12 Steps To Nowhere?
Time for sober look at rehab, AA programs
August 18, 2010
By: Bankole A. Johnson
Lindsay Lohan recently left jail and entered a drug and alcohol rehabilitation facility. If the scene inspired déjà vu, it wasn't just because it was the fourth time she had headed to rehab in four years. It was because the spectacle of a celebrity entering a drug and alcohol treatment centre, relapsing, then heading to rehab again -- and again and again -- has become depressingly familiar.
For decades, Americans have clung to a near-religious conviction that rehab -- and the 12-step model pioneered by Alcoholics Anonymous that almost all facilities rely upon -- offers effective treatment for alcoholism and other addictions.
Here's the problem: We have little indication that this treatment is effective. When an alcoholic goes to rehab but does not recover, it is he who is said to have failed. But it is rehab that is failing alcoholics. The therapies offered in most alcohol treatment centres are so divorced from state-of-the-art medical knowledge that we might dismiss them as merely quaint -- if it weren't for the fact alcoholism is a deadly and devastating disease.
And the way we attempt to treat alcoholism isn't just ineffective, it's ruinously expensive: Promises Treatment Centre's Malibu facility, where Lohan reportedly went for her second round of rehab, in 2007, has stunning vistas, gourmet food, poolside lounging and acupuncture. It costs a reported $48,000 a month.
Even non-profit facilities that don't cater to Hollywood types are too costly for most people. At the 61-year-old Hazelden centre in Minnesota, which bills itself as one of the world's largest and most respected private not-for-profit alcohol and drug addiction treatment centres, a typical 28-day stay costs $26,000.
These prices might be justified if these programs worked. But finding out the success rate of a given program is extremely difficult. Controlled studies of specific treatment centres are rare; compounding the problem, many programs simply don't follow up with former patients. And when they do report a success rate, be it 30 per cent or 100, a closer look almost always reveals problems. That 100 per cent rate turns out to apply only to those who successfully completed the program. Well, no kidding. The 30 per cent rate applies to patients' sobriety immediately after treatment, not months or years later.
It's understandable, if unfortunate, that treatment centres that have a financial stake in recruiting patients might be reluctant to aggressively track -- much less publicize -- data on their patients' success down the road. But the problem is more fundamental than that: There is little compelling evidence that the AA method works, inside or outside a rehab facility.
Although AA's emphasis on anonymity makes it difficult for outside researchers to determine its success rates, some have tried. What they have found doesn't inspire much confidence in AA's approach.
A recent review by the Cochrane Library, a health-care research group, of studies on alcohol treatment conducted between 1966 and 2005 states its results plainly: No experimental studies unequivocally demonstrated the effectiveness of AA or TSF (12-step facilitation) approaches for reducing alcohol dependence or problems.
AA itself has released success rates at times, but these numbers are based only on voluntary self-reports by alcoholics who maintain their ties to AA -- not exactly a representative sample.
Even taken at face value, the numbers are not impressive. In a 1990 summary of five membership surveys from 1977 through 1989, AA reported that 81 per cent of alcoholics who began attending meetings stopped within one month. At any one time, only five per cent of those still attending had been doing so for a year.
Many health conditions resolve themselves through what's known as spontaneous remission -- that is, they improve on their own. In the case of the common cold, for example, nearly everyone gets over the virus without medical intervention. In a 2005 article in the journal Addiction, Deborah Dawson and her colleagues calculated a natural recovery rate for alcoholism of 24.4 per cent -- that is, over the course of a year, 24.4 per cent of the alcoholics studied simply wised up, got sick and tired of being sick and tired, and quit. Without treatment and without meetings.
When AA's retention numbers are compared with alcoholism's rate of spontaneous remission, they look even worse.
Many proponents of AA cite Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), a study completed in 1996 by the National Institute on Alcohol Abuse and Alcoholism that seemed to find that 12-step treatment works. The study randomly assigned alcoholics to one of three behaviorally based treatments with marked differences in philosophy and practice: a 12-step therapy based on the principles of Alcoholics Anonymous, cognitive behavioral therapy and motivational enhancement therapy.
After eight years and $27 million, the study concluded that the techniques were equally effective. More to the point, a 2005 article in the journal BMC Public Health that reanalyzed the data from Project MATCH reported that almost all of the effect of treatment was achieved after attending a single session. In other words, it was the initial decision to try to get better that determined a person's chances of succeeding; what followed made little difference.
Although AA doubtless helps some people, it is not magic. I have seen, in my work with alcoholics, how its philosophy can be harmful to patients who chronically relapse: AA holds that, once a person starts to slip, he or she is powerless to stop. The stronger an alcoholic's belief in this perspective, the longer and more damaging relapses can be. An evening of drinking turns into a month-long bender.
Equally troubling, AA maintains that when an alcoholic fails, it is his fault, not the program's. As outlined in the organization's namesake bible, Alcoholics Anonymous (also known as The Big Book): Those who do not recover are those who cannot or will not give themselves completely to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates ... they seem to have been born that way. This message can be devastating.
In the end, there is simply no need to remove alcoholics from the support of relatives and friends and shut them away for the customary month in rehab. There is no need for alcoholics to be led to expect a miracle, only to be judged a failure if one does not occur. And there is no need to spend tens of thousands of dollars, again and again and again, on an approach that keeps landing people back where they started.
Alcoholism is an illness. But although those in the rehab business sometimes use that word, the 12-step approach they advocate is weak medicine. When any other illness causes great suffering, our society devotes time and money and effort to studying it and to developing treatments that are empirically found to work.
Alcoholism and drug addiction should be no exception. Recent advances in neuroscience have led to a greater understanding of how alcohol and other drugs affect the brain. They have, in turn, allowed medical researchers, myself included, to begin to approach alcohol dependence as we would any other disease: by searching for effective medicine.
Bankole A. Johnson is chairman of the department of psychiatry and neurobehavioral sciences at the University of Virginia and has served as a paid consultant to pharmaceutical companies developing medications to treat alcoholism. His book The Rehab Myth: New Medications That Conquer Alcoholism will be published in January.