The Interview: Does AA fail addicts?

Dr. Lance Dodes on why AA’s promotion of abstinence may be a problem

Photographs by Kourosh Keshiri

Photographs by Kourosh Keshiri

Dr. Lance Dodes has spent more than 35 years treating people who are battling addiction, including alcoholism. In his new book (co-written with Zachary Dodes), The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, Dodes takes a hard look at Alcoholics Anonymous, a worldwide organization that describes itself as a “non-professional fellowship of alcoholics helping other alcoholics get and stay sober.” Today, there are more than 5,000 AA groups in Canada alone, which are free and open to anyone. Dodes, a retired assistant clinical professor of psychiatry at Harvard Medical School, argues that some groups—and many for-profit private rehab centres based on the 12-step model—are often ineffective, and can cause further damage to addicts.

Q: How did you come to work on addiction?

A: I first became involved with alcoholism and addiction in the ’70s, when the place I was working, which is now part of Massachusetts General Hospital in Boston, needed to develop an alcoholism treatment unit. I was director of psychiatry, so I said, “I’ll develop it.” Afterward, I became involved in various addiction treatment programs, including running the state’s largest compulsive-gambling program. Over the years, I became very familiar with AA. It became clear that, while AA works for some people, the statistics just didn’t back it up. The real problem is that [doctors] refer 100 per cent of their patients with alcoholism to AA, and that’s the wrong thing to do 90 per cent of the time.

Q: AA has more than two million members around the world. You say its success rate is between five and 10 per cent. How, then, do you account for its enduring popularity?

A: AA is a proselytizing organization. The 12th step is to go out and spread the word, and they do. Because there are so many people in prominent positions who are members of AA, it gets tremendously good press. If AA were simply harmless, then I would agree that a seven per cent success rate is better than zero. But that’s not the case. It can be very destructive. According to AA, AA never fails—you fail. AA says that if you’re not doing well in the program, then it’s you. So you should go back and do the same thing you did before: Do more of the 12 steps, and go to more meetings.

Q: AA promotes complete abstinence; you argue that this can contribute to feelings of failure.

A: Abstinence as a goal is not evil or bad. If you can be abstinent, that’s better than not. But in AA, it does have this rigid, moralistic quality, specifically, in the way they treat you when you have a slip. If you haven’t had a drink for six months and you have a beer, your number of days sober, according to AA, goes to zero. That’s horribly moralistic, completely unwarranted, and it makes no sense, scientifically or clinically. For people who don’t do well, it’s very disheartening: Not only are you an alcoholic or an addict, but you haven’t been able to work the program. You haven’t done it right. If you look at [alcoholism] as a public health problem, certainly AA would be part of the mix. The real thrust of my book is not to eliminate or destroy AA, but to put it in its proper perspective.

Q: AA famously uses sponsors in recovery—alcoholics helping other alcoholics. Therapists have reported to me that sponsors sometimes instruct patients not to take a medication, for example, even though AA says it’s okay to take medications. Do you think that’s true?

A: That is absolutely true. That’s been a problem for a long time. AA has gotten better about this, but it used to be that they’d say, “Don’t take any medication, because that’s”— to use their expression—“ ‘chewing your booze.’ ”

Q: You write about rehab centres such as Promises or the Betty Ford Center. Promises Malibu charges up to $90,000 for a one-month stay in a private suite, according to your book. These centres offer amenities such as yoga, acupuncture, life coaching and “equine therapy,” and they’re based on the 12-step model. Why do people go into private rehab centres when they could be getting the 12 steps through AA, as you write, “for free in a church basement?”

A: Because they’re doing so badly that they, or somebody else, think they need to be hospitalized. Sometimes that’s true. If you have somebody who’s drinking or taking another drug in very large quantities, they may need to be medically detoxified for their safety. Sometimes it helps to get away for a while.

There’s no objecting to a brief hospitalization; the objection is to what they do during that hospitalization.

AA has its limitations, but it’s true, you can get it for free. To AA’s credit, they don’t endorse rehabs, but the fact is that almost all of them are 12-step programs. They’re basing their program on something that has a five- to 10 per cent success rate. The horror is that people spend their fortunes; I mean, not everyone is wealthy. We’ve all heard terrible stories about families who’ve spent all their life savings trying to help a kid who goes in and out of rehab, time after time, and it’s $30,000 and up for a month. If you or your family has spent a fortune, the experience of failing is that much greater.

Q: Addiction is now generally agreed upon to be a disease, but you challenge this in your book. If it’s not a disease, what is it?

