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.
Lance Dodes, M.D.
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Reader Comments (13)
Dear Dr. Dodes... I haven't read the book yet, but plan to. However, I did hear you recently on a radio talk show that aired in Calgary Alberta this week. I have been in the AA program for seven years. So far it works for me. I don't know what the success rate of AA is. A lot of people come and go and then come again. The one observation I will make in listening to the Talk Show is that I heard some confusion or blurring between AA and treatment (rehab) centres. AA has nothing to do with any treatment centre in the world as far as I know...our preamble and traditions are quite clear on that. I have seen many, many cases of hopeless, desperate people who have come to AA and stayed sober and clean. The key to AA working or not working is as you said on the radio "it works, if you work it"... and the message we give each other at every meeting is "keep coming back." If an individual choses not to come back, that is their call, and they put themselves at risk of relapse. Whatever alcoholism is, it is not cured. It is chronic, progressive and fatal. If you stick with the AA program it can work and does work. Rehab is not AA. Rehab can help a person get their head straight - point people in the right direction, but after rehab they need to do and live the AA program. And of the people I have sponsored I have never hesitated to advise them to also seek professional counselling to help them deal with some of their life issues. And the psychologists I have gone to myself, have never advised me any different strategies than are also found in the principles of AA's 12 step program.
I loved this thought provoking and well researched book. The very questions that have been bugging me since I read the Cochrane Collaboration Reciew as part of background reading for a research module..finally some answers!
I wasn't misunderstanding what I had read. I kept on thinking I MUST have got it wrong given the standing AA and other 12 step organisations appear to have.
My understanding that the evidence that 12 steps performs little or no better than the doing nothing option was not wrong! My sense of deep discomfort on reading passages from the Big Book is shared by others. It was not my imagination that the programme also did harm.
Oh ..the relief on reading this. Thank you!
FYI..... http://www.livescience.com/44452-alcoholics-anonymous-is-modern-miracle.html
Thanks for such an excellent book, I am sure that it will provoke many that struggle when confronted by the 12 step solution, to find an alternative that works for them.
I suffered severe depression after 18 months in AA, but was fortunate to be able to afford good therapy, from a non alcoholic, who really helped me work through the underlying problems that I had. I do not believe I would have made such progress using the steps, which moralise alcoholism.
I see many struggle with AA, yet they are told to carry on going, often by counsellors who are 12 step based and little more than AA sponsors,who are not capable of really helping somebody understand their problems,in the way that a Dr with proper training can.
I was actually surprised to see all the history of AA in the book and how it grew, using rather dubious recommendations. I did not know that Bill Wilson's grandfather had also claimed a similar religious experience etc!
I also think that any success that people have in AA is down to the fact that they have chosen to do something about alcoholism, and through having some fellowship, rather than through any insight gained through the steps.
AA obviously suits some people, who often become evangelical about it, and wrongly believe it will help everyone. The fact that there are so many pro and against comments on any internet based discussion, shows that people are divided on the issue and that many did not do well with AA.
I do think things are changing and many are looking for self empowerment solutions. In the UK the Soberistas group has sprung up on the web and has gone from nothing to 26000 members in a year. Most members prefer solutions that employ self empowerment compared to the powerless/higher power solution.
You talk about those who did not use AA, yet who have had successful recoveries, not having much of a voice compared to AA members. This is very true and I think it is important that normal people also write about their experiences, to show that the AA idea of inevitable relapse if you stop meetings is simply untrue. I did identify with a lot of the stories by ex AA members in your book. I have my own small site called http://www.recoveringfromrecovery.com in which I post things that may be of interest to people who wish to move on from the 12 step world. I can see a lot of people find my site through searches in google such as "leaving AA and staying sober", and I feel there is a real need to give these people some appropriate information. I think your books will certainly help.
Regards Michael
I read about your book in an email from Judge Hora. Both as a criminal defense lawyer and as a judge I have struggled with finding treatment for those who need it. Particularly during my years as a drug court judge I found myself frustrated with the options available. I have come to see 12-step programs as a form of after care that can prolong sobriety, but not as treatment in and of themselves. I tell offenders they must do some sort of maintenance treatment every week, but I leave it up to them to work out the details. I write, however, to another purpose. Oregon sends 20,000 people a year to alcohol treatment based on a DUII arrest. Yet we have never compared treatment programs to see if one is better at reducing recidivism than another. We have a state agency that “evaluates” these treatment programs, but it does not look at recidivism and doesn’t collect the data that would allow anyone else to look at it. I remain amazed that we have sent 200,000 people to alcohol treatment over the last ten years without ever asking ourselves if there is any evidence that it works. To your knowledge, are there states that have done useful assessments of treatment in reducing arrests?
Thanks for any help you can be.
