Are 12 Steps Too Many?
Health & Science
By John Cloud
Jan. 27, 2009
January is a big month for winter sports and post-Christmas sales. It's also as people who treat substance abuse know a big month for drinkers who want to quit. The holidays are over and bank accounts are thin, but addicts can't stop partying. Many choose January to ask, at long last, for help. But what sort of help is the most useful? (See "The Year in Medicine 2008: From A to Z.")
For decades, the primary approach to rehabilitation in the U.S. has been 12-step programs like Alcoholics Anonymous (AA). Twelve-step doctrine defines addiction in a contradictory way: as a medical problem, like a lifelong illness, with a spiritual solution (surrendering to a higher power). The model has become so culturally hegemonic that it's hard for many to imagine any other way to stop getting drunk or doing drugs or gambling, overeating or watching porn, for that matter. When we see Anne Hathaway's character in the film Rachel Getting Married at a 12-step meeting or when we watch D-list celebrities work the steps on VH1's new reality show Celebrity Rehab Presents Sober House, it's easy to think 12-step is not only the best way to get well, but the only way. There's a growing body of evidence, however, that suggests that's not so. (Read a 1940 TIME article about Alcoholics Anonymous.)
In last month's Journal of Substance Abuse Treatment, University of New Mexico addiction specialist William Miller and his colleagues presented findings from two controlled trials in which patients underwent drug treatment. Some of the patients received spiritual guidance as part of the treatment learning such practices as prayer, meditation and service to others, all of which are central to 12-step programs. Others received secular psychotherapy. Because of the enduring popularity of AA and similar programs that involve a spiritual component, Miller and his team expected the patients in the spiritual group to do better than those in the secular group. They were wrong at least in the short term.
While both groups eventually benefited relatively equally from their treatment abusing substances on fewer days it took longer to see improvement among those in the spiritual group. What's more, those who received spiritual guidance reported being significantly more anxious and depressed after four months than those who got secular help. Those problems abated at about the eight-month point, but because substance abusers are at high risk for suicide, some worry that it may not be a good idea to put them through demanding spiritual calisthenics in the early months of their recovery. (Read a 2007 TIME cover story, "How We Get Addicted.")
This study amplifies a fascinating paper Miller co-authored in 1997, which found that patients who reported knowing that someone was praying for them used significantly more substances after leaving treatment than those who didn't know someone was praying for them. Taken together, Miller's studies suggest that spirituality can be demanding even when others are being spiritual on your behalf and that many addicts may simply not be up to the pressure. For those people, non-faith-based treatments like cognitive behavioral therapy or mindfulness-based acceptance and commitment therapy might be better.
These challenges to addiction orthodoxy come along as scientists and sufferers alike continue to look for a faster fix for substance abuse. New York cardiologist Dr. Olivier Ameisen who now lives in France but remains a visiting professor at the State University of New York has authored a new book describing his recovery from alcoholism, which was achieved with the aid of a common drug called baclofen, a muscle-relaxant designed to prevent the spasms behind a range of conditions from hiccups to multiple sclerosis symptoms. The claim is drawing a lot of attention, but it is too soon to say how effective the drug will be for other alcoholics or how widely it will be embraced by the addiction community. (Read a 1974 TIME cover story, "Alcoholism: New Victims, New Treatment.")
Last month, investigators in the U.S. reported good test results for a monthly dose of the common antidrinking drug naltrexone a medication that currently must be taken every day to be effective. But naltrexone is controversial because for some, it doesn't do anything to reduce the craving for alcohol until those addicts actually take a drink, whereupon it helps them resist taking more a twisted bit of physiological irony if ever there was one. Twelve-step believers say the only proper response to alcoholism is total abstinence, and that a drug that allows you to drink a little puts you on a slippery slope to drinking a lot.
About 1 in 5 people with alcohol dependence stop drinking without any treatment, according to the Diagnostic and Statistical Manual of Mental Disorders, the field guide mental-health professionals use to diagnose illnesses. That means we have to figure out a way to help the 80% who won't get better through willpower. The latest evidence suggests that those who think that spirituality or a pill alone can save them are wrong. The answer almost certainly lies deeper inside ourselves.
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