A: It’s a symptom. I had [a patient] who was an alcoholic. Her husband was very domineering and she always obeyed him, and then she’d have a drink. That’s how she dealt with her helplessness. One time, he gave her a letter to mail in his usual imperious way, and in her usual way, she said, “Yes, dear.” But instead of getting a drink, she lost the letter. When she lost the letter, she didn’t feel like she had to drink. That’s why I say it’s a symptom: It’s a compulsive way of dealing with feelings of helplessness.

Q: Studies have indicated certain changes in addicts’ brains, which show up on fMRI scans. Doesn’t that support the notion that addiction is a disease?

A: Since the ’90s, [in studies] people have gotten rats addicted to heroin and given them certain cues. Later, without any heroin, they showed the rats the same cue; the rats would run around, get excited and look for heroin. They looked into their brains, and what they found is that this conditioned reflex had a biological basis, namely, when the rats were exposed to cues like a bell ringing, they released dopamine in the reward pathway of their brains. They had a hyper-response to the drug, compared to rats who hadn’t been exposed to heroin, and this change in their brains was permanent. Scientists [argued that] this is a chronic brain disease in rats, and that must be the cause of addiction in humans.

It is true that we and rats share the same reward pathway, and it is true that, if you look at alcoholics or other addicts, their brains do show the kinds of changes the rats had. But the problem is, it doesn’t cause addiction in humans, because our brains have a massive cerebrum, and that’s what determines what we do most of the time. If we were like rats, there would be no civilization.

Q: Isn’t that a controversial perspective?

A: I’d say it’s extremely controversial, in that everyone accepts it’s a disease. This takes out some of the moralizing about addiction: Instead of being bad, you are sick. That’s a good thing, because there is no reason to moralize about people suffering from addiction. But the word “disease” becomes a black box and doesn’t explain anything. From the standpoint of trying to understand it as a psychological symptom, it’s a problem.

Q: In that case, how do you believe addiction should be treated?

A: I have a theory that works well for my patients. When people have that first urge, or even the thought, of doing something—drinking alcohol, gambling, it doesn’t matter—that’s the key moment in addiction. You can sort of ignore everything that comes after that, including the addictive act. The question is: What starts you down that path?

What I’ve found is that there is always a moment of feeling overwhelmingly helpless. The kind of thing people feel helpless about is individual; you have to figure out what it is that makes you feel that way. When people feel helpless, they also feel a great rage. That’s what I believe drives addiction.

You can [learn to] anticipate when the next urge is going to occur by looking at all the instances when these urges come upon you. I have patients who say to me, “I will have an urge to take my pills on April 20.” They already know something coming up in their lives will be a trigger.

Q: Many experts say we have a “patchwork” system of treating addiction, with a huge variety of methods, models and opinions. What’s at stake if addiction treatment doesn’t improve?

A: We’ll have the same major public health problem we have now, and we’ll have more loss of life. In recent years, more people are questioning AA, and I’m hoping this will [continue]. I’d like to have doctors stop referring everybody to AA. Instead, make an assessment, figure out who are the five per cent who will benefit, and send them.


The Interview: Does AA fail addicts?

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  2. I dunno what it is lately, but lots of things are being removed from the ‘disease’ list. Thank goodness ‘alcoholism’ is one of them.

  3. Why Punish Pain?

    A hit of compassion could keep drugs from becoming a crime problem.

    by Gabor Maté

    All drug addicts, even (or perhaps especially) the abject and marginalized street user, seek in their habit the same paradise de Quincey rhapsodized: a sense of comfort, vitality, and freedom from pain. It’s a doomed search that puts in peril their health, societal position, dignity, and freedom. “I’m not afraid of death,” another patient told me. “I’m more afraid of life.” What kind of despair could lead someone to value short-term pain relief over life itself? And what might be the source of such despair?

    We can punish people more, or we can reduce crime more. One cancels out the other.

    Mr. Høidal has explained in earlier interviews that revenge and suffering have no place in the Norwegian prison system. “We want to build them up, give them confidence through education and work and have them leave as better people.”

    Does that make you feel all warmhearted and hopeful for the kid who disfigured you? Are you yearning to give him the chance to become a better person? Probably not. There’s a good chance it infuriates you. Especially when you learn that it’s costing more money to keep him in this luxe prison than you earn in a year.

    But consider this: Fewer than one in five prisoners in Halden will commit another serious crime after being released. In Canada, the United States and Britain, the rate is more like three in five.


