Authors: Lance Dodes
There is another issue that gets tangled up with the question of AA’s success rate; namely, that a certain percentage of alcoholics get better without any treatment at all. This percentage is sometimes called the rate of
spontaneous remission
, a phrase commonly used in the world of oncology.
It is important to include spontaneous remission in any calculation of treatment efficacy, as it offers a more accurate baseline. It can also help to reveal the error in putative “cures” that are, on closer inspection, doing nothing at all. If one is trying to determine whether a certain drug can reverse arthritis, for instance, it’s not enough to point out that 13 to 55 percent of people presenting with undifferentiated arthritis experienced a regression of the disease when given the drug: undifferentiated arthritis reverses on its own at precisely that rate.
38
Different diagnoses have different degrees of spontaneous remission. In pancreatic cancer, spontaneous remission is unusual. For colds and flus, spontaneous remission is the norm. The burden of proof for any “cure” is to show that it clearly exceeds the rate of spontaneous remission for the targeted illness. If a treatment cannot perform better than doing nothing, it is likely that any apparent benefit is simply the phenomenon of spontaneous remission at work. Statistically speaking, it’s background noise.
So what is the rate of spontaneous remission for alcoholism? One large study calculated it to be somewhere between 3.7 and 7.4 percent per year.
39
That is, in a given year, between 3.7 and 7.4 percent of alcoholics are likely to stop drinking without any help at all. A large 1990 meta-analysis by Sheldon Zimburg of the Beth Israel Medical Center in New York reviewed the available data about this and summarized the results:
Kissin, Platz, and Su . . . reported a 4 percent one-year improvement rate in untreated lower class alcoholics. Imber et al. . . . described a follow-up of 58 alcoholics who received no treatment for their alcoholism. It was noted that the rate of abstinence was 15 percent at one year and 11 percent after three years. . . . In sum, the preponderance of these studies suggests that a spontaneous remission rate for alcoholism of at least one-year duration is about 4–18 percent. Successful treatment would, therefore, have to produce rates of improvement significantly above this probable range of spontaneous remission.
40
Could it be that some of AA’s own modest success rate is attributable to spontaneous remission? Studies seem to support this idea. For instance, one controlled study from 2001 in Germany left patients free to choose AA treatment or no treatment at all. After one year, relapse rates were identical between the groups, leading the authors to conclude, “The present study was unable to show an advantage of self-help group attendance in reducing relapses compared to the control group [no treatment].”
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Even one of AA’s own board members, Harvard’s George Vaillant, conducting an unusually long follow-up of his own AA-based hospital program, found “compelling evidence that the results of our treatment were no better than the natural history of the disease.”
42
In the late 1990s, one of the most ambitious studies ever undertaken to assess 12-step treatment was conducted. Called Project MATCH, it was underwritten by the National Institute on Alcohol Abuse and Alcoholism and funded to the tune of $27 million. Its stated goal was to determine which kind of treatment was best suited to which “kind” of alcoholics. The research showed a surprising finding, which has by now become an important statement about the power and frequency of spontaneous remission in alcoholism:
Overall, a median of only 3% of the drinking outcome at follow-up could be attributed to treatment. However this effect appeared to be present at week one before most of the treatment had been delivered. The zero treatment dropout group showed great improvement, achieving a mean of 72 percent days abstinent at follow-up. Effect size estimates showed that two-thirds to three-fourths of the improvement in the full treatment group was duplicated in the zero treatment group.
43
In 2005, Deborah Dawson and colleagues conducted a survey of 4,422 men to determine how many people classified as alcohol dependent remained that way in the absence of treatment.
44
They found a similar trend toward natural recovery:
Of people classified with [prior] alcohol dependence, 25.0% were still classified as dependent in the past year; 27.3% were classified as being in partial remission; 11.8% were asymptomatic risk drinkers who demonstrated a pattern of drinking that put them at risk of relapse; 17.7% were low-risk drinkers; and 18.2% were abstainers. Only 25.5% of people with [prior] dependence ever received treatment.