I bet you're not sober Dr. Dodes? Very dangerous territory. Good example: Audrey Kishline, the founder of alternative Moderation Management (which preached moderation instead of abstinence), went to prison for vehicular homicide after a drunk driving incident.
AA and the 12 steps work! I should know...I have 21 years sober.
Your entire book has been debunked by experts in the field of addiction from Harvard Medical School. You are doing real HARM; people may DIE of their disease (which you claim isn't a disease) because of erroneous information given by you. I wish the laws of this country could hold you accountable for those deaths.
http://commonhealth.wbur.org/2014/04/defense-12-step-addiction?utm_source=facebook&utm_medium=social&utm_campaign=140407
(I cannot include the links in the article, which is why I include the link TO the article.)
In a recent WBUR interview, Dr. Lance Dodes discussed his new book, which attempts to “debunk” the science related to the effectiveness of 12-step mutual-help programs, such as Alcoholics Anonymous, as well as 12-step professional treatment. He claims that these approaches are almost completely ineffective and even harmful in treating substance use disorders.
What he claims has very serious implications because hundreds of Americans are dying every day as a result of addiction. If the science really does demonstrate that the millions of people who attend AA and similar 12-step organizations each week are really deluding themselves as to any benefit they may be getting, then this surely should be stated loud and clear.
In fact, however, rather than support Dr. Dodes’ position, the science actually supports the exact opposite: AA and 12-step treatments are some of the most effective and cost-effective treatment approaches for addiction.
In his book, Dr. Dodes commits the same misguided offenses he condemns. His critique of the science behind treatment of addiction is deeply flawed, and ironically, his own psychoanalytic model of an approach to solve the “problem of addiction” has no independent scientific proof of effectiveness, particularly in comparison to other methods of treatment.
Below, we address some of the specific pronouncements he made on Radio Boston and in his book in order to convey what well-conducted science actually tells us about how to treat addiction.
What he says: 12-Step programs do not work, are not backed by science, and are probably harmful.
The evidence is overwhelming that AA, and treatments that facilitate patients’ engagement with groups like AA, are among the most effective and best studied treatments for helping change addictive behavior.
This conclusion is consistent with the views of prominent organizations such as the National Institute of Health (NIH), the Substance Abuse and Mental Health Services Administration (SAMHSA), the American Psychiatric Association (APA), and the Department of Veterans Affairs Health Care System (VAHCS), all of whom recommend patients’ participate in AA or similar groups to aid recovery.
Dr. Dodes begins his criticism of AA and related treatment by citing a 1991 study published in the prestigious New England Journal of Medicine. This paper studied the treatment of a large number of individuals with alcohol problems. Dr. Dodes notes in his book that compulsory inpatient treatment had a better outcome than AA alone. But what he fails to mention is that the inpatient unit is a 12-step-based program with AA meetings during treatment, and requirements to attend AA meetings three times a week after discharge in the year following treatment.
Importantly, too, when you compare the alcohol outcomes (average number of daily drinks, number of drinks per month, number of binges, and serious symptoms of alcohol use), AA alone was just as good as the AA-based inpatient treatment. Yet Dr. Dodes uses this study to argue that AA is poor while inpatient treatment is good — a bizarrely distorted, misleading and incorrect interpretation of the study’s findings.
Dr. Dodes then cites a review article from another prestigious entity, the Cochrane Collaboration, to condemn AA and 12-step treatment. The Cochrane group is considered by health professionals to be the “gold standard” of good scientific procedure in its series of reviews. The article reviewed 8 studies from 1991-2004, comparing AA and 12-step treatment to other approaches, such as cognitive-behavioral relapse prevention therapies.
He concludes from this important paper that AA and 12-step treatment were ineffective. However, the study actually concluded that AA and 12-step treatment were shown to be as effective as anything else to which they were compared.
Perhaps not surprisingly, given his apparent agenda, Dr. Dodes doesn’t acknowledge the more recent randomized controlled trials of addiction treatment (that is, studies in which individuals with addictions were randomly assigned to different treatment approaches, comparing outcomes. See here, here, and here. Such studies are considered the most reliable sort of research.) These studies show that 12-step treatment improves outcomes by up to 20% for as long as two years post-treatment via its ability to engage patients, and also tends to produce much higher rates of continuous abstinence than other forms of treatment.
Finally, in the largest randomized controlled study of treatment for alcohol use disorder ever undertaken (Project MATCH), which he does mention, he fails to state that compared to the cognitive-behavioral and motivational-enhancement treatments included in that study, the 12-step treatment had more than double the number of patients who were continuously abstinent at one year after treatment and about one third more at three years after treatment.
What he does not mention: cost or access to care
Dr. Dodes fails to mention cost. Unlike psychoanalysis and other treatments, AA is free, and can be accessed almost anywhere at any time in the United States and many other countries (notably at high-risk relapse times when professionals are not available like weekends, holidays, and evenings.)
