Association as “a curious combination of organizing propaganda and religious exhortation,” a volume that deserved credit for recognizing the seriousness of alcohol addiction, but that otherwise “has no scientific merit or interest.”

AA could easily have disappeared, if not for highly laudatory articles touting its near-miraculous success (though without providing statistical evidence of it) in mass-market magazines like Liberty and Saturday Evening Post. Instead, a media juggernaut carried it into the American mainstream, where it’s remained ever since. Helping its growth is the proselytism of AA’s 12th step: “Having had a spiritual awakening as the result of these steps, we tried to carry this message to other addicts and to practice these principles in all our affairs.” But it’s those among the 12 steps that evoke and surrender to a higher power that lead Dodes to comment, “If AA were simply presented as a religious movement dedicated to trying to comfort addicts through faith and prayer, the program would not be so problematic.”

The trouble is that AA wants to be recognized as a rigorous, scientific roadmap for a cure. And in addition to having more religious faith than science behind it, it also offers moralizing instead of psychology. Witness, for instance, the repeated equating in steps five through seven of alcohol and other addictions to moral shortcomings and character defects. “The degradation woven through these steps,” Dodes writes, “seems unwittingly designed to exacerbate, rather than relieve, the humiliating feelings so common in addiction. If moral self-flagellation could cure addiction, we could be sure there would be precious few addicts.” By contrast, Dodes argues, AA’s decided lack of psychological or therapeutic insight can reinforce already existing self-hating beliefs and self-destructive behavior and make subsequent recovery even more difficult.

Central to the book is a lengthy statistical analysis of the efficacy of the 12-step approach, based on the scant number of studies that have been conducted. You don’t have to be a math major to grasp that study after study found disappointing results for 12-step treatments. The most substantive review came from the Cochrane Collaboration, a highly regarded independent international research group, which evaluates medical research to ensure evidence-based health practices. Its conclusion: “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF [Twelve Step Facilitation] approaches for reducing alcohol dependence or problems.”

Nor does Dodes discover any research to suggest that extravagantly priced—running as high as $30,000 per month—spa-like rehab retreats basing their approach on 12-step programs do any better, even if they also offer tranquil settings and horseback-riding sessions. He puts it this way: “Given that virtually every rehab is an elaborate expansion of 12-step meetings, why do people spend a fortune for programs that aren’t fundamentally different from what they could find for free in a church basement?” This is an especially poignant question since the expenses incurred in private rehab can wipe out the resources of less-than-wealthy families. And if failure ensues—as the low success rate would suggest—look out for a toxic cycle of family blame, resentment, and guilt.

Dodes concedes that AA does help some people get better, often as the result of its social function and what he terms “the curative power of group dynamics.” Others may respond to the spiritual aspect, finding solace in the idea of surrendering to a higher power. But even when AA succeeds, Dodes believes, it doesn’t address the deeper psychological causes and issues behind the addictions. This type of understanding is what psychotherapy does best, he believes. It’s that core piece of learning about one’s own internal emotional workings that leads to the ability to begin to control it. Absent that awareness, one addiction just becomes substituted for another. Bill Wilson himself, for instance, may have quit alcohol for good, but he continued to battle smoking and sexual compulsions for the rest of his life.

To further illustrate AA’s highly mixed bag of results, Dodes includes an illuminating chapter filled with interview transcripts from men and women who found different degrees of success and failure in AA programs. “Submitting to a higher power seemed kind of illogical to me,” one man said. “It seemed like they were trying to force beliefs on me that I wasn’t willing or ready to accept.” One woman reported, “I feel like I’m putting my ego down, saying I’m an alcoholic or an addict,” but she added that making “a fearless moral inventory” of herself gave her self-insight. Another woman summed it up simply enough: “AA is just not for everybody.”

Dodes can be repetitive, and at times his tone can begin to sound pedantic, but he’s an incisive critic of AA and the field of addiction therapy. He bemoans both the sparseness of research in the field of addiction and the lack of emphasis given to psychological awareness in the major addiction journals. He proposes assessment tools that would allow professionals to evaluate better those who might benefit from AA’s social aspects, those who might be turned off by any mention of religion, and those who might be damaged by self-blame after a lapse.

He states throughout that he favors talk therapy and, if indicated by other symptoms or psychiatric diagnoses, medication. Beyond that generalization, I wish he’d been more specific about his own professional successes—what strategies worked with which types of patients and why. Those case studies may not constitute the evidence-based research he calls for, but it’d be a welcome start.


Photo © Zachary Dodes

Diane Cole

Diane Cole is the author of the memoir After Great Pain: A New Life Emerges and writes for The Wall Street Journal and many other publications.