In other words, about 36 percent of alcohol-dependent people in a general population study had become either low-risk drinkers or abstinent at the one-year mark, even though only 25.5 percent had received any treatment. It is worth noting that these were very serious drinkers, classified under the DSM criteria for “dependence,” which requires not only a history of alcohol abuse but also physical dependence.
Many claim that Alcoholics Anonymous is the only safe, effective, and consistent cure for alcoholism. Narcotics Anonymous, Gamblers Anonymous, and other 12-step offshoots enjoy a similar reputation for the treatment of their respective behaviors. Celebrity doctor Drew Pinsky (“Dr. Drew”), often described as an addiction medicine specialist and the host of VH1’s
Celebrity Rehab
, once told
Wired
magazine, “In my 20 years of treating addicts, I’ve never seen anything else that comes close to the 12 steps. In my world, if someone says they don’t want to do the 12 steps, I know they aren’t going to get better.”
45
But, as we have seen, this unadulterated enthusiasm is quite simply unfounded. Most studies of AA that purport to show its effectiveness are observational in nature, with no controls that might help us capably determine results. They consistently point only to a correlation no one could debate; namely, that AA works well for the people who are the most invested in it. But this correlation becomes considerably less impressive when it is placed in the context of all the people who try but fail to benefit from 12-step recovery. An objective calculation puts AA’s success rate at 5 to 8 percent. Controlled, randomized studies, on the other hand, have revealed an even more discouraging picture: no such study to date has been able to prove that AA is effective at all.
The issue of spontaneous remission further erodes AA’s reputation. If alcoholism were something that people never recovered from on their own, then the 5–8 percent figure would be a small but meaningful slice of those with alcoholism in the general population. But many people do get better without treatment. In fact, as we’ve seen, a higher percentage of alcoholics get better without any treatment than with AA, suggesting that some of AA’s success rate may simply be nature taking its course. There is also evidence that some people do worse by attending AA, as indicated in the McKellar results and in the experience of many who have foundered for years in AA before seeking more appropriate treatment (I will return to this later).
All that said, there is no question that AA is useful for some people. Some of this is due to characteristics that it shares with all collective organizations, such as camaraderie and support, as we will see later. In a later chapter, I will also explore some of the other factors that can help us understand AA through the prism of a more sophisticated understanding of the nature of addiction. Before we can get to that discussion, however, we must explore the industry Dr. Drew most strongly endorses. What about rehab?
“The great thing about the Steps is they can be incorporated in so many facets of our lives, and working the Steps day after day makes us even better at it, too. The other great thing about the Steps is that they work. If they didn’t work, then doing them over and over again would be insanity.”
—BETTY FORD CENTER WEBSITE
THE ERA OF THE modern American addiction rehabilitation center officially began in 1949, when Hazelden Treatment Center opened its doors in Minnesota. Hazelden took the dictates of Alcoholics Anonymous and turned them into an inpatient model. It promised visitors and patients immersion in a version of the popular program that was more refined, without the interruptions present in regular 12-step meetings. It was, in a very real sense, an extension of AA into the twenty-four-hour day. Today, Hazelden still says that its program is “grounded in Twelve Step philosophy.”
1
(Notably, although Hazelden also lists remaining “open to innovation” as a value, it has apparently not found ideas worthy of replacing the Twelve Steps over the past sixty-five years.)
Hazelden quickly became a tremendous financial and cultural success. Today, it commands fees in the range of $30,000 for a one-month stay. Its impact emboldened similar rehab centers to open across the nation, with a notable boom in the 1980s that birthed famous entries like the Betty Ford Center (1982) and Sierra Tucson (1983). As it happened, there was a large ready-made market for these programs, since millions of people were failing to stay sober in AA. The new “Cadillac” rehabs offered alcoholics a way to double down on the 12-step model—trying more, not less, of the same approach with which they were struggling. This was a seductive idea that felt entirely consonant with the theme of spiritual cleansing and purity, and it rekindled the hope first created by Alcoholics Anonymous.