    He found that what causes prisoners to reoffend at lower rates, everywhere, is basic education, vocational and employability programs, anger management and therapy while behind bars (or, in Norway, no bars). On the other hand, things that cause prisoners to reoffend more after release include longer sentences, strict discipline, deterrent “shock incarceration” programs and regular sanctions (such as withdrawal of privileges).

    In other words, we have a stark choice: We can punish people more, or we can reduce crime more. One cancels out the other. Sadly, though, it is a sense of anger and vengeance that motivates policy decisions in most countries these days.

  4. AA is a program that is funded by alcoholics for alcoholics, completely free of any kind of intervention from the government or healthcare system. Yes physicians send people who believe they have alcohol addictions problems to AA…why? Because it is easily done. There is no referral process. There is no wait list. It is completely volunteer run. Truth be known, there is a huge failure rate in all addictions counselling. Why does the good doctor tell us the success rate in other programs. If AA has a 5 to 7 percent success rate, what do the others have? Further, how does he plan to change what he sees wrong with AA when it is a bunch of addicts spending their own money and their own time trying to stay sober and help others stay sober but only if they arrive at a meeting and want to get sober.

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  6. I’d be interested in knowing Dodes’ success rate versus AA’s (I notice his isn’t listed). He makes some good points about AA and the rehab centres, but his own theory sounds like so much quackery. If all that were to addiction was Pavlovian classical conditioning, as he implies, a cure should be simple. We should also see addictions to a much greater range of things.

    There are psychological addictions, and there are physical addictions. Dodes seems to completely discount the latter. And so, without something more grounded in science than this article, I have no trouble discounting his theory on treatment (assuming he has one; the article seems rather vague on his alternate methodology).

    • It would be interesting to read what his book/studies say. AA has been around since I was a kid when my mom quit drinking in the early 70s, in my view, thanks to AA. My step-dad couldn’t and died from a heart attack at 48 directly related to his drinking. Lots of stories like that…

      The thing I concur with Dodes on is the proselytizing aspect of AA. I also agree with the demoralizing parts where your length of sobriety is shot to h-ll if you take one drink. My mother, sober for almost 40 years, freaked out when she accidentally took a sip of vodka and water at a party. She spit it out before swallowing, threw up, and was shaken to think she just blew her 40-year credits. The shame experienced by those who fall off the wagon is too high if they get right back on again.

      • I wanted to reply to your comment about your mom. My dad has been in AA for 63 years. Once I saw him take a sip of an alcohol drink by accident but he did not seem fazed. He merely poured it out. Years later he told me that it had initially taken him 2 years to get sober and he had been suicidal at times during those 2 years. I don’t think he ever considered AA as demoralizing. He made very good friends there. and many of his old friends ended up in the program with him. I think he felt glad to be alive.

  7. As a man who has edited newspapers and magazines for 25 years (incidentally the length of my sobriety thanks in large part to the 12 Step movement in its many forms) I must say I was pretty disappointed that a magazine editor would allow an interview to run as such without a balanced counter argument. Are you kidding me? So discount AA, discount the whole 12 Step movement which he knows has policies in place preventing it from entering the argument. After carving them up, don’t offer any stats which back up a damned thing you say. Then dump on treatment centres as well for good measure. Hmmmm. A medical professional who writes scripts and keeps pharmaceutical companies smiling in a mutually beneficial arrangement. So AA doesn’t have the answers to addiction. And treatment centres don’t. But at least they have 10 per cent. What the hell do YOU have? Shame on MacLeans’ editorial staff for presenting a prime example of why balanced journalism is dead and gone. Journalism 101 folks. Get the other side and let the reader decide. I wonder how many sick alcoholics will now look at their partners, their crying, scared children and say ‘see? This AA thing is all a bunch of crap” because of this one-sided, puffed up, stuffed-shirt opinion?

  8. As a family member of people in AA, I just want to say that I don’t think the good doctor has ever been to a meeting if he thinks it is full of demoralizing and proselyting. I remember attending a family meeting and being astounded by the complete honesty of the members who spoke so openly about some of the terrible things they had done while inebriated….injured people in car accidents; shamed their family members, etc. Meanwhile the other members listened quietly not judging because so many of them had similar tales. These people find AA to be a safe haven where they can share their burdens with those who understand.

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  10. We can only help. But in the end, with or without AA, NA,…, the decision of controlling, or abstaining from substance self-abuse is ONLY up to the individual themselves.

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