In fact, studies published in prestigious peer-reviewed scientific journals have found that 12-step treatments that facilitate engagement with AA post-discharge can not only produce about one third higher continuous abstinence rates, but also 64% lower health care costs compared to cognitive-behavioral treatments.
With the current pressure to configure a leaner and more cost-effective health care system, it is these kinds of double bonus effects that we are looking for.
What he says: 12-step programs are no better than doing nothing.
In addition, Dr. Dodes then goes on to try and make the case that 12-step treatment for substance use disorder is no better than doing nothing; he’s apparently implying that if we actually just stood back and waited, people with substance use disorders would overcome addiction at the same rate as our current best efforts. Presumably, his own approach to addiction treatment would work best? Unfortunately, his own method, promoted on the air and in his book, has not a single scientific study to demonstrate its effectiveness.
What he says: 12-step programs are no more than “religious” efforts that reinforce powerlessness and helplessness
Dr. Dodes’ book and comments are so far off the track of scientific research that he doesn’t realize that for the past several years, the addiction research field has moved beyond asking whether AA and 12-step treatment works, to investigating how and why they work. We have now discovered that the reason why 12-step based interventions so often do better than others is that they engage people with groups like AA, which increase people’s ability to cope with the demands of recovery, and foster critically important social network changes within the communities in which they live every day.
For some, AA also has been shown to work by increasing spirituality, which helps people reframe and take a different viewpoint on stress, such that instead of being seen as a negative it becomes viewed as the fertilizer that fuels personal growth.
Dr. Dodes complains that AA’s focus on admitting powerlessness over one’s addiction is a step in seeking a “higher power” and he interprets this literally as seeking God. For some, this is true and helpful. For others, particularly those for whom spirituality is not appealing, it is seeking help from the AA fellowship (for some “GOD” can stand for “Group Of Drunks, or ‘Good Orderly Direction’), and acknowledging that you cannot solve the problem alone; you need what Carl Jung called “the protective wall of human community.” Strength comes from assuming personal accountability and responsibility to a group, your AA sponsor and, most importantly, to yourself. This process empowers individuals to make the changes needed for recovery.
What he says: Genetics does not play a role in addictions. They are not diseases.
In a blog on the Dodes webpage, there is an assertion that genetics has no role in addictions. This assertion once again contradicts scientific evidence. Research demonstrates that about half of the risk for addiction is conferred by genetics. But the environment is critical too. Like many diseases, the condition is caused by a personal biological vulnerability coupled with environmental exposure and experiences.
In summary, while claiming to “debunk the bad science behind 12-step programs” Dr. Dodes instead reveals a selective and superficial review of the research, at times misinterpreting the studies that he uses to support his own assertions. From a clinician who professes to care about individuals suffering from addiction, Dr. Dodes’ conclusions are not only incorrect, they may have grave consequences.
For the families who have a loved one struggling with addiction, life is beyond tragic. Nights are sleepless while many wait for the proverbial shoe to drop. Will someone be killed by your son, daughter or spouse getting behind the wheel? Will you get the often-awaited call in the middle of the night that your child was found dead in her apartment? We know these stories. We hear them on the news daily.
What can we do to prevent the scourge of addiction? And what can we do when it appears in a family member? Surely we all want a magic bullet. But we also want care that is based on sound scientific research and evidence-based treatments. There are no cures. But there is hope for recovery, sobriety, and, while AA and 12-step treatments are not cure-alls themselves, research demonstrates that they are some of the most effective and cost-effective approaches to addressing chronic diseases of addiction in our society.
John F. Kelly, PhD., is the Elizabeth R. Spallin Associate Professor of Psychiatry in Addiction Medicine at Harvard Medical School, and the President of the American Psychological Association, Society of Addiction Psychology. He is also the Director of the Recovery Research Institute at Massachusetts General Hospital.
Gene Beresin, MD, MA, is Professor of Psychiatry at Harvard Medical School and Executive Director of The Clay Center for Young Health Minds at Massachusetts General Hospital.
Well Doctor you are very wrong. I have not read your book nor I plan to do so. I have been sober for 21 years and AA is not a science its a way of life. We know the low success rate that AA has because it is not for everybody "its for those who want it, not for those who need it". All you are doing is bashing something you have no idea of what you are talking about, of course you get paid by the publisher and from the sales of your book. All the people that talk badly about the program (like you) its because they really never tried getting into it that is why they never reached any amount of sobriety, they are other ways to beat alcoholism I have seen them; some find religion, some rehab it works (very little)but with you its about the money. I can not believe you are so ignorant despite your credential you love to credit your self with, we can't expect any else from you. I hope you never have a relative with an addiction like you call it (it's an obsession) with alcohol or any other drug because then you will see the reality of how it works.
I just read The Sober Truth. It confirmed a number of concerns I have had about the 12 step approach despite my being one of its (apparently) rare successes. I have tried without success to find good clinical studies - like a randomly controlled trial with adequate sample size - to corroborate the very dated and sparse support from the medical community found in the Big Book. As well as real evidence to support the many assertions that nothing else has been shown to work at all. I understand better now why I have had such little success in my search.
I suspect your frustration may have contributed to the book's strident condemnation of the current attitude of unquestioning support for the 12 step approach. In reading it I noted some of the tautologies in the approach did not even get raised as I sensed a desire to "go for the jugular". Though I rather liked the analogy to the saying that the longer you live the older you will be when you die.
Like you, I would like to understand what is working and why. I think there is great value for some people (like me) in the 12 step approach. However, as it arose out of well documented chaotic circumstances I strongly suspect there is a great deal of chaff in with the grain, and there has been an attitude of "if it works - don't fix it" ever since Bill W.'s satori.
I suspect the current 12 step approach is a bit analogous to the old willow bark infusion cure for inflammation and headache. It worked, but no-one really knew what was working. When the active ingredient - aspirin - was isolated, a lot of the guesswork went out of its use.
I am particularly curious about the loss to follow up in the studies done to date. I suspect some of it may be attributable to the spontaneous remission rate. Some of it may even reflect "cures" or at least folks having found a less damaging obsession. My curiosity has a personal impetus. Though I like the people at AA and have enjoyed my involvement in the local group's operation, I would like to think I could pursue a life without it and not automatically go back to my addiction. This seems to be the assumption of the folks I have talked to and I would look to the proposed "ideal study" to help elucidate things like this.
The question of course is - "What Next?". The ideal study may be expensive, and other respondents on this blog have noted that there are other ways to interpret the existing data. But in the final analysis, even if the 12 step approach really is 20% better at some metric and is far less expensive than other approaches it falls short of anything that would be deemed effective in almost any other medical or sociological intervention. The Sober Truth is perhaps a cry of frustration. How about a full court press for the kind of study that actually answers the critical questions? The contributors to this blog - both for and against the book - would seem to be fertile territory for a groundswell of support for such a study. Use it.
Done with the shame game. Need a cause and a solution. It's something to do with isolation/loneliness/weird family dynamics. Where might I go to find relief?
Dr. Dodes,I greatly enjoyed your book,The Sober Truth. I believe that it explains my situation to me exactly;as a result I am using it in conjunction with The Sinclair Method. So far(3 months),there is definite improvement. I had been evaluated( go to Midas,and you will be told that you need a muffler experience). Two weeks later I went to their rehabfor atleast 70(or more) days of restrictive inpatient treatment. At the end of day 2,they decided to treat me for withdrawal(I wasn't) before finally sending me out to a local hospital. It turned out that my duodenal ulcer was bleeding and I required surgery. After 8 days in that hospital,I went home to recover. I ended up retiring from work rather than subject myself to the cost,strss,boredom,etc. of satisfying a system. I tried to find alternatives,but could find no compromize. I do recognize that AA works for some people,but it is not for me. I can force myself to do things I don't want to do if they make good sense. This does not particularly if it is to be for life. Thanks for the book and for letting me vent! Another book that I found good was Wilfred Sheed's"In Love With The Daylight".
For someone with your credentials who is a supposed expert in addiction, your ignorance of A.A. is stunning. I am at a loss as to what your motive could possibly be. It certainly can't be helping the afflicted. By disseminating an amalgam of half-truths, lies and myth, you have abdicated your responsibility to do no harm in what appears to be a trade off for self aggrandizement and money. Shame on you.
Dr. Dodes,
I'm curious if you or others who support your cause and the scientific results of these studies have began confronting cities, counties and states who blindly and without thought or consideration, send people to AA, whether they even show any symptoms of alcoholism at any stage. I know it's easy to just evaluate the person with an arbitrary and subjective set of tests to determine if someone drinks too much (I recently had an OUI in Michigan, which was 100% my fault and responsibility but the alcohol assessment screener was a complete joke in so many ways...but I digress), but more often than not there are several underlying circumstances for why people drink in access or drink in drive; heck, maybe it was just one dumb mistake even. My point is, if no one is out there confronting our elected officials with the FACTS that AA is not even close to be for everyone let alone the majority of people who have alcohol related arrests, then can we/I/someone start to organize this? I, as many others I know, have made a mistake, and have no problem with alcoholism. Many others I know turn to AA when they have terrible anxiety, depression, and overall issues with addiction that AA does not and cannot address. Please, help me help others spread the word; spread the word to those that need it, the judiciary system?