Almost immediately, a fierce competition began among the major rehab programs to add more and more “enhancements” to their treatment. Sure, these features added more cost, but what the programs were offering was practically priceless. Who would not be willing to spend a small fortune for a life free of the agony of addiction? For many addicts, the only question became: where to spend that fortune?
Sierra Tucson quickly developed what it calls the Sierra Model, which includes education about the disease model, recovery education, relapse prevention, “equine-assisted therapy,” “adventure therapy,” grief and spirituality sessions, and psychodrama. The Betty Ford Center has added meditation, fitness, educational lectures, relapse-prevention group, and therapeutic duty assignments. Hazelden offers, among other things, meditation, educational lectures, leisure skills groups, anger groups, stress management groups, relaxation, exercise, recreational activities, and biofeedback.
Rehabs also became increasingly opulent to compete for clientele. Playing into the idea that alcoholics needed a tranquil and beatific place to contemplate their problem or achieve spiritual fulfillment, many programs began to market themselves as spas. Betty Ford notes that its twenty-acre gated campus is “surrounded by serene mountains” and patients are housed in “spacious, double occupancy rooms.”
2
Sierra Tucson boasts that its 160-acre campus sits in the shadow of the Santa Catalina Mountains; patients can move into “rustic and elegant lodges with cozy fireplaces, high beamed ceilings, outdoor balconies and patios.”
3
The Menninger Clinic, previously justly famous as a psychiatric center, moved into the rehab business and released a flyer promising “outdoor terraces for each unit and a meditation labyrinth in the expansive courtyard.”
4
And Promises Malibu, well-known redoubt of many A-list celebrities, entices its potential clients with descriptions like this:
The property includes a garden, swimming pools, Jacuzzis, a tennis court, and numerous meditation areas for quiet reflection. Sun streams through the beautifully decorated residences, bringing a feeling of warmth and healing comfort to the private rooms and common areas. With the mountains and ocean in your backyard, there are countless opportunities for outdoor, experiential activities including rock climbing and hiking. The beauty of the natural surroundings inspires a sense of awe and gratitude that encourages the recovery process.
Inside the facility, guests will be treated to gourmet meals, a fireplace, phone and internet access, and numerous patios and sitting areas.
5
Today, as a result of this aggressive marketing, and helped along by a credulous media, rehab centers enjoy a reputation as the ultimate facilities for the treatment of addiction, the biggest and most comprehensive solutions the human mind can imagine. Hit TV shows like
Celebrity Rehab
and
Intervention
further the cause by continually preaching the gospel of rehab, often subtly equating “success” with mere admission. “Going to rehab” appears regularly in music and film as the ultimate hope for treating addiction.
Yet a surprisingly small number of these people have asked:
Is this industry actually helping people?
In this chapter I’ll attempt to answer this question, beginning with an overview of the ways that rehab is both like, and unlike, Alcoholics Anonymous and other 12-step programs.
Most rehab programs that borrow their philosophy from AA do so explicitly and do not attempt to hide their affiliation. If anything, it is generally a badge of pride within the rehab community that their methods have been adapted from a model that is widely seen as the best addiction treatment in the world. According to Hazelden’s website, “The ‘Minnesota Model’ [is a] Twelve Step facilitation model [that] utilizes the philosophy of Alcoholics Anonymous as a therapeutic tool for recovery from addiction.” Betty Ford informs us, “All our programs are based on the 12-steps of Alcoholics Anonymous,” adding, “If, with courage and with total truth, you take the steps with absolutely no reservation, and eliminate those things from your life which, in good conscience, can’t be reconciled with living the steps, you will stay sober.” Sierra Tucson describes the Sierra Model as reflecting “a deep commitment to treating the whole person with integrated, individualized psychiatric and non-traditional therapies rooted in the Twelve-Step recovery process.” The Kaiser Permanente Chemical Dependency Recovery Program that I mentioned in chapter 3 requires two 12-step meetings in the community each week plus an on-site 12-step meeting, and says that the 12-step philosophy is incorporated into some of its group